26.1-45 Long-Term Care Insurance

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CHAPTER 26.1-45LONG-TERM CARE INSURANCE26.1-45-01. Definitions. In this chapter, unless the context requires otherwise:1.&quot;Applicant&quot; means:a.In the case of an individual long-term care insurance policy, the person who<br>seeks to contract for benefits.b.In the case of a group long-term care insurance policy, the proposed certificate<br>holder.2.&quot;Certificate&quot; means any certificate issued under a group long-term care insurance<br>policy that has been delivered or issued for delivery in this state.3.&quot;Group long-term care insurance&quot; means a long-term care insurance policy that is<br>delivered or issued for delivery in this state to:a.One or more employers or labor organizations, or to a trust or to the trustees of<br>a fund established by one or more employers or labor organizations, or a<br>combination thereof, for employees or former employees or a combination<br>thereof, or for members or former members or a combination thereof, of the<br>labor organizations.b.Any professional, trade, or occupational association for its members or former<br>or retired members, or combination thereof, if the association:(1)Is composed of individuals all of whom are or were actively engaged in<br>the same profession, trade, or occupation; and(2)Has been maintained in good faith for purposes other than obtaining<br>insurance.c.An association, a trust, or the trustee of a fund established, created, or<br>maintained for the benefit of members of one or more associations meeting the<br>requirements of section 26.1-45-02.d.A group other than a group described in subdivision a, b, or c if the<br>commissioner finds that:(1)The issuance of the group policy is not contrary to the best interest of the<br>public;(2)The issuance of the group policy would result in economies of acquisition<br>or administration; and(3)The benefits are reasonable in relation to the premiums charged.4.&quot;Long-term care insurance&quot; means any insurance policy or rider primarily advertised,<br>marketed, offered, or designed to provide coverage for not less than twelve<br>consecutive months for each covered person on an expense incurred, indemnity,<br>prepaid, or other basis, for one or more necessary or medically necessary<br>diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care<br>services provided in a setting other than an acute care unit of a hospital. The term<br>includes group and individual annuities and life insurance policies or riders, whether<br>issued by insurers, fraternal benefit societies, nonprofit health service corporations,<br>prepaid health plans, health maintenance organizations, or any similar entity, whichPage No. 1provide directly or which supplement long-term care insurance.The term alsoincludes home health care type insurance policies or riders which provide directly or<br>which supplement long-term care insurance; and includes a policy or rider which<br>provides for payment of benefits based upon cognitive impairment or the loss of<br>functional capacity. The term includes qualified long-term care insurance contracts.<br>The term includes long-term care insurance products issued by insurers; fraternal<br>benefit societies; nonprofit health, hospital, and medical service corporations;<br>prepaid health plans; health maintenance organizations; or a similar organization to<br>the extent that the organization is otherwise authorized to issue life or health<br>insurance. The term does not include any insurance policy that is offered primarily<br>to provide basic medicare supplement coverage, basic hospital expense coverage,<br>basicmedical-surgicalexpensescoverage,hospitalconfinementindemnitycoverage,majormedicalexpensecoverage,disabilityincomeorrelatedasset-protection coverage, accident only coverage, specified disease or specified<br>accident coverage, or limited benefit health coverage. With regard to life insurance,<br>this term does not include life insurance policies which accelerate the death benefit<br>specifically for one or more of the qualifying events of terminal illness, medical<br>conditions requiring extraordinary medical intervention, or permanent institutional<br>confinement, and which provide the option of a lump sum payment for those benefits<br>and in which neither the benefits nor the eligibility for the benefits is conditioned<br>upon the receipt of long-term care. Notwithstanding any other provision contained<br>herein, any product advertised, marketed, or offered as a long-term care insurance<br>is subject to the provisions of this chapter.5.&quot;Policy&quot; means any policy, contract, subscriber agreement, rider, or endorsement<br>delivered or issued for delivery in this state by an insurer, fraternal benefit society,<br>nonprofit health, hospital, or medical service corporation, prepaid health plan, health<br>maintenance organization, or any similar entity.6.a.