Section 2012.10  Purpose

 

The purpose of this Part is to implement Article XIXA of the Illinois Insurance Code, to promote the public interest, to promote the availability of long-term care insurance coverage, to protect applicants for long-term care insurance from unfair or deceptive sales or enrollment practices, to facilitate public understanding and comparison of long-term care insurance coverages and to facilitate flexibility and innovation in the development of long-term care insurance.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.20  Applicability and Scope

 

a)         Except as otherwise specifically provided, this Part applies to all long-term care insurance policies including qualified long-term care insurance contracts and life insurance policies that accelerate benefits for long-term care insurance delivered or issued for delivery in this State by any insurer on or after June 15, 1990.  Certain provisions of this Part apply only to qualified long-term care insurance contracts as noted.

 

b)         Additionally, this Part is intended to apply to policies having indemnity benefits that are triggered by activities of daily living and sold as disability income insurance, if:

 

1)         The benefits of the disability income policy are dependent upon or vary in amount based on the receipt of long-term care services;

 

2)         The disability income policy is advertised, marketed or offered as insurance for long-term care services; or

 

3)         Benefits under the policy may commence after the policyholder has reached Social Security's normal retirement age unless benefits are designed to replace lost income or pay for specific expenses other than long-term care services.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.30  Definitions

 

"Accelerated Long-Term Care Benefit" means a life insurance policy, contract, rider endorsement or amendment that contains benefits providing payment from life or endowment or annuity benefits in advance of the time they would otherwise be payable at any time during the insured's lifetime as an indemnity for long-term care.

 

"Applicant", as defined in Section 351A-1 of the Illinois Insurance Code, means:

 

in the case of an individual long-term care insurance policy, the person who seeks to contract for benefits;

 

in the case of a group long-term care insurance policy, the proposed certificateholder.

 

"Certificate", as defined in Section 351A-1 of the Illinois Insurance Code, means any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this State.

 

"Chronically Ill Individual", for all long-term care policies that are marketed as "qualified" pursuant to the Internal Revenue Code of 1986, as amended (26 USC 7702B(c)(2)(A)), means any individual who has been certified by a licensed health care practitioner as:

 

being unable to perform (without substantial assistance from another individual) at least 2 activities of daily living for a period of at least 90 days due to a loss of functional capacity;

 

having a level of disability similar (as determined under regulations prescribed by the Secretary in consultation with the Secretary of Health and Human Services) to the level of disability described in the preceding paragraph; or

 

requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment.

 

The term does not include any individual otherwise meeting the requirements of this definition unless within the preceding 12-month period a licensed health care practitioner has certified that the individual meets these requirements.

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Director" means the Director of the Illinois Department of Insurance. 

 

"Exceptional Increase" means only those increases filed by an insurer as exceptional for which the Director determines the need for the premium rate increase is justified due to changes in laws or regulations applicable to long-term care coverage in this State, or to increased and unexpected utilization that affects the majority of insurers of similar products.

 

Except as provided in Sections 2012.112 and 2012.113, exceptional increases are subject to the same requirements as other premium rate schedule increases found in Section 2012.112 or 2012.113.

 

The Director may request a review by an independent actuary or a professional actuarial body of the basis for a request that an increase be considered an exceptional increase.

 

The Director, in determining that the necessary basis for exceptional increase exists, shall also determine any potential offsets to higher claims costs.

 

"Group Long-Term Care Insurance", as defined in Section 351A-1 of the Code [215 ILCS 5/351A-1], means a long-term care insurance policy which is delivered or issued for delivery in this State and issued to one of the following:

 

One or more employers or labor organizations, or to a trust or to the trustee(s) of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

 

Any professional, trade or occupational association for its members or former or retired members, or combination thereof, if such association:

 

is composed of individuals all of whom are or were actively engaged in the same profession, trade or occupation; and

 

has been maintained in good faith for purposes other than obtaining insurance.

 

An association or a trust or the trustee(s) of a fund established, created or maintained for the benefit of members of one or more associations.  Prior to advertising, marketing or offering such policy within this State, the association or associations, or the insurer of the association or associations, shall file evidence with the Director that the association or associations have at the outset a minimum of 100 members and have been organized and maintained in good faith for purposes other than that of obtaining insurance; have been in active existence for at least one year; and have a constitution and by-laws which provide that:

 

the association or associations hold regular meetings not less than annually to further purposes of the members;

 

except for credit unions, the association or associations collect dues or solicit contributions from members; and

 

the members have voting privileges and representation on the governing board and committees.

 

Thirty days after such filing the association or associations will be deemed to satisfy such organizational requirements, unless the Director makes a finding that the association or associations do not satisfy those organizational requirements.

 

A group other than as described in subparagraphs under the definition of Group Long-Term Care Insurance, subject to a finding by the Director that:

 

the issuance of the group policy is not contrary to the best interest of the public;

 

the issuance of the group policy would result in economies of acquisition or administration; and

 

the benefits are reasonable in relation to the premiums charged.

 

"Incidental", as used in Sections 2012.112(j) and 2012.113(j), means that the value of the long-term care benefit provided is less than 10% of the total value of the benefits provided over the life of the policy.  These values shall be measured as of the date of issue.

 

"Insurer" includes  insurance companies; fraternal benefit societies; nonprofit health, hospital, and medical service corporations; prepaid health plans; health maintenance organizations or any similar organization.

 

"Long-Term Care Insurance", as defined in Section 351A-1 of the Code, means any accident and health insurance policy or rider advertised, marketed, offered or designed to provide coverage for not less than 12 consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital.  The term includes group and individual annuities and life insurance policies or riders which provide directly or which supplement long-term care insurance.  The term also includes a policy or rider which provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. The term shall also include qualified long-term care insurance contracts.  Long-term care insurance may be issued by insurers, fraternal benefit societies, nonprofit health, hospital, and medical service corporations, prepaid health plans, health maintenance organizations or any similar organization, to the extent they are otherwise authorized to issue life or health insurance.  Long-term care insurance shall not include any insurance policy which is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset-protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage.  Long-term care insurance may include benefits for care and treatment in accordance with the tenets and practices of any established church or religious denomination which teaches reliance on spiritual treatment through prayer for healing.

