3 AAC 28 — Life, Health, Variable, and Related Insurance (Article 1 to 13)

In this chapter, (1) "applicant" has the meaning given in AS 21.53.200(1); (2) "benefit trigger", for the purposes of independent review, means a contractual provision in the insured's policy of long-term care insurance conditioning the payment of benefits on a determination of t…

The 1983 Table "a", the 1983 GAM Table, the Annuity 2000 Mortality Table, the 2012 lAR Table, and the 1994 GAR Table for mortality rates are adopted by reference and are recognized for use in determining the minimum standard of valuation for annuity and pure endowment contracts. …

(a) Except as provided in (b) and (c) of this section, the 1983 Table "a" is recognized and approved as an individual annuity mortality table for valuation and, at the option of the insurance company, may be used to determine the minimum standard of valuation for any individual a…

(a) Except as provided in (b) and (c) of this section, the 1983 GAM Table, the 1983 Table "a", and the 1994 GAR Table are recognized and approved as group annuity mortality tables for valuation and, at the option of the insurance company, any one of these tables may be used to de…

In using the 1994 GAR Table, the mortality rate for a person age x in year (1994 + n) is calculated as follows: q x 1994+n = q x 1994 (1-AAx) n where q x 1994 and AAx are as specified in the 1994 GAR Table. Notes 3 AAC 28.610 Eff. 12/31/85, Register 96; am 3/11/98, Register 145 T…

In using the 2012 lAR Table, the mortality rate for a person age x in year (2012 + n) is calculated as follows: qx2012+n = qx2012 (1 - G2x)n The resulting qx2012+n must be rounded to three decimal places per 1,000, for example, 0.741 deaths per 1,000. Also, the rounding must occu…

If any provision of 3 AAC 28.600 - 3 AAC 28.611, or 3 AAC 28.690, or the application of it to any person or circumstances is for any reason held to be invalid, the remainder of the section and the application of its provisions to other persons or circumstances is not affected by …

(a) Except as provided in (g) of this section, the 2001 CSO Mortality Tables are adopted by reference and are recognized for use under (b) and (c) of this section in determining the minimum standard of valuation for policies for which AS 21.18.110(b)(1)(A)(iii) and AS 21.45.300(t…

(a) At the election of an insurer, for each calendar year of issue, for any one or more specified plans of insurance and subject to the conditions set out in (b) and (c) of this section, the insurer may substitute, as the minimum valuation standard for policies issued on or after…

The 2001 CSO Mortality Tables may be used in complying with 3 AAC 21.900 - 3 AAC 21.949 subject to the following: (1) the net level reserve premium under 3 AAC 21.900(2) (B) must be based on the ultimate mortality rates in the 2001 CSO Mortality Tables; (2) calculations under 3 A…

(a) An insurer may elect to use a gender-blended mortality table for determining minimum cash surrender values and amounts of paid-up nonforfeiture benefits for each plan of insurance if the (1) same premium rates and charges are used for male and female lives; or (2) insurer is …

In this chapter, (1) "the 1983 Table 'a'" means the mortality table developed by the Society of Actuaries Committee to Recommend a New Mortality Basis for Individual Annuity Valuation, and adopted as a recognized mortality table for annuities in June 1982 by the National Associat…

(a)3 AAC 28.700 - 3 AAC 28.725 apply to all insurers transacting health insurance in this state for claims that are paid on an expense-incurred basis. (b)3 AAC 28.700 - 3 AAC 28.725 do not apply to claims for vision care or drugs, or to benefits paid on other than an expense-incu…

(a) An insurer shall accept a properly completed claim submitted on the applicable uniform form set out in Uniform Claim Forms for Health Insurance, dated June 23, 1995 and hereby adopted by reference. A properly completed claim includes (1) completion of a uniform claim form wit…

For purposes of 3 AAC 28.700 - 3 AAC 28.725, "health insurance" means an individual or group contract or other plan providing coverage for health care services that is issued by an insurer licensed to transact the business of health insurance; a health maintenance organization un…

(a) A health care insurer that offers, issues for delivery, delivers, or renews a health care insurance plan that provides coverage for prescription drugs or devices and that issues, uses, requires, or reissues a card for prescription claims processing shall issue to a covered in…

A health care insurer must comply with 3 AAC 28.740 for new policies issued on or after 12 months from the effective date of 3 AAC 28.740 and for renewal policies on the first renewal date after 12 months from the effective date of 3 AAC 28.740. Notes 3 AAC 28.745 Eff. 9/15/2004,…

The purpose of 3 AAC 28.800 - 3 AAC 28.849 is to protect the public from false, misleading, or deceptive illustrations of life insurance policies by (1) providing formats for life insurance policy illustrations; (2) specifying the disclosures that are required for life insurance …

(a)3 AAC 28.800 - 3 AAC 28.849 apply to all group and individual life insurance policies and certificates except (1) variable life insurance; (2) individual and group annuity contracts; (3) credit life insurance under AS 21.57; and (4) individual and group life insurance policies…

(a) When a policy form subject to 3 AAC 28.800 - 3 AAC 28.849 is filed under AS 21.42.120, the insurer marketing that policy form shall notify the director in writing whether the policy form will be marketed with or without an illustration. For a policy form subject to 3 AAC 28.8…

(a) Failure to comply with 3 AAC 28.800 - 3 AAC 28.849 is a violation of AS 21.36.020 and 21.36.030. (b) An illustration used in the sale of a life insurance policy must satisfy the requirements of 3 AAC 28.800 - 3 AAC 28.849, be clearly labeled "life insurance illustration," and…

(a) Format. A basic illustration must conform with the following requirements: (1) the terms used in an illustration must be consistent with the terms used in the policy that is being illustrated; (2) an illustration must be labeled with the date on which it was prepared; (3) eac…

