Section 65.101 - Outline of Coverage[CARRIER NAME]
[ADDRESS - CITY & STATE], [TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE - OUTLINE OF COVERAGE
Policy Number:
[The following three paragraphs must be included in substantially similar language at the top of the policy.]
FEDERAL INCOME TAX EXEMPTIONS: This policy (IS)(IS NOT) intended to be a federally qualified long-term care insurance contract under section 7702B(b) of the Internal Revenue Code of 1986, as amended. STATE MASSHEALTH (MEDICAID) EXEMPTIONS: This policy (IS)(IS NOT) intended to satisfy Massachusetts' minimum long-term care insurance coverage requirements as of the policy's effective date for certain asset and liability exemptions under the Massachusetts MassHealth (Medicaid) Program. Please note that there may be other MassHealth (Medicaid) requirements to qualify for these exemptions. Please read Your Options for Financing Long-Term Care: A Massachusetts Guide for important information about the federal and state exemptions. PLEASE NOTE THAT STATE AND FEDERAL LAWS ARE SUBJECT TO CHANGE AND THAT FEDERAL AND STATE EXEMPTIONS MAY NOT APPLY TO THIS POLICY AT A FUTURE DATE. |
1. This policy is [an individual policyofinsurance/a group policy which was issued in (indicate jurisdiction in which group policy was issued)]. THIS IS A LIMITED POLICY. This policymaynot cover all the expenses associated with your long-term care needs. [Except for policies or certificates that are guaranteed issue, the following cautionstatement, orlanguage substantially similar, must appear as follows in the outline of coverage.]
Caution: The issuance of this long-term care insurance [policy] [certificate] is based upon your responses to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue as of the date you signed the applications, the carrier has the right to deny benefits or rescind your policy subject to the [Time Limit on Certain Defenses, Incontestable] section of your policy. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers were incorrect, contact the carrier at this address: [insert address]
2. SUMMARY OF POLICY FEATURESThis policy:
1. is not a Medicare Supplement policy.2. [is guaranteed renewable/is noncancelable] for your lifetime.3. [is/is not] subject to automatic premium increases as you get older.4. [may be/is not] subject to across the board premium increases for all policyholders in your class.5. [does/does not] offeranoption to purchase inflation protection after the policy is issued without any medical underwriting.6. [does/does not] offer an option to purchase nonforfeiture protection after the policy is issued without any medical underwriting.7. [does/does not] contain special age limitations for purchase.8. [does not cover services due to pre-existing conditions (existing health problems) for a period of __ months from policy issue][does not have a waiting period before pre-existing conditions (existing health problems) are covered].9. [may have/has] an elimination period of __ days before benefits are payable by policy.10. [offers a waiver of premium after __ days of __ benefits][does not offer a waiver of premium].3. PURPOSE OF OUTLINE OF COVERAGE. An outline of coverage provides a very brief description of the important features of the coverage. You should compare this outline of coverage to outlines of coverage for other policies available to you. This is not an insurance contract, but only a summary of coverage. Only the individualor group policy contains actual contractual provisions. This means that your [policy/certificate] sets forth in detail the rights and obligations ofbothyouand the carrier. Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR [POLICY/ CERTIFICATE] CAREFULLY!4. TERMS UNDER WHICH THE [POLICY/CERTIFICATE] MAY BE CONTINUED IN FORCE OR DISCONTINUED.(a) [For long-term care insurance policies or certificates describe one of the following permissible policy renewability provisions:(1) Policies and certificates that are guaranteed renewable must contain the following statement:] RENEWABILITY: THIS [POLICY[/CERTIFICATE] IS GUARANTEED RENEWABLE. This means youhave the right, subject to the terms of your policy, to continue this coverage as long as you pay your premiums on time. [Carrier Name] cannot change any of the terms of your policy on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY. OR
(1) Policies and certificates that are noncancelable must contain the following statement:] RENEWABILITY: THIS [POLICY/CERTIFICATE] IS NONCANCELABLE. This means you have the right, subject to the terms of your policy, to continue this coverage as long as you pay your premiums ontime. [Carrier Name] cannot change any of the terms of your policy on its ownwithout your agreement, and cannot change the premiumyoucurrentlypay. However, if your policy contains an inflation protection feature where you choose to increase your benefits, [Carrier Name] may increase your premium at that time for those additional benefits. OR
(1) Policies and certificates that are convertible from a group policy must contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS CONVERTIBLE TO AN INDIVIDUAL POLICY.](For group coverage, specifically describe continuation/conversion provisions applicable to the certificate and group policy:](b) [Describe waiver of premium provisions or state such provisions are not in the policy.](c) [State whether or not the carrier has a right to change premium, and if the right exists, describe clearly and concisely each circumstance under which premium may change,includingthat it is subject to the commissioner's approval.]5. TERMS UNDER WHICH THE [POLICY/CERTIFICATE] MAYBE RETURNED AND PREMIUM REFUNDED. (a) [Provide a brief description of the right to return-the policy's "free look" provision, which must be a minimum of ten days from the date of policy delivery.](b) [Include a statement that the policy either does or does not contain provisions providing for a refund or partial refund of premium upon the death of an insured or surrender of the policy or certificate. If the policy contains such provisions, include a description of them.]6. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the carrier. (a) [For agents] Neither [insert carrier name] nor its agents represent Medicare, the federal government, or any state government.(b) [For direct response] [insert carrier name] is not representing Medicare, the federal government or any state government.7. LONG-TERM CARE COVERAGE. Policies of this category are designed to provide coverage for one or more necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital, including, but not limited to care in a nursing home, other longterm care facility or program or in the home. [Except for policies or certificates which have unlimited daily benefits and no coinsurance cost-sharing features, the following caution statement, or language substantially similar, must appear as follows in the outline of coverage.]