 

"Maintenance or Personal Care Services", within the meaning of the Internal Revenue Code of 1986, as amended (26 USC 7702B(c)(3)), means any care the primary purpose of which is the provision of needed assistance with any of the disabilities as a result of which the individual is a chronically ill individual (including the protection from threats to health and safety due to severe cognitive impairment).

 

"Policy", as defined in Section 351A-1 of the Illinois Insurance Code, means any policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery in this State by an insurer, fraternal benefit society, non-profit health, hospital, or medical service corporation, prepaid health plan, health maintenance organization or any similar organization.

 

"Qualified Actuary" means a member in good standing of the American Academy of Actuaries.

 

"Qualified Long-Term Care Contract" has the same meaning as that for a "Qualified long-term care insurance contract" described in Section 351A-1 of the Code.

 

"Qualified Long-Term Care Insurance Partnership Policy" means a policy that meets all of the following requirements:

 

It covers an insured who was a resident of Illinois when coverage first became effective under the policy;

 

It is a qualified long-term care insurance policy as defined in section 7702B(b) of the Internal Revenue Code of 1986 issued not earlier than the effective date of the State plan amendment;

 

It meets the model regulations and requirements of the National Association of Insurance Commissioners model specified in paragraph (5) of Title VI, section 6021 of the federal Deficit Reduction Act of 2005 (42 USC 1305), and the Director of the Department of Insurance certifies it as meeting these requirements; and

 

If the policy is sold to an individual who:

 

has not attained age 61 as of the date of purchase, the policy provides compound annual inflation protection;

 

has attained age 61 but has not attained age 76 as of the date of purchase, the policy provides some level of inflation protection; or

 

has attained age 76 as of the date of purchase, the policy may, but is not required to, provide some level of inflation protection.

 

"Qualified Long-Term Care Services" means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitation services, and maintenance or personal care services that are required by a chronically ill individual, that are provided pursuant to a plan of care prescribed by a licensed heath care practitioner.

 

"Respite Service" may include, but is not limited to, temporary care for insureds aimed at relieving stress for the insureds families.  Respite service shall be provided for vacation, rest, errands, family crisis or emergency.

 

"Similar Policy Forms" means all of the long-term care insurance policies and certificates issued by an insurer in the same long-term care benefit classification as the policy form being considered.  Certificates of groups that meet the definition of "Group Long-Term Care Insurance" found in Section 351A-1(e)(1) of the Code are not considered similar to certificates or policies otherwise issued as long-term care insurance, but are similar to other comparable certificates with the same long-term care benefit classifications.  For purposes of determining similar policy forms, long-term care benefit classifications are defined as follows:  institutional long-term care benefits only, non-institutional long-term care benefits only, or comprehensive long-term care benefits.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.40  Policy Definitions

 

a)         For policies issued after January 1, 2009, no long-term care insurance policy delivered or issued for delivery in this State shall use the terms set forth below, unless the terms are defined in the policy and the definitions satisfy the following requirements.

 

"Activities of Daily Living" means at least bathing, continence, dressing, eating, toileting and transferring.

 

"Acute Condition" means a condition that causes the individual to be medically unstable.  Such individual requires frequent monitoring by medical professionals, such as physicians and registered nurses, in order to maintain his or her health status.

 

"Adult Day Care" means a program, for 6 or more individuals, of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside the home.

 

"Assistive Equipment" may include, but is not limited to, tangible personal property with a useful life of at least one year, expressly designed and used for increasing independent functioning in specific tasks or activities of independent living in the home that directly results in a demonstrated decrease in need for assistance from another individual in performing certain tasks or activities.

 

"Bathing" means washing oneself by sponge bath, or in either a tub or shower, including the task of getting into or out of the tub or shower.

 

"Cognitive Impairment" means a deficiency in a person's short- or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.

 

"Continence" means the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).

 

"Dressing" means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.

 

"Eating" means feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously.

 

"Electronic Home Response Services" may include, but are not limited to, services designed to provide a 24 hour per day emergency communication link to assistance outside the home for individuals with such severe disabilities that they are incapable of using conventional or modified communication devices such as the telephone, and who have no other persons available in the home should an emergency arise.

 

"Hands-on Assistance" means physical assistance (minimal, moderate or maximal) without which the individual would not be able to perform the activity of daily living.

 

"Home Health Care Services" means medical and nonmedical services provided to persons in their residences who are ill or have disabilities or infirmities.  Examples of such services may include, but are not limited to, homemaker services, assistance with activities of daily living and respite care services.

 

"Homemaker Service" may include, but is not limited to, non-medical support provided by trained and professionally supervised homemakers to maintain, strengthen and safeguard the functioning of individuals in their own homes.

 

"Licensed Health Care Practitioner" means any physician (as defined in section 1861(r)(1) of the Social Security Act) and any registered professional nurse, licensed social worker, or other individual who meets requirements as may be prescribed by the Secretary.

 

"Maintenance Home Health Care Services" may include, but is not limited to, medically related services provided in the home in accordance with services prescribed by a physician.  Specific components of maintenance home health care may include: nursing services; physical, respiratory or speech therapy; and medical/health care services provided by a home health care aide.

 

"Medicare" means "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended", or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof", or words of similar import.

 

"Mental or Nervous Disorder" shall not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

 

"Personal Care" means the provision of hands-on services to assist an individual with activities of daily living, such as bathing, eating, dressing, transferring and toileting.

 

"Plan of Care" in qualified plans means the specific type and frequency of all services required to maintain the individual in the community, the service providers, and the cost of services.  The plan of care shall be specified in writing by a licensed health care provider.

 

"Respite Service" may include, but is not limited to, temporary care for insureds aimed at relieving stress for the insureds' families.  Respite service shall be provided for vacation, rest, errands, family crisis or emergency.

 

"Skilled Nursing Care", "Intermediate Care", "Personal Care", "Home Care", "Specialized Care", "Assisted Living Care" and other services shall be defined in relation to the level of skill required, the nature of the care and the setting in which care must be delivered.

 

"Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

 

"Transferring" means moving into or out of a bed, chair or wheelchair.

 

b)         For policies issued after January 1, 2009, all providers of services, including, but not limited to, "skilled nursing facility", "intermediate care facility", "extended care facility", "specialized care providers", "assisted living facility", "convalescent nursing home", "personal care facility", and "home care agency" shall be defined in relation to the services and facilities required to be available and the licensure, certification, registration or degree status of those providing or supervising the services.  When the definition requires that the provider be appropriately licensed, certified or registered, it shall also state what requirements a provider must meet in lieu of licensure, certification or registration when the state in which the service is to be furnished does not require a provider of these services to be licensed, certified or registered, or when the state licenses, certifies or registers the provider of services under another name.

