Chapter 20:06:21 — LONG-TERM CARE INSURANCE

20:06:21:71. Permitted compensation arrangements. No insurer or other entity may provide commission or other compensation greater than the renewal compensation, to a producer or other representative, for the sale of a long-term care insurance policy or certificate which replaces …

20:06:21:72. Disclosure to applicant for a claim denial. If a claim under a long-term care insurance contract is denied, the issuer shall, within 60 days of the date of a written request by the policyholder or certificateholder, or a representative thereof: (1) Provide a written …

20:06:21:73. Providers in a different state. No long-term care issuer may deny a claim because services are provided in a state other than the state of policy issue if the following conditions are met: (1) If the state other than the state of policy issue does not have the provid…

20:06:21:74. Producer training required to market long-term care plans. An individual may not sell, solicit, or negotiate long-term care insurance unless the individual: (1) Is licensed as a health or life producer; (2) Has completed a one-time, eight-hour training course prior t…

20:06:21:74.01. Long-term care plan training topics for producers. The training required under § 20:06:21:74 must consist of the following topics related to long-term care insurance and services, and, if applicable, qualified state long-term care insurance partnership programs: (…

20:06:21:75. Insurers required to verify agent training and maintain records. Any insurer subject to this chapter shall obtain verification that its agent receives training required by § 20:06:21:74 before the agent is permitted to sell, solicit, or negotiate the insurer's long-t…

20:06:21:76. Long-term care partnership policies -- Inflation protection requirements. An insurer may not issue a policy intended to qualify as a partnership policy unless in addition to the requirements of §§ 20:06:21:06 to 20:06:21:06.05, inclusive, the policy includes the foll…

20:06:21:77. Long-term care partnership policies -- Required policy disclosures. A policy, certificate, or contract designed or marketed as a long-term care partnership policy must prominently disclose on the schedule page the following: (1) The [policy, certificate, or contract]…

20:06:21:78. Long-term care partnership policies -- Filing requirements. Schedule pages issued in compliance with § 20:06:21:77 are not required to be re-filed for approval. An informational filing notifying the division that the language specified in § 20:06:21:78 will be used m…

20:06:21:79. Long-term care -- Minimum benefit requirements. Any long-term care policy, certificate, or contract issued in this state must contain at least one year of nursing facility coverage. A daily benefit of not less than $100 per day must be included in the policy, certifi…

20:06:21:80. Long-term care partnership policies -- Policy amendments. Any amendment to the policy that alters the status of a partnership policy so that it no longer meets the applicable partnership standards must affirmatively disclose that fact and include an amended schedule …

20:06:21:81. Long-term care policies -- Policy amendments. No long-term care policy, certificate, or contract may be amended or benefits reduced pursuant to § 20:06:21:86 to: (1) Reduce the nursing home benefit to less than one year; (2) Reduce or delete benefits for assisted liv…

20:06:21:82. Availability of new services or providers. An insurer shall notify policyholders of the availability of a new long-term care policy series that provides coverage for new long-term care services or providers material in nature and not previously available through the …

20:06:21:83. Policies issued considered exchanges. Policies issued pursuant to § 20:06:21:82 are considered exchanges and not replacements. These exchanges are not subject to §§ 20:06:21:28.01, 20:06:21:53.01 to 20:06:21:53.04, inclusive, and the reporting requirements of § 20:06…

20:06:21:84. Policies offered through employers, labor unions, and associations. If the policy is offered through an employer, a labor organization, or a professional, trade, or occupational association, the required notification in § 20:06:21:82 shall be made to the offering ent…

20:06:21:85. Applicability of new provider or service requirements. Nothing in §§ 20:06:21:82 to 20:06:21:84, inclusive, prohibits an insurer from offering any policy, rider, certificate, or coverage change to any policyholder or certificateholder. However, upon request any polic…

20:06:21:86. Right to reduce coverage and lower premiums. Each long-term care insurance policy and certificate shall include a provision that allows the policyholder or certificateholder to reduce coverage and lower the policy or certificate premium in at least one of the followi…

20:06:21:87. Authorized representative. For purposes of §§ 20:06:21:87 to 20:06:21:104, inclusive, an authorized representative is a person authorized to act as the covered person's personal representative within the meaning of 45 CFR 164.502(g) promulgated by the Secretary under…

20:06:21:88. Notice to insured. If an insurer determines that the benefit trigger of a long-term care insurance policy has not been met, the insurer shall provide a clear, written notice to the insured and the insured's authorized representative, if applicable, of all of the foll…

20:06:21:89. Internal appeal. The insured or the insured's authorized representative may appeal the insurer's adverse benefit trigger determination by sending a written request to the insurer, along with any additional supporting information, within 120 calendar days after the in…

20:06:21:90. Internal appeal notice requirements. If the insurer's original determination is upheld upon internal appeal, the notice of the internal appeal decision shall describe any additional internal appeal rights offered by the insurer. Nothing in this chapter requires the i…

20:06:21:91. Independent review of benefit trigger determination. The insured or the insured's authorized representative may request an independent review of the insurer's benefit trigger determination after the internal appeal process outlined in §§ 20:06:21:89 and 20:06:21:90 h…

20:06:21:92. Independent review process. Within five business days of receiving a written request for independent review, the insurer shall refer the request to the independent review organization that the insured or the insured's authorized representative has chosen from the lis…

20:06:21:93. Additional appeal information. If the insured or the insured's authorized representative has new or additional information not previously provided to the insurer, whether submitted to the insurer or the independent review organization, such information shall first be…

20:06:21:94. Independent review notification. The insurer shall acknowledge in writing to the insured and the insured's authorized representative, if applicable, and the director that the request for independent review has been received, accepted, and forwarded to an independent …

20:06:21:95. Independent review organization selection. Within five business days of receipt of the request for independent review, the independent review organization assigned pursuant to this section shall notify the insured and the insured's authorized representative, if appli…

20:06:21:96. Review of information. The independent review organization shall review all of the information and documents received pursuant to § 20:06:21:95 that have been provided to the independent review organization. The independent review organization shall provide copies of…

20:06:21:97. Additional information to independent review. The insured or the insured's authorized representative may submit, at any time, new or additional information not previously provided to the insurer but pertinent to the benefit trigger denial. The insurer shall consider …

20:06:21:98. Process if determination overturned. If the insurer overturns its benefit trigger determination: (1) The insurer shall provide notice to the independent review organization and the insured and the insured's authorized representative, if applicable, and the director o…

20:06:21:99. Review decision requirements. The independent review organization shall provide the insured and the insured's authorized representative, if applicable, the insurer, and the director written notice of its decision, within 30 calendar days from receipt of the referral …