&quot;Qualified long-term care insurance contract&quot; or &quot;federally tax-qualified<br>long-term care insurance contract&quot; means an individual or group insurance<br>contract that meets the requirements of section 7702B(b) of the Internal<br>Revenue Code of 1986, as amended, as follows:(1)The only insurance protection provided under the contract is coverage of<br>qualified long-term care services. A contract satisfies the requirements<br>of this paragraph even if payments are made on a per diem or other<br>periodic basis without regard to the period in which the expenses are<br>incurred;(2)The contract does not pay or reimburse expenses incurred for services or<br>items to the extent that the expenses are reimbursable under title XVIII of<br>the Social Security Act, as amended, or would be so reimbursable but for<br>the application of a deductible or coinsurance amount. The requirements<br>of this paragraph do not apply to expenses that are reimbursable under<br>title XVIII of the Social Security Act only as a secondary payer.Acontract satisfies the requirements of this paragraph even if payments<br>are made on a per diem or other periodic basis without regard to the<br>period in which the expenses are incurred;(3)The contract is guaranteed renewable, within the meaning of section<br>7702B(b)(1)(c) of the Internal Revenue Code of 1986, as amended;(4)The contract does not provide for a cash surrender value or other money<br>that can be paid, assigned, pledged as collateral for a loan, or borrowed<br>except as provided in paragraph 5;(5)All refunds of premiums and all policyholder dividends or similar amounts<br>under the contract are to be applied as a reduction in future premiums orPage No. 2to increase future benefits, except that a refund on the event of death of<br>the insured or a complete surrender or cancellation of the contract cannot<br>exceed the aggregate premiums paid under the contract; and(6)The contract meets the consumer protection provisions set forth in<br>section 7702B(g) of the Internal Revenue Code of 1986, as amended.b.&quot;Qualified long-term care insurance contract&quot; or &quot;federally tax-qualified<br>long-term care insurance contract&quot; also means the portion of a life insurance<br>contract that provides long-term care insurance coverage by rider or as part of<br>the contract and that satisfies the requirements of sections 7702B(b) and (e) of<br>the Internal Revenue Code of 1986, as amended.26.1-45-02. Group long-term care insurance - Association requirements - Approval.Group long-term care insurance may be issued or delivered for the benefit of members of an<br>association, as defined in subdivision c of subsection 3 of section 26.1-45-01, if prior to<br>advertising, marketing, or offering a policy within this state, the association, or the insurer of the<br>association, files evidence with the insurance commissioner that the association has at the outset<br>a minimum of one hundred persons, has been organized and maintained in good faith for<br>purposes other than that of obtaining insurance, has been in active existence for at least one<br>year, and has a constitution and bylaws that provide that:1.The association hold regular meetings not less than annually to further the purposes<br>of the members.2.Except for credit unions, the association collect dues or solicit contributions from<br>members.3.The members have voting privileges and representation on the governing board and<br>committees.Thirty days after the filing, the association is deemed to satisfy the organizational requirements,<br>unless the commissioner makes a finding that the association does not satisfy the organizational<br>requirements.26.1-45-03.Limits of group long-term care insurance.No group long-term careinsurance coverage may be offered to a resident of this state under a group policy issued in<br>another state to a group described in subdivision d of subsection 3 of section 26.1-45-01 unless<br>the insurance commissioner or an insurance department in another state having statutory and<br>regulatory long-term care insurance requirements substantially similar to those in this state has<br>made a determination that the long-term care insurance requirements have been met.26.1-45-04. Disclosure and standards for long-term care insurance. The insurancecommissioner may adopt rules that include standards for full and fair disclosure setting forth the<br>manner, content, and required disclosures for the sale of long-term care insurance policies,<br>terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage<br>provisions,coverageofdependents,preexistingconditions,terminationofinsurance,continuation or conversion, probationary periods, limitations, exceptions, reductions, elimination<br>periods, requirements for replacement, recurrent conditions, and definitions of terms.26.1-45-04.1.Adoption of long-term care benefits comparison guides bycommissioner.The insurance commissioner shall adopt rules to create a long-term carebenefits comparison guide to be presented at the point of sale between the client and insurance<br>producer. The guide must include information regarding nursing home coverage and alternatives<br>to nursing home coverage.26.1-45-05. Cancellation - Nonrenewal - Termination. No long-term care insurancepolicy may:Page No. 31.Be canceled, nonrenewed, or otherwise terminated on the grounds of the age or the<br>deterioration of the mental or physical health of the insured individual or certificate<br>holder.2.Contain a provision establishing a new waiting period in the event existing coverage<br>is converted to or replaced by a new or other form within the same company, except<br>with respect to an increase in benefits voluntarily selected by the insured individual<br>or group policyholder.3.Provide coverage for skilled nursing care only or provide significantly more coverage<br>for skilled care in a facility than coverage for lower levels of care.26.1-45-05.1. Incontestability and rescission of long-term care insurance policy orcertificate.1.If a policy or certificate has been in force for less than six months, an insurer