Disclosure and performance standards for limited long-term care insurance.
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(1) A limited long-term care insurance policy may not:
(a) be cancelled, nonrenewed, or otherwise terminated because of the age, gender, or the deterioration of the mental or physical health of the insured individual or certificate holder;
(b) contain a provision establishing a new waiting period if existing coverage is converted to or replaced by a new or other form within the same insurer, or the insurer's affiliates, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or
(c) provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care.
(2)
(a) A limited long-term care insurance policy or certificate may not:
(i) use a definition of "preexisting condition" that is more restrictive than the definition under this part; or
(ii) exclude coverage for a loss or confinement that is the result of a preexisting condition, unless the loss or confinement begins within six months after the day on which the coverage of the insured person becomes effective.
(b) A preexisting condition does not prohibit an insurer from:
(i) using an application form designed to elicit the complete health history of an applicant; or
(ii) on the basis of the answers on the application described in Subsection (2)(b)(i), underwriting in accordance with the insurer's established underwriting standards.
(c)
(i) Unless otherwise provided in the policy or certificate, an insurer may exclude coverage of a preexisting condition:
(A) for a time period of six months, beginning the day on which the coverage of the insured person becomes effective; and
(B) regardless of whether the preexisting condition is disclosed on the application.
(ii) A limited long-term care insurance policy or certificate may not exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions for more than a time period of six months, beginning the day on which the coverage of the insured person becomes effective.
(3)
(a) An insurer may not deliver or issue for delivery a limited long-term care insurance policy that conditions eligibility for any benefits:
(i) on a prior hospitalization requirement;
(ii) provided in an institutional care setting, on the receipt of a higher level of institutional care; or
(iii) other than waiver of premium, post-confinement, post-acute care, or recuperative benefits, on a prior institutionalization requirement.
(b) A limited long-term care insurance policy or rider may not condition eligibility for noninstitutional benefits on the prior or continuing receipt of skilled care services.
(4)
(a) If, after examination of a policy, certificate, or rider, a limited long-term care insurance applicant is not satisfied for any reason, the applicant has the right to:
(i) within 30 days after the day on which the applicant receives the policy, certificate, endorsement, or rider, return the policy, certificate, endorsement, or rider to the company or a producer of the company; and
(ii) have the premium refunded.
(b)
(i) Each limited long-term care insurance policy, certificate, endorsement, and rider shall:
(A) have a notice prominently printed on the first page or attached thereto detailing specific instructions to accomplish a return; and
(B) include the following free-look statement or language substantially similar: "You have 30 days from the day on which you receive this policy certificate, endorsement, or rider to review it and return it to the company if you decide not to keep it. You do not have to tell the company why you are returning it. If you decide not to keep it, simply return it to the company at its administrative office. Or you may return it to the producer that you bought it from. You must return it within 30 days of the day you first received it. The company will refund the full amount of any premium paid within 30 days after it receives the returned policy, certificate, or rider. The premium refund will be sent directly to the person who paid it. The policy certificate or rider will be void as if it had never been issued."
(ii) The requirements described in Subsection (4)(b)(i) do not apply to a certificate issued to an employee under an employer group limited long-term care insurance policy.
(5)
(a)
(i) An insurer shall deliver an outline of coverage to a prospective applicant for limited long-term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and the document's purpose.
(ii) In the case of an agent solicitation, the agent shall deliver the outline of coverage before the presentation of an application or enrollment form.
(iii) In the case of a direct response solicitation, the outline of coverage shall be presented in conjunction with any application or enrollment form.
(iv)
(A) In the case of a policy issued to a group, the outline of coverage is not required to be delivered if the information described in Subsections (5)(b)(i) through (iii) is contained in other materials relating to enrollment, including the certificate.
(B) Upon request, an insurer shall make the other materials described in this Subsection (5)(a)(iv) available to the commissioner.
(b) An outline of coverage shall include:
(i) a description of the principal benefits and coverage provided in the policy;
(ii) a description of the eligibility triggers for benefits and how the eligibility triggers are met;
(iii) a statement of the principal exclusions, reductions, and limitations contained in the policy;
(iv) a statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium.
(v) a specific description of each continuation or conversion provision of group coverage;
(vi) a statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;
(vii) a description of the terms under which a person may return the policy or certificate and have the premium refunded;
(viii) a brief description of the relationship of cost of care and benefits; and
(ix) a statement that discloses to the policyholder or certificate holder that the policy is not long-term care insurance.
(6) A certificate pursuant to a group limited long-term care insurance policy that is delivered or issued for delivery in this state shall 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 the policy; and
(c) a statement that the group master policy determines governing contractual provisions.
(7) If an application for a limited long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later that 30 days after the day on which the application is approved.