This [policy/certificate] provides coverage in the form of a fixed dollar indemnity benefit for covered long-term care expenses, subject to policy [limitations] [waiting periods] and [coinsurance] requirements.
8. BENEFITS PROVIDED BY THIS [POLICY/CERTIFICATE].(a) [Covered services, deductible(s), waiting periods, elimination periods and maximums.](b) [Institutional benefits, by skill level.](c) [Non-institutional benefits, by skill level.] [A policy that provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import must include an explanation of such terms in this section of the outline of coverage.]
[Any benefit screeningmust be explained inthis section. If these screens differ for different benefits, explanation of the screen should accompany each benefit description. If an attending physician or other specified person must certify a certain level of functional dependency in order to be eligible for benefits, this too must be specified. If activities of daily living (ADLs) are used to measure an insured's need for long-term care, then these qualifying criteria or screens must be explained.]
9. LIMITATIONS AND EXCLUSIONS[Describe:
(a) Pre-existing conditions(b) Non-eligible facilities/provider(c) Non-eligible levels of care (e.g. unlicensed providers, care by a family member, etc.)(d) Exclusions/exceptions(e) Limitations] [This section should provide a brief specific description of any policy provisions which limit, exclude, restrict, reduce, delay, or in any other manner operate to qualify payment of the benefits described in (6) above.]
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG-TERM CARE NEEDS.
10. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of long-term care services will likely increase over time, you should consider whether and how the benefits of this plan may be adjusted. [As applicable, indicate the following: (a) That the benefit level will not increase over time;(b) Any automatic benefit adjustment provisions;(c) Whether the insured will be guaranteed the option to buy additional benefits and the basis upon which benefits will be increased over time if not by specified amount or percentage;(d) If there is not a guarantee, include whether additional underwriting or health screening will be required, the frequency and amounts of the upgrade options, and any significant restrictions or limitations;(e) Describe whether there will be any additional premium charge imposed, and how that is to be calculated.] [Carriers must include the following information in or with the outline of coverage:
(1) A graphic comparison of the benefit levels of a policy that increases benefits over the policy period with the benefit levels of a policy that does not increase benefits. The graphic comparison must show benefit levels over at least a 20-year period.(2) Any expected premium increases or additional premiums to pay for automatic or optional benefit increases. A carrier may use a reasonable hypothetical, or a graphic demonstration, for the purposes of this disclosure.](3) Whether or not the benefit was chosen by the policyholder.]11. NONFORFEITURE BENEFITS. As an accident and sickness policy, this policy does not have a cash value associated with life insurance products. This policy does offer [for an additional charge (if applicable)] a nonforfeiture benefit that will continue until exhausted even ifthe policylapses due tononpayment of policy premiums. The following represents an example of how this benefit would apply to your policy: [As applicable, indicate the following: [Carriers must include the following information in or with the outline of coverage:
(1) A description of the benefits that would accrue at different periods of policy lapse(2) Whether or not the benefit was chosen by the policyholder.]12. ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS[State that the policy provides coverage for a person clinically diagnosed as having Alzheimer's disease or related degenerative and dementing illnesses. Specifically describe each benefit screen or other policy provision that provides preconditions to the availability of policy benefits for such an insured.]
13. PREMIUM(a)[ State the total annual premium for the policy;(b) If the premium varies with an applicant's choice of benefit options, indicate the portion of annual premium that corresponds to each benefit option; OR(c) Refer individual to schedule page of the policy. For reference duringthe presentation, individual may be referred to policy illustration form for premium.] COMPLAINTS. If you have a complaint, callus at () ____ or your agent. If you are not satisfied, you may call or write the Massachusetts Division of Insurance.