 

c)         For policies issued prior to January 1, 2009, no insurance policy or certificate may be advertised, solicited, delivered or issued for delivery in this State as a traditional long-term care policy unless the policy or subscriber contract contains definitions or terms that are not more restrictive than the requirements of this Section.

 

"Activities of Daily Living" means at least bathing, continence, dressing, eating, toileting and transferring.

 

"Acute Condition" means a condition that causes the individual to be medically unstable.  Such individual requires frequent monitoring by medical professionals, such as physicians and registered nurses, in order to maintain his or her health status.

 

"Adult Day Care" means a program for 6 or more individuals, of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired elderly or other adults with disabilities who can benefit from care in a group setting outside the home.

 

All providers of services, including but not limited to skilled nursing facility, intermediate care facility, convalescent nursing home, personal care facility, and home care agency shall be defined in relation to the services and facilities required to be available and the licensure or degree status of those providing or supervising the services. The definition may require that the provider be appropriately licensed or certified.

 

"Bathing" means washing oneself by sponge bath, or in either a tub or shower, including the task of getting into or out of the tub or shower.

 

"Chronically Ill Individual", for all traditional long-term care policies that are marketed as "qualified" pursuant to the Internal Revenue Code of 1986, as amended (26 USC 7702B(c)(2)(A)), the term "chronically ill individual" means any individual who has been certified by a licensed health care practitioner as:

 

            being unable to perform (without substantial assistance from another individual) at least 2 activities of daily living for a period of at least 90 days due to a loss of functional capacity,

 

            requiring substantial supervision to protect such individual from threats to health and safety due to severe cognitive impairment.

 

Such term shall not include any individual otherwise meeting the requirements of the preceding sentence unless within the preceding 12-month period a licensed health care practitioner has certified that such individual meets such requirements.

 

"Cognitive Impairment" means a deficiency in a person's short- or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.

 

"Continence" means the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).

 

"Dressing" means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.

 

"Eating" means feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously.

 

"Exceptional Increase" means only those increases filed by an insurer as exceptional for which the Director determines the need for the premium rate increase is justified:

 

Due to changes in laws or regulations applicable to traditional long-term care coverage in this State; or

 

Due to increased and unexpected utilization that affects the majority of insurers of similar products.

 

Except as proved in Sections 2012.112 and 2012.113, exceptional increases are subject to the same requirements as other premium rate schedule increases.

 

The Director may request a review by an independent actuary or a professional actuarial body of the basis for a request that an increase be considered an exceptional increase.

 

The Director, in determining that the necessary basis for exceptional increase exists, shall also determine any potential offsets to higher claims costs.

 

"Hands-on Assistance" means physical assistance (minimal, moderate or maximal) without which the individual would not be able to perform the activity of daily living.

 

"Home Health Care Services" means medical and nonmedical services provided to persons in their residences who are ill or have disabilities or infirmities.  Examples of such services may include but are not limited to homemaker services, assistance with activities of daily living and respite care services.

 

"Incidental", as used in Sections 2012.112(j) and 2012.113(j), means that the value of the traditional long-term care benefit provided is less than 10% of the total value of the benefits provided over the life of the policy.  These values shall be measured as of the date of issue.

 

"Licensed Health Care Practitioner" means any physician (as defined in Section 1861(r)(1) of the Social Security Act) and any registered professional nurse, licensed social worker, or other individual who meets requirements as may be prescribed by the Secretary.

 

"Maintenance or Personal Care Services" within the meaning of the internal Revenue Code of 1986, as amended (26 USC 7702B(c)(3)), means any care the primary purpose of which is the provision of needed assistance with any of the disabilities as a result of which the individual is a chronically ill individual (including the protection from threats to health and safety due to severe cognitive impairment).

 

"Medicare" means "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended", or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof", or words of similar import.

 

"Mental or Nervous Disorder" shall not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

 

"Personal Care" means the provision of hands-on services to assist an individual with activities of daily living, such as bathing, eating, dressing, transferring and toileting.

 

"Plan of Care" in qualified plans means the specific type and frequency of all services required to maintain the individual in the community, the service providers, and the cost of services.  The plan of care shall be specified in writing by a licensed health care provider.

 

"Qualified Actuary" means a member in good standing of the American Academy of Actuaries.

 

"Qualified Long-Term Care Contract" has the same meaning as that for a "Qualified long-term care insurance contract" described in Section 351A-1 of the Code.

 

"Qualified Long-Term Care Services" means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitation services, and maintenance or personal care services that are required by a chronically ill individual and provided pursuant to a plan of care prescribed by a licensed heath care practitioner.

 

"Similar Policy Forms" means all of the traditional long-term care insurance policies and certificates issued by an insurer in the same traditional long-term care benefit classification as the policy form being considered.  Certificates of groups that meet the definition found in Section 2012.30 are not considered similar to certificates or policies otherwise issued as traditional long-term care insurance, but are similar to other comparable certificates with the same traditional long-term care benefit classifications.  For purposes of determining similar policy forms, traditional long-term care benefit classifications are defined as follows:  institutional traditional long-term care benefits only, non-institutional traditional long-term care benefits only, or comprehensive traditional long-term care benefits.

 

"Skilled Nursing Care", "Intermediate Care", "Personal Care", "Home Care", and other services shall be defined in relation to the level of skill required, the nature of the care and the setting in which care must be delivered.

 

"Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

 

"Transferring" means moving into or out of a bed, chair or wheelchair.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.50  Policy Practices and Provisions

 

a)         Renewability.  The terms "guaranteed renewable" and "noncancellable" shall not be used in any individual long-term care insurance policy or certificate without explanatory language in accordance with the disclosure requirements of Section 2012.62.

 

1)         A policy issued to an individual shall not contain renewal provisions other than "guaranteed renewable" or "noncancellable".

 

2)         The term "guaranteed renewable" may be used only when the insured has the right to continue the long-term care insurance in force by the timely payment of premiums and when the insurer has no unilateral right to make any change in any provision of the policy or rider while the insurance is in force, and cannot decline to renew, except that rates may be revised by the insurer on a class basis.