may<br>not rescind a long-term care insurance policy or certificate or deny an otherwise<br>valid long-term care insurance claim except upon a showing of misrepresentation<br>that is material to the acceptance for coverage.2.If a policy or certificate has been in force for at least six months but less than two<br>years, an insurer may not rescind a long-term care insurance policy or certificate or<br>deny an otherwise valid long-term care insurance claim except upon a showing of<br>misrepresentation that is both material to the acceptance for coverage and that<br>pertains to the condition for which benefits are sought.3.If a policy or certificate has been in force for two years, the policy or certificate may<br>be contested only upon a showing that the insured knowingly and intentionally<br>misrepresented relevant facts relating to the insured's health.The policy orcertificate may not be contested based upon misrepresentation alone.4.A long-term care insurance policy or certificate may not be field-issued based on<br>medical or health status. For purposes of this section, &quot;field-issued&quot; means a policy<br>or certificate issued by an agent or a third-party administrator pursuant to the<br>underwriting authority granted to the agent or third-party administrator by an insurer.5.If an insurer has paid benefits under the long-term care insurance policy or<br>certificate, the benefit payments may not be recovered by the insurer in the event<br>that the policy or certificate is rescinded.6.In the event of the death of the insured, this section does not apply to the remaining<br>death benefit of a life insurance policy that accelerates benefits for long-term care.<br>In this situation, the remaining death benefits under these policies are governed by<br>section 26.1-33-05.In all other situations, this section applies to life insurancepolicies that accelerate benefits for long-term care.26.1-45-05.2. Nursing home policy - Guaranteed renewable for life - Limitation onpreexisting conditions. Any long-term care insurance policy or certificate providing benefits for<br>confinement to a nursing home must be guaranteed renewable for life. For purposes of this<br>section, &quot;guaranteed renewable for life&quot; means the insured has the right to continue the policy in<br>force for life subject to the policy's terms by the timely payment of premiums during which the<br>insurer has no right to make unilaterally any change in any provision of the policy while the policy<br>is in force. The insurer may, however, in accordance with the provisions of the policy, make<br>changes in premium rates as to all insureds who are placed in the same class for purposes of<br>rate determination in the process of issuance of the policy or making it guaranteed renewable.A policy or certificate of insurance providing benefits for confinement to a nursing homewhich is sold to a consumer in addition to another nursing home policy or which is sold to a<br>consumer to replace such a policy may not contain any provision limiting payment of benefits duePage No. 4to preexisting conditions of the insured except if there is any time period remaining relating to the<br>exclusion of coverage for preexisting conditions as specified in the underlying policy that the<br>remaining waiting period for coverage of preexisting conditions shall apply to the new policy<br>unless the policy otherwise provides.26.1-45-06. Preexisting conditions.1.No long-term care insurance policy or certificate other than a policy or certificate<br>issued to a group as defined in subdivision a of subsection 3 of section 26.1-45-01<br>may define &quot;preexisting condition&quot; as more restrictive than meaning a condition for<br>which medical advice or treatment was recommended by, or received from a<br>provider of health care services, within six months preceding the effective date of<br>coverage of an insured person.2.No long-term care insurance policy or certificate issued on a group long-term care<br>insurance policy other than a policy or certificate issued to a group as defined in<br>subdivision a of subsection 3 of section 26.1-45-01 may exclude coverage for a loss<br>or confinement that is the result of a preexisting condition unless the loss or<br>confinement begins within six months following the effective date of coverage of an<br>insured person.3.The commissioner may extend the limitation periods set forth in this section as to the<br>specific age group categories or specific policy forms upon findings that the<br>extension is in the best interest of the public.4.The limitation on defining a preexisting condition does not prohibit an insurer from<br>using an application form designed to elicit the complete health history of an<br>applicant, and, on the basis of the answers on that application, from underwriting in<br>accordance with that insurer's established underwriting standards. Unless otherwise<br>provided in the policy or certificate, a preexisting condition, regardless of whether it<br>is disclosed on the application, need not be covered until the waiting period<br>described in subsection 2 expires. No long-term care insurance policy or certificate<br>may exclude or use waivers or riders of any kind to exclude, limit, or reduce<br>coverage or benefits for specifically named or described preexisting diseases or<br>physical conditions beyond the waiting period described in subsection 2.26.1-45-07. Prior institutionalization requirement prohibited.1.No long-term care insurance policy or certificate may be delivered