(a) A supplemental illustration may be provided if: (1) it is appended to, accompanied by, or preceded by a basic illustration that complies with 3 AAC 28.800 - 3 AAC 28.849; (2) the non-guaranteed elements shown in the supplemental illustration are not more favorable to the poli…

(a) If a basic illustration is used in the solicitation of a life insurance policy that is applied for as illustrated, the person soliciting the policy must provide a copy of that illustration, signed as required under 3 AAC 28.820, to the applicant at the time of application and…

(a) If a policy is designated as one for which an illustration will be used, the insurer shall provide each policy owner with an annual report on the status of the policy that contains at least the following information: (1) for a universal life policy, the report must include (A…

(a) The board of directors of an insurer shall appoint one or more illustration actuaries. The illustration actuary or actuaries shall annually certify that the disciplined current scale used in each illustration in current use, as well as those used since the prior certification…

(a) In determining the disciplined current scale, an insurer may rely on the standards established by the Actuarial Standards Board if the standards (1) conform with the requirements of 3 AAC 28.800 - 3 AAC 28.849; (2) limit a disciplined current scale to reflect only actions tha…

For the purposes of 3 AAC 28.800 - 3 AAC 28.849, (1) "Actuarial Standards Board" means the board established by the American Academy of Actuaries to develop and adopt standards of actuarial practice; (2) "basic illustration" means a presentation or depiction used in the sale of a…

3 AAC 28.900 - 3 AAC 28.918 apply to (1) a health care insurer that (A) transacts health care insurance in this state; and (B) provides or performs utilization review services; (2) a designee of the health care insurer under (1) of this section, including a utilization review org…

A health care insurer shall (1) monitor all utilization review activities carried out by, or on behalf of, the health care insurer; (2) ensure that the requirements of 3 AAC 28.900 - 3 AAC 28.918 are met; and (3) ensure that appropriate personnel have operational responsibility f…

If a health care insurer contracts to have a utilization review organization or other entity perform the utilization review functions required under 3 AAC 28.900 - 3 AAC 28.918, the director will (1) hold the health care insurer responsible for monitoring the activities of the ut…

(a) A health care insurer that requires utilization review of a benefit request under a health care insurance policy shall develop and implement a written utilization review program that describes, at a minimum, the following utilization review activities: (1) filing of a benefit…

(a) A utilization review program must use documented clinical review criteria that are (1) based on sound clinical evidence; and (2) evaluated periodically by a health care insurer's organizational mechanism specified under 3 AAC 28.906(b)(6) to ensure the program's effectiveness…

(a) A health care insurer shall establish and maintain written procedures for (1) receiving a benefit request from a covered person or the covered person's authorized representative; (2) making a standard utilization review and benefit determination; and (3) notifying a covered p…

(a) A health care insurer shall establish and maintain written procedures for (1) receiving a benefit request from a covered person or the covered person's authorized representative; (2) making an expedited utilization review and benefit determination with respect to(A) an urgent…

(a) A health care insurer shall follow the provisions of this section when conducting a utilization review or making a benefit determination for emergency services. (b) A health care insurer shall cover emergency services to screen and stabilize a covered person (1) without the n…

A health care insurer shall annually certify in writing to the director that the utilization review program of the health care insurer or the health care insurer's designee complies with all applicable state and federal laws that establish confidentiality and reporting requiremen…

(a) A health care insurer shall set out in, or attach to, a policy, certificate of coverage, membership booklet, or other evidence of coverage provided to a covered person by a health care insurer a clear and comprehensive description of the health care insurer's utilization revi…

Except as otherwise provided, 3 AAC 28.930- 3 AAC 28.938 apply to a health care insurer transacting health care insurance in this state. Notes 3 AAC 28.930 Eff. 3/15/2018,Register 225, April 2018 Authority:AS 21.06.090 AS 21.07.005

(a) A health care insurer shall maintain a written calendar year register, in a manner that is reasonably clear and accessible to the director, to document (1) each grievance received; (2) a general description of the reason for the grievance; (3) the date the grievance was recei…

(a) Except as specified under 3 AAC 28.938, a health care insurer shall use written procedures for receiving and resolving a grievance under 3 AAC 28.930 - 3 AAC 28.938. (b) A covered person will be considered to have exhausted the provisions of 3 AAC 28.930 - 3 AAC 28.938 if a h…

(a) A covered person or the covered person's authorized representative may file a grievance with a health care insurer requesting a review of an adverse determination, The covered person or the covered person's authorized representative shall file the request not later than 180 d…

(a) A health care insurer shall establish written procedures for the expedited review of an urgent care request of a grievance involving an adverse determination. The procedures must allow a covered person or the covered person's authorized representative to request an expedited …

(a) Except under (b) of this section, 3 AAC 28.950-3 AAC 28.982 apply to a health care insurer that transacts health care insurance in this state. (b) The provisions of 3 AAC 28.950 - 3 AAC 28.982 do not apply to (1) a policy or certificate that provides coverage only for a speci…

(a) A health care insurer shall notify a covered person or the covered person's authorized representative in writing of the covered person's right to request an external review under 3 AAC 28.958 - 3 AAC 28.962. A health care insurer shall provide the notice of the right to reque…

(a) A covered person or the covered person's authorized representative may make a request to the director for an external review of an adverse determination or a final adverse determination. Except for a request for an expedited external review, a covered person or the covered pe…

(a) Except as otherwise provided under this section, before making a request for an external review, a covered person or the covered person's authorized representative must exhaust a health care insurer's internal grievance process under 3 AAC 28.930 - 3 AAC 28.938. (b) A covered…