 

3)         The term "noncancellable" may be used only when the insured has the right to continue the long-term care insurance in force by the timely payment of premiums during which period the insurer has no right to unilaterally make any change in any provision of the insurance or in the premium rate.

 

4)         The term "level premium" may only be used when the insurer does not have the right to change the premium.

 

5)         In addition to the other requirements of subsection (a), a qualified long-term care insurance contract shall be guaranteed renewable, within the meaning of Section 7702B(b)(1)(C) of the Internal Revenue Code of 1986, as amended.

 

b)         Limitations and Exclusions.  A policy may not be delivered or issued for delivery in this State as long-term care insurance if the policy limits or excludes coverage by type of illness, treatment, medical condition or accident, except as follows:

 

1)         Preexisting conditions or diseases;

 

2)         Mental or nervous disorders; however, this shall not permit exclusion or limitation of benefits on the basis of Alzheimer's Disease or senile dementia;

 

3)         Alcoholism and drug addiction;

 

4)         Illness, treatment or medical condition arising out of:

 

A)        war or act of war (whether declared or undeclared);

 

B)        participation in a felony, riot or insurrection;

 

C)        service in the armed forces or units auxiliary thereto;

 

D)        suicide (sane or insane), attempted suicide or intentionally self-inflicted injury; or

 

E)        aviation (this exclusion applies only to non-fare paying passengers);

 

5)         Treatment provided in a government facility (unless otherwise required by law), services for which benefits are available under Medicare or other governmental program (except Medicaid), any state or federal workers' compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law, services provided by a member of the covered person's immediate family and services for which no charge is normally made in the absence of insurance;

 

6)         Expenses for services or items available or paid under another traditional long-term care insurance or health insurance policy;

 

7)         In the case of a tax qualified long-term care insurance contract, expenses for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act or would be so reimbursable but for the application of a deductible or coinsurance amount;

 

8)         This subsection (b) is not intended to prohibit exclusions and limitations by type of provider.  However, no long term care issuer may deny a claim because services are provided in a state other than in the state in which the policy was issued under the following conditions:

 

A)         When the state other than the state in which the policy was issued does not have the provider licensing, certification or registration required in the policy, but when the provider satisfies the policy requirements outlined for providers in lieu of licensure, certification or registration; or

 

B)        When the state other than the state in which the policy was issued licenses, certifies or registers the provider under another name.

 

9)         This subsection (b) is not intended to prohibit territorial limitations.

 

c)         Extension of Benefits.  Termination of long-term care insurance shall be without prejudice to any benefits payable for institutionalization if such institutionalization began while the long-term care insurance was in force and continues without interruption after termination.  Such extension of benefits beyond the period the long-term care insurance was in force may be limited to the duration of the benefit period, if any, or to payment of the maximum benefits and may be subject to any policy waiting period, and all other applicable provisions of the policy.

 

d)         Continuation or Conversion

 

1)         Group long-term care insurance issued in this State on or after February 1, 1994 shall provide covered individuals with a basis for continuation or conversion of coverage.

 

2)         For the purposes of this Section, "a basis for continuation of coverage" means a policy provision which maintains coverage under the existing group policy when such coverage would otherwise terminate and which is subject only to the continued timely payment of premium when due.  Group policies which restrict provision of benefits and services to, or contain incentives to use certain providers or facilities may provide continuation benefits which are substantially equivalent to the benefits of the existing group policy.  The Director shall make a determination as to the substantial equivalency of benefits, and in doing so shall take into consideration the differences between managed care and non-managed care plans, including, but not limited to, provider system arrangements, service availability, benefit levels and administrative complexity.

 

3)         For the purposes of this Section, "a basis for conversion of coverage" means a policy provision that an individual whose coverage under the group policy would otherwise terminate or has been terminated for any reason, including discontinuance of the group policy in its entirety or with respect to an insured class, and who has been continuously insured under the group policy (and any group policy which it replaced), for at least six months immediately prior to termination, shall be entitled to the issuance of a converted policy by the insurer under whose group policy the individual is covered, without evidence of insurability.

 

4)         For the purposes of this Section, "converted policy" means an individual policy of long-term care insurance providing benefits identical to or benefits determined by the Director to be substantially equivalent to or in excess of those provided under the group policy from which conversion is made.  Where the group policy from which conversion is made restricts the provision of benefits and services, or contains incentives to use certain providers and/or facilities, the Director, in making a determination as to the substantial equivalency of benefits, shall take into consideration the differences between managed care and non-managed care plans, including, but not limited to, provider system arrangements, service availability, benefit levels and administrative complexity.  The converted policy offered shall be on a form that is available for general sale in this State.

 

5)         Written application for the converted policy shall be made and the first premium due, if any, shall be paid as directed by the insurer not later than thirty-one days after termination of coverage under the group policy.  The converted policy shall be issued effective on the day following the termination of coverage under the group policy, and shall be guaranteed renewable.

 

6)         Unless the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated on the basis of the insured's age at inception of coverage under the group policy from which conversion is made.  Where the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated on the basis of the insured's age at inception of coverage under the group policy replaced.

 

7)         Continuation of coverage or issuance of a converted policy shall be mandatory, except where:

 

A)        Termination of group coverage resulted from an individual's failure to make any required payment of premium or contribution when due; or

 

B)        The terminating coverage is replaced not later than 31 days after termination, by group coverage effective on the day following the termination of coverage:

 

i)          Providing benefits identical to or benefits determined by the Director to be substantially similar to, or in excess of, those provided by the terminating coverage; and

 

ii)         The premium for which is calculated in a manner consistent with the requirements of subsection (d)(6).

 

8)         Notwithstanding any other provision of this Section, a converted policy issued to an individual who at the time of conversion is covered by another long-term care insurance policy that provides benefits on the basis of incurred expenses, may contain a provision which results in a reduction of benefits payable if the benefits provided under the additional coverage, together with the full benefits provided by the converted policy, would result in payment of more than 100% of incurred expenses.  This provision shall only be included in the converted policy if the converted policy also provides for a premium decrease or refund which reflects the reduction in benefits payable.

 

9)         The converted policy may provide that the benefits payable under the converted policy, together with the benefits payable under the group policy from which conversion is made, shall not exceed those that would have been payable had the individual's coverage under the group policy remained in force and effect.