or issued for<br>delivery in this state if such policy:a.Conditions eligibility for any benefits on a prior hospitalization requirement.b.Conditions eligibility for benefits provided in an institutional care setting on the<br>receipt of a higher level of such institutional care.c.Conditions eligibility for any benefits other than waiver of premium,<br>postconfinement, postacute care, or recuperative benefits on a prior<br>institutionalization requirement.2.a.A long-term care insurance policy containing postconfinement, postacute care,<br>or recuperative benefits must clearly label in a separate paragraph of the policy<br>or certificate entitled &quot;limitations or conditions on eligibility for benefits&quot; such<br>limitations or conditions, including any required number of days of confinement.b.A long-term care insurance policy or rider which conditions eligibility of<br>noninstitutional benefits on the prior receipt of institutional care may not require<br>a prior institutional stay of more than thirty days.Page No. 53.No long-term care insurance policy or rider which provides benefits only following<br>institutionalization may condition such benefits upon admission to a facility for the<br>same or related conditions within a period of less than thirty days after discharge<br>from the institution.26.1-45-08.Loss ratio standards.The commissioner may adopt or amend rulesestablishing loss ratio standards for long-term care insurance policies; provided, that a specific<br>reference to long-term care insurance policies is contained in the rules.26.1-45-09.Right to return policy - Outline of coverage required - Contents ofcertificate - Summary of policy provisions - Report of benefits status.1.Long-term care insurance applicants have the right to return the policy or certificate<br>within thirty days of the date of its delivery or within thirty days of its effective date,<br>whichever occurs later, and to have the premium refunded if, after examination of<br>the policy or certificate, the applicant is not satisfied for any reason. Long-term care<br>insurance policies and certificates must have a notice prominently printed on the first<br>page or attached thereto stating in substance that the applicant has the right to<br>return the policy or certificate within thirty days of the date of its delivery or within<br>thirty days of its effective date, whichever occurs later, and to have the premium<br>refunded if, after examination of the policy or certificate, other than a certificate<br>issued pursuant to a policy issued to a group defined in subdivision a of subsection 3<br>of section 26.1-45-01, the applicant is not satisfied for any reason.2.a.An outline of coverage must be delivered to a prospective applicant for<br>long-term care insurance at the time of initial solicitation through means that<br>prominently direct the attention of the recipient to the document and its<br>purpose.(1)The commissioner shall prescribe a standard format, including style,<br>arrangement, overall appearance, and the content of an outline of<br>coverage.(2)In the case of insurance producer solicitations, an insurance producer<br>must deliver the outline of coverage prior to the presentation of an<br>application or enrollment form.(3)In the case of direct response solicitations, the outline of coverage must<br>be presented in conjunction with any application or enrollment form.(4)In the case of a policy issued to a group defined in subdivision a of<br>subsection 3 of section 26.1-45-01, an outline of coverage is not required<br>to be delivered, provided that the information described in paragraphs 1<br>through 7 of subdivision b is contained in other materials relating to<br>enrollment. Upon request, these other materials must be made available<br>to the commissioner.b.The outline of coverage must include:(1)A description of the principal benefits and coverage provided in the<br>policy.(2)A statement of the principal exclusions, reductions, and limitations<br>contained in the policy.(3)A statement of the terms under which the policy or certificate, or both,<br>may be continued in force or discontinued, including any reservation in<br>the policy of a right to change premium.Continuation or conversionprovisions of group coverage must be specifically described.Page No. 6(4)A statement that the outline of coverage is a summary only, not a<br>contract of insurance, and that the policy or group master policy contains<br>the governing contractual provisions.(5)A description of the terms under which the policy or certificate may be<br>returned and premium refunded.(6)A brief description of the relationship of cost of care and benefits.(7)A statement that discloses to the policyholder or certificate holder<br>whether the policy is intended to be a federally tax-qualified long-term<br>care insurance contract under 7702B(b) of the Internal Revenue Code of<br>1986, as amended.3.A certificate issued pursuant to a group long-term care insurance policy which policy<br>is delivered or issued for delivery in this state must include:a.A description of the principal benefits and coverage provided in the policy.b.A statement of the principal exclusions, reductions, and limitations contained in<br>the policy.c.A statement that the group master policy determines governing contractual<br>provisions.4.If an application for a long-term care insurance contract or certificate is approved<br>and issued, the issuer, directly or through an authorized representative, shall deliver<br>the contract or certificate of insurance