 

10)         Notwithstanding any other provision of this Section, any insured individual whose eligibility for group long-term care coverage is based upon his or her relationship to another person, shall be entitled to continuation of coverage under the group policy upon termination of the qualifying relationship by death or dissolution of marriage.

 

11)         For the purposes of this Section,  a "Managed-Care Plan" is a health care or assisted living arrangement designed to coordinate patient care or control costs through utilization review, case management or use of specific provider networks.

 

e)         Discontinuance and Replacement

If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy on its date of termination.  Coverage provided or offered to individuals by the insurer and premiums charged to persons under the new group policy:

 

1)         Shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced; and

 

2)         Shall not vary or otherwise depend on the individual's health or disability status, claim experience or use of long-term care services.

 

f)         The premiums charged to an insured shall not increase due to either:

 

1)         The increasing age of the insured at ages beyond 65; or

 

2)         The duration the insured has been covered under the policy.

 

g)         No long-term care insurance policy shall 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.

 

h)         Electronic Enrollment for Group Policies

 

1)         In the case of a group defined in Section 351A-1(e) of the Code, any requirement that a signature of an insured be obtained by an insurance producer or insurer shall be deemed satisfied if:

 

A)        The consent is obtained by telephonic or electronic enrollment by the group policyholder or insurer.  A verification of enrollment information shall be provided to the enrollee;

 

B)        The telephonic or electronic enrollment provides necessary and reasonable safeguards to assure the accuracy, retention and prompt retrieval of records; and

 

C)        The telephonic or electronic enrollment provides necessary and reasonable safeguards to assure that the confidentiality of individually identifiable information and privileged information is maintained.

 

2)         Upon request of the Director the insurer shall make available records that will demonstrate the insurer's ability to confirm enrollment and coverage amounts.

 

i)          Except for subsections (a)(1), (b)(8) and (9) and (g), which become effective January 1, 2009, subsections (a) through (h) become effective July 1, 2008.

 

j)          For policies issued from July 1, 2008 through January 1, 2009, the following requirements taken from subsections (a)(1), (b)(8) and (g) apply:

 

1)         For purposes of subsection (a), no individual long-term care insurance policy or certificate issued to an individual shall contain renewal provisions less favorable to the insured than "guaranteed renewable".

 

2)         Subsection (b) is not intended to prohibit exclusions and limitations for payment of services provided outside the United States. 

 

3)         For purposes of subsection (g), no traditional long-term care insurance policy shall:

 

A)        be cancelled, nonrenewed or otherwise terminated on grounds of the age or deterioration of the mental or physical health of the insured individual or certificateholder;

 

B)        contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by new or other coverage, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder;

 

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.

 

4)         There is no requirement for subsection (b)(9) prior to January 1, 2009.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.55  Unintentional Lapse

 

Each insurer offering long-term care insurance shall, as a protection against unintentional lapse, comply with the following:

 

a)         Notice before lapse or termination.

 

1)         No individual long-term care policy or certificate shall be issued until the insurer has received from the applicant a written designation of at least one person, in addition to the applicant, who is to receive notice of lapse or termination of the policy or certificate for nonpayment of premium; or a written waiver dated and signed by the applicant electing not to designate additional persons to receive notice.  The applicant has the right to designate at least one person who is to receive the notice of termination, in addition to the insured.  Designation shall not constitute acceptance of any liability on the third party for services provided to the insured.  The form used for the written designation must provide space clearly designated for listing at least one person.  The designation shall include each person's full name and home address.  In the case of an applicant who elects not to designate an additional person, the waiver shall state:  "Protection against unintended lapse.  I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long-term care insurance policy for nonpayment of premium.  I understand that notice will not be given until 30 days after a premium is due and unpaid.  I elect NOT to designate any person to receive such notice."  The insurer shall also notify the insured of the right to change this written designation, no less often than once every 2 years.

 

2)         When the policyholder or certificateholder pays premium for a long-term care insurance policy or certificate through a payroll or pension deduction plan, the requirements contained in subsection (a)(1) need not be met until 60 days after the policyholder or certificateholder is no longer on such a payment plan.  The application or enrollment form for such policies or certificates shall clearly indicate the payment plan selected by the applicant.

 

3)         Lapse or termination for nonpayment of premium.  No individual long-term care policy or certificate shall lapse or be terminated for nonpayment of premium unless the insurer, at least 30 days before the effective date of the lapse or termination, has given notice to the insured and to those persons designated pursuant to subsection (a)(1), at the address provided by the insured for purposes of receiving notice of lapse or termination.  Notice shall be given by first class United States mail, postage prepaid; and notice shall not be given until 30 days after a premium is due and unpaid.  Notice shall be deemed to have been given as of 5 days after the date of mailing.

 

b)         In addition to the requirements of subsection (a), a long-term care insurance policy or certificate shall include a provision that provides for reinstatement of coverage, in the event of lapse if the insurer is provided proof that the policyholder or certificateholder was cognitively impaired or had a loss of functional capacity before the grace period contained in the policy expired.  This option shall be available to the insured if requested within 5 months after termination and shall allow for the collection of past due premium when appropriate.  The standard of proof of cognitive impairment or loss of functional capacity shall not be more stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional capacity contained in the policy and certificate.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.60  Required Disclosure Provisions

 

a)         Renewability.  Individual long-term care insurance policies shall contain a renewability provision.  The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state that the coverage is guaranteed renewable or noncancellable.  This provision shall not apply to policies which do not contain a renewability provision and under which the right to nonrenew is reserved solely to the policyholder as long as required premiums are paid on time.  A long-term care insurance policy or certificate, other than one where the insurer does not have the right to change the premium, shall include a statement that premium rates may change.

 

b)         Riders and Endorsements.  Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual long-term care insurance policy, all riders or endorsements added to an individual long-term care insurance policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the individual insured.  After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, except if the increased benefits or coverage are required by law.  Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy, rider or endorsement.

 

c)         Payment of Benefits.  A long-term care insurance policy or certificate that provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

 

d)         Limitations:  If a long-term care insurance policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy or certificate and shall be labeled "Preexisting Condition Limitations".  Limitations to preexisting conditions shall be in accordance with Section 351A-5 of the Code.

 

e)         Other Limitations or Conditions on Eligibility for Benefits.  In addition to complying with Section 351A-6 of the Code, beginning August 30, 1990, a long-term care insurance policy or certificate containing any limitations or conditions for eligibility other than those prohibited in Section 351A-6 shall set forth a description of such limitations or conditions, including any required number of days of confinement in a separate paragraph of the policy or certificate and shall label such paragraph "Limitations or Conditions on Eligibility for Benefits".

 

f)         Disclosure Requirements for Accelerated Life Products

 

1)         Policy Summary

At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy that provides long-term care benefits within the policy or by rider.  This requirement does not apply to qualified long-term care insurance contracts.  In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make delivery no later than at the time of policy delivery.  In addition to complying with all applicable requirements, the summary shall also include:

 

A)        an explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;

 

B)        an illustration of the amount of benefits, the length of benefit, and the guaranteed lifetime benefits if any, for each covered person;

 

C)        any exclusion, reductions and limitations on benefits of long-term care; and

 

D)        if applicable to the policy type, the summary shall also include:

 

i)          disclosure of the effects of exercising other rights under the policy;

 

ii)         disclosure of guarantees related to long-term care costs of insurance charges; and

 

iii)        current and projected maximum lifetime benefits.

 

2)         Benefit Reports

Any time a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder.  The report shall include:

 

A)        any long-term care benefits paid during the month;

 

B)        an explanation of any changes in the policy, including changes in death benefits or cash values, due to long-term care benefits being paid out; and

 

C)        the amount of long-term care benefits existing or remaining.

 

3)         Outline of Coverage

The Outline of Coverage should include an example filled out in John Doe form that illustrates how the long-term care benefit is calculated.  Refer to Section 2012.110 and Exhibit C for format and content requirements.

 

g)         Disclosure of Tax Consequences.  With regard to life insurance policies that provide an accelerated benefit for long-term care, a disclosure statement is required at the time of application for the policy or rider and at the time the accelerated benefit payment request is submitted, that receipt of these accelerated benefits may be taxable, and that assistance should be sought from a personal tax advisor.  This disclosure statement shall be prominently displayed on the first page of the policy or rider and any other related documents.  This subsection (g) shall not apply to qualified long-term care insurance contracts.

 

h)         Benefit Triggers.  Activities of daily living and cognitive impairment shall be used to measure an insured's need for long-term care and shall be described in the policy or certificate in a separate paragraph and shall be labeled "Eligibility for the Payment of Benefits".  Any additional benefit triggers shall also be explained in this paragraph.  If these triggers differ for different benefits, explanation of the trigger shall 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 shall be specified.

 

i)          A qualified long-term care insurance contract shall include a disclosure statement in the policy and in the outline of coverage as contained in Exhibit C(3) that indicates that the policy is intended to be a qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended (26 USC 7702B(b)).

 

j)          A nonqualified traditional long-term care insurance contract shall include a disclosure statement in the policy and in the outline of coverage as contained in Exhibit C(3).  The disclosure statement shall indicate that the policy is not intended to be a qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended (26 USC 7702B).

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.62  Required Disclosure of Rating Practices to Consumers

 

a)         This Section shall apply as follows:

 

1)         Except as provided in subsection (a)(2), this Section applies to any long-term care policy issued in this State on or after January 1, 2003.

 

2)         For certificates issued on or after July 1, 2002, under a group long-term care insurance policy as defined in Section 351A-1(e)(1) of the Code that was in force prior to July 1, 2002, the provisions of this Section shall apply on the policy anniversary following July 1, 2003.

 

b)         Other than policies for which no applicable premium rate or rate schedule increases can be made, insurers shall provide all of the information listed in this subsection (b) to the applicant at the time of application or enrollment, unless the method of application does not allow for delivery at that time.  In such a case, an insurer shall provide all of the information listed in this Section to the applicant no later than at the time of delivery of the policy or certificate.

 

1)         A statement that the policy may be subject to rate increases in the future;

 

2)         An explanation of potential future premium rate revisions, and the policyholder's or certificateholder's option in the event of a premium rate revision;

 

3)         The premium rate or rate schedules applicable to the applicant that will be in effect until a request is made for an increase;

 

4)         A general explanation for applying premium rate or rate schedule adjustments that shall include:

 

A)        A description of when premium rate or rate schedule adjustments will be effective (e.g., next anniversary date, next billing date, etc.); and

 

B)        The right to a revised premium rate or rate schedule as provided in subsection (b)(3) of this Section if the premium rate or rate schedule is changed;

 

5)         Required Rate Information

 

A)        Information regarding each premium rate increase on this policy form or similar policy forms over the past 10 years for this State or any other state that, at a minimum, identifies:

 

i)          The policy forms for which premium rates have been increased;

 

ii)         The calendar years when the form was available for purchase; and

 

iii)        The amount or percent of each increase. The percentage may be expressed as a percentage of the premium rate prior to the increase, and may also be expressed as minimum and maximum percentages if the rate increase is variable by rating characteristics.

 

B)        The insurer may, in a fair manner, provide additional explanatory information related to the rate increases.

 

C)        An insurer shall have the right to exclude from the disclosure premium rate increases that only apply to blocks of business acquired from other nonaffiliated insurers or the long-term care policies acquired from other nonaffiliated insurers when those increases occurred prior to the acquisition.

 

D)        If an acquiring insurer files for a rate increase on a long-term care policy form acquired from nonaffiliated insurers or a block of policy forms acquired from nonaffiliated insurers on or before July 1, 2002, or the end of a 24 month period following the acquisition of the block or policies, the acquiring insurer may exclude that rate increase from the disclosure.  However, the nonaffiliated selling company shall include the disclosure of that rate increase in accordance with subsection (b)(5)(A) of this Section.

 

E)        If the acquiring insurer in subsection (b)(5)(D) of this Section files for a subsequent rate increase, even within the 24 month period, on the same policy form acquired from nonaffiliated insurers or block of policy forms acquired from nonaffiliated insurers referenced in subsection (b)(5)(D) of this Section, the acquiring insurer shall make all disclosures required by subsection (b)(5)(A) of this Section, including disclosure of the earlier rate increase referenced in subsection (b)(5)(D) of this Section.