to the applicant no later than thirty days after<br>the date of approval.5.At the time of policy delivery, a policy summary must be delivered for an individual<br>life insurance policy which provides long-term care benefits within the policy or by<br>rider. In the case of direct response solicitations, the insurer shall deliver the policy<br>summary upon the applicant's request, but regardless of request shall make such<br>delivery no later than at the time of policy delivery. In addition to complying with all<br>applicable requirements, the summary must also include:a.An explanation of how the long-term care benefit interacts with other<br>components of the policy, including deductions from death benefits;b.An illustration on the amount of benefits, the length of benefit, and the<br>guaranteed lifetime benefits, if any, for each covered person;c.Any exclusions, reductions, and limitations on benefits of long-term care;d.A statement as to whether a long-term care inflation protection option is<br>available under this policy;e.If applicable to the policy type, the summary shall also include:(1)A disclosure of the effects of exercising other rights under the policy;(2)A disclosure of guarantees relating to long-term care costs of insurance<br>charges; and(3)Current and projected maximum lifetime benefits; andPage No. 7f.The provisions of the policy summary listed above may be incorporated into a<br>basic illustration or into a life insurance policy summary delivered to the<br>consumer.6.Any time a long-term care benefit, funded through a life insurance vehicle by the<br>acceleration of the death benefit, is in benefit payment status a monthly report must<br>be provided to the policyholder. Such report must include:a.Any long-term care benefits paid out during the month;b.An explanation of any changes in the policy, e.g., death benefits or cash values,<br>due to long-term care benefits being paid out; andc.The amount of long-term care benefits existing or remaining.7.If a claim under a long-term care insurance contract is denied, the issuer shall, within<br>sixty days of the date of a written request by the policyholder or certificate holder, or<br>a representative thereof:a.Provide a written explanation of the reasons for the denial; andb.Make available all information directly related to the denial.26.1-45-10.Application.Any policy or rider advertised, marketed, or offered aslong-term care or nursing home insurance must comply with the provisions of this chapter and all<br>other applicable insurance laws insofar as they do not conflict with this chapter.26.1-45-11. Rulemaking authority. The commissioner may adopt reasonable rules topromote premium adequacy, protect the policyholder in the event of substantial rate increases,<br>and to establish minimum standards for correcting abusive marketing practices, replacement<br>forms, insurance producer testing, penalties, and reporting practices for long-term care<br>insurance.26.1-45-12. Penalties. In addition to any other penalties provided by the laws of thisstate, any insurer and any insurance producer found to have violated any requirement of this title<br>relating to the regulation of long-term care insurance or the marketing of such insurance shall be<br>subject to a fine of up to three times the amount of any commissions paid for each policy<br>involved in the violation or up to ten thousand dollars, whichever is greater.26.1-45-13. Qualified service providers. Any insurance company providing long-termcare coverage for home and community-based services shall pay a provider meeting qualified<br>service provider standards a daily payment allowance as defined in the policy or certificate.<br>&quot;Qualified service provider&quot; means a county agency or independent contractor that agrees to<br>meet standards for personal attendant care service as established by the department of human<br>services.26.1-45-14. Nonforfeiture benefits.1.Except as provided in subsection 2, a long-term care insurance policy may not be<br>delivered or issued for delivery in this state unless the policyholder or certificate<br>holder has been offered the option of purchasing a policy or certificate, including a<br>nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a<br>rider that is attached to the policy. In the event the policyholder or certificate holder<br>declines the nonforfeiture benefits, the insurer shall provide a contingent benefit<br>upon lapse that is available for a specific period of time following a substantial<br>increase in premium rates.2.When a group long-term care insurance policy is issued, the offer required in<br>subsection 1 must be made to the group policyholder.However, if the policy isPage No. 8issued as group long-term care insurance as defined in subdivision d of subsection 3<br>of section 26.1-45-01, other than to a continuing care retirement community or other<br>similar entity, the offering must be made to each proposed certificate holder.3.The commissioner shall adopt rules specifying the type of nonforfeiture benefits to<br>be offered as part of long-term care insurance policies and certificates, the<br>standards for nonforfeiture benefits, and the rules regarding contingent benefit upon<br>lapse, including a determining of the specific period of time during which a<br>contingent benefit upon lapse will be available and the substantial premium rate<br>increase that triggers a contingent benefit upon lapse as described in subsection 1.Page No. 9Document Outlinechapter 26.1-45 long-term care insurance