 

c)         An applicant shall sign an acknowledgment at the time of application, unless the method of application does not allow for signature at that time, that the insurer made the disclosure required under subsections (b)(1) and (5) of this Section. If due to the method of application the applicant cannot sign an acknowledgment at the time of application, the applicant shall sign no later than at the time of delivery of the policy or certificate.

 

d)         An insurer shall use Exhibits F and J to comply with the requirements of subsections (b) and (c) of this Section.

 

e)         An insurer shall provide notice of an upcoming premium rate schedule increase to all policyholders or certificateholders, if applicable, at least 45 days prior to the implementation of the premium rate schedule increase by the insurer.  The notice shall include the information required by subsection (b) of this Section when the rate increase is implemented.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.64  Initial Filing Requirements

 

a)         This Section applies to any long-term care policy issued in this State on or after January 1, 2003, except that subsections (b)(2)(D) and (b)(3) apply to any long-term care policy issued in this State on or after July 1, 2018.

 

b)         An insurer shall provide the information listed in this subsection (b) to the Director 30 days prior to making a long-term care insurance form available for sale.

 

1)         A copy of the disclosure documents required in Section 2012.62; and

 

2)         An actuarial certification consisting of at least the following:

 

A)        A statement that the initial premium rate schedule is sufficient to cover anticipated costs under moderately adverse experience and that the premium rate schedule is reasonably expected to be sustainable over the life of the form with no future premium increases anticipated;

 

B)        A statement that the policy design and coverage provided have been reviewed and taken into consideration;

 

C)        A statement that the underwriting and claims adjudication processes have been reviewed and taken into consideration;

 

D)        A statement that the premiums contain at least the minimum margin for moderately adverse experience defined in subsection (b)(2)(D)(i) or the specification of and justification for a lower margin as required by subsection (b)(2)(D)(ii). 

 

i)          A composite margin shall not be less than 10% of lifetime claims.

 

ii)         A composite margin that is less than 10% may be justified in uncommon circumstances. The proposed amount, full justification of the proposed amount and methods to monitor developing experience that would be the basis for withdrawal of approval for such lower margins must be submitted. 

 

iii)        A composite margin lower than otherwise considered appropriate for the stand-alone long-term care policy may be justified for long-term care benefits provided through a life policy or an annuity contract. The lower composite margin, if utilized, shall be justified by appropriate actuarial demonstration addressing margins and volatility when considering the entirety of the product.

 

iv)        A greater margin may be appropriate in circumstances in which the company has less credible experience to support its assumptions used to determine the premium rates.

 

E)        Either:

 

i)          A statement that the premium rate schedule is not less than the premium rate schedule for existing similar policy forms also available from the insurer, except for reasonable differences attributable to benefits; or

 

ii)         A comparison of the premium schedules for similar policy forms that are currently available from the insurer with an explanation of the differences.

 

 F)        A statement that reserve requirements have been reviewed and considered. Support for this statement shall include: 

 

            i)          Sufficient detail or sample calculations that provide a complete depiction of the reserve amounts to be held; and

 

ii)         A statement that the difference between the gross premium and the net valuation premium for renewal years is sufficient to cover expected renewal expenses or, if such a statement cannot be made, a complete description of the situations where this does not occur.  An aggregate distribution of anticipated issues may be used as long as the underlying gross premiums maintain a reasonably consistent relationship.  

 

            3)         An actuarial memorandum prepared, dated and signed by the member of the Academy of Actuaries shall be included and shall address and support each specific item required as part of the actuarial certification and shall provide at least the following information: 

 

                        A)        An explanation of the review performed by the actuary prior to making the statements in subsections (b)(2)(B) and (C);

 

                        B)        A complete description of pricing assumptions; 

 

C)        Sources and levels of margins incorporated into the gross premiums that are the basis for the statement in subsection (b)(2)(A) of the actuarial certification and an explanation of the analysis and testing performed in determining the sufficiency of the margins. Deviations in margins between ages, sexes, plans or states shall be clearly described. Deviations in margins required to be described are other than those produced utilizing generally accepted actuarial methods for smoothing and interpolating gross premium scales; and

 

D)        A demonstration that the gross premiums include the minimum composite margin specified in subsection (b)(2)(D).

 

c)         In any review of the actuarial certification and actuarial memorandum, the Director may request review by an actuary with experience in long-term care pricing who is independent of the company. In the event the Director asks for additional information as a result of any review, the period in subsection (b) does not include the period during which the insurer is preparing the requested information.

                                                                                   

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.65  Prohibition Against Post Claims Underwriting

 

a)         All applications for long-term care insurance policies or certificates except those which are guaranteed issue shall contain unambiguous questions designed to ascertain the health condition of the applicant.

 

1)         If an application for long-term care insurance contains a question which asks whether the applicant has had medication prescribed by a physician, it must also ask the applicant to list the medication that has been prescribed.

 

2)         If the medications listed in the application were known by the insurer, or should be known at the time of application, to be directly related to a medical condition for which coverage would otherwise be denied, then the policy or certificate shall not be rescinded for that condition.

 

b)         Except for policies or certificates that are guaranteed issue:

 

1)         The following language shall be set out conspicuously and in close conjunction with the applicant's signature block on an application for a traditional long-term care insurance policy or certificate:

 

Caution:  If your answers on this application are incorrect or untrue, [company] may have the right to deny benefits or rescind your policy.

 

2)         The following language shall be set out on the long-term care insurance policy or certificate at the time of delivery:

 

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, the company may have the right to deny benefits or rescind your policy.  The best time to clear up any questions is now, before a claim arises!  If, for any reason, any of your answers are incorrect, contact the company at this address:  [insert address]

 

3)         Prior to issuance of a long-term care policy or certificate to an applicant age 80 or older, the insurer shall obtain one of the following:

 

A)        A report of a physical examination;

 

B)        An assessment of functional capacity;

 

C)        An attending physician's statement; or

 

D)        Copies of medical records.

 

c)         A copy of the completed application or enrollment form (whichever is applicable) shall be delivered to the insured no later than at the time of delivery of the policy or certificate unless it was retained by the applicant at the time of application.

 

d)         Every insurer, as defined in Section 2012.30 of this Part, selling or issuing long-term care insurance benefits shall maintain a record of all policy or certificate rescissions, both State and countrywide, except those the insured voluntarily effectuated and shall annually furnish this information to the Director of Insurance in the format prescribed in Exhibit D.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.70  Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies

 

a)         A long-term care insurance policy or certificate may not, if it provides benefits for home health care or community care services, limit or exclude benefits:

 

1)         By requiring that the insured/claimant would need skilled care in a skilled nursing facility if home health care services were not provided;

 

2)         By requiring that the insured/claimant first or simultaneously receive nursing  and/or therapeutic services in a home or community or institutional setting before home health care services are covered;

 

3)         By limiting eligible services to services provided by registered nurses or licensed practical nurses;

 

4)         By requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide, or other licensed or certified home care worker acting within the scope of his or her licensure or certification;

 

5)         By requiring that the insured/claimant have an acute condition before home health care services are covered;

 

6)         By excluding coverage for personal care services provided by a home health aide;

 

7)         By requiring that the provision of home health care services be at a level of certification or licensure greater than that required by the eligible service;

 

8)         By limiting benefits to services provided by Medicare-certified agencies or providers;

 

9)         By excluding coverage for adult day care services.

 

b)         A long-term care insurance policy or certificate, if it provides for home health or community care services, shall provide total home health or community care coverage that is a dollar amount equivalent to at least one-half of one year's coverage available for nursing home benefits under the policy or certificate, at the time covered home health or community care services are being received.  This requirement shall not apply to policies or certificates issued to residents of continuing care retirement communities.

 

c)         Home health care coverage may be applied to the nonhome health care benefits provided in the policy or certificate when determining maximum coverage under the terms of the policy or certificate.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.80  Requirement to Offer Inflation Protection

 

a)         No insurer may offer a long-term care insurance policy unless the insurer also offers to the policyholder in addition to any other inflation protection the option to purchase a policy that provides for benefit levels to increase with benefit maximums or reasonable durations which are meaningful to account for reasonably anticipated increases in the costs of long-term care services covered by the policy.  Insurers must offer to each policyholder, at the time of purchase, the option to purchase a policy with an inflation protection feature no less favorable than one of the following:

 

1)         Increases benefit levels annually in a manner so that the increases are compounded annually at a rate not less than 5%;

 

2)         Guarantees the insured individual the right to periodically increase benefit levels without providing evidence of insurability or health status so long as the option for the previous period has not been declined.  The amount of the additional benefit shall be no less than the difference between the existing policy benefit and that benefit compounded annually at a rate of at least 5% for the period beginning with the purchase of the existing benefit and extending until the year in which the offer is made; or

 

3)         Covers a specified percentage of actual or reasonable charges and does not include a maximum specified indemnity amount or limit.

 

b)         Where the policy is issued to a group, the required offer in subsection (a) shall be made to the group policyholder; except, if the policy is issued to a discretionary group, as defined in Section 351A-1(e)(4) of the Code, other than to a continuing care retirement community, the offering shall be made to each proposed certificateholder.

 

c)         The offer in subsection (a) shall not be required of life insurance policies or riders containing accelerated long-term care benefits.

 

d)         Insurers shall include the following information in the outline of coverage:

 

1)         A graphic comparison of the benefit levels of a policy that increases benefits over the policy period with a policy that does not increase benefits.  The graphic comparison shall 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.

 

3)         An insurer may use a reasonable hypothetical or a graphic demonstration for the purposes of this disclosure.

 

e)         Inflation protection benefit increases under a policy which contains such benefits shall continue without regard to an insured's age, claim status or claim history, or the length of time the person has been insured under the policy.

 

f)         An offer of inflation protection which provides for automatic benefit increases shall include an offer of a premium which the insurer expects to remain constant.  The offer shall disclose in a conspicuous manner that the premium may change in the future unless the premium is guaranteed to remain constant.

 

g)         Inflation protection as provided in subsection (a)(1) of this Section shall be included in a long-term care insurance policy unless an insurer obtains a rejection of inflation protection signed by the policyholder as required by this Section.  The rejection may be either in the application or on a separate form. The rejection shall be considered a part of the application and shall state, "I have reviewed the outline of coverage and the graphs that compare the benefits and premiums of this policy with and without inflation protection.  Specifically, I have reviewed plan(s) ________, and I reject inflation protection."

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.83  Incontestability Period

 

a)         For a policy or certificate that has been in force for less than 6 months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage.

 

b)         For a policy or certificate that has been in force for at least 6 months but less than 2 years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and that pertains to the condition for which benefits are sought.

 

c)         After a policy or certificate has been in force for 2 years, it is not contestable upon the grounds of misrepresentation alone; the policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.

 

d)         A long-term care insurance policy or certificate may be field issued based on medical or health status if the compensation to the field issuer is not based on the number of policies or certificates issued.  For purposes of this Section, "field issued" means a policy or certificate issued by a producer or an agent or a third-party administrator pursuant to the underwriting authority granted to the producer, agent or third party administrator by an insurer and using the insurer's underwriting guidelines.

 

e)         If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer in the event that the policy or certificate is rescinded.

 

f)         In the event of the death of the insured, this Section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care.  In this situation, the remaining death benefits under these policies shall be governed by Section 224(1)(c) of the Code.  In all other situations, this Section shall apply to life insurance policies that accelerate benefits for long-term care.

 

(Source:  Added at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.86  Nonforfeiture Benefits

 

a)         Except as provided in subsection (b), a long-term care insurance policy may not be delivered or issued for delivery in this State unless the policyholder or certificateholder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit as specified in Section 2012.127 of this Part.  The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy.  In the event the policyholder or certificateholder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates.

 

b)         When a group long-term care insurance policy is issued, the offer required in subsection (a) shall be made to the group policyholder.  However, if the policy is issued as group long-term care insurance as defined in Section 351A-1(e)(4) of the Code, other than to a continuing care retirement community or other similar entity, the offering shall be made to each proposed certificateholder.

 

(Source:  Added at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.90  Requirements for Application Forms and Replacement Coverage

 

a)         Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another long-term care insurance policy or certificate in force or whether a long-term care policy or certificate is intended to replace any other accident and sickness or long-term care policy or certificate presently in force.  A supplementary application or other form to be signed by the applicant and insurance producer, except where the coverage is sold without an insurance producer, containing such questions may be used.  With regard to a replacement policy issued to a group defined by Section 351A-1(e)(1) of the Code the following questions may be modified only to the extent necessary to elicit information about health or long-term care insurance policies other than the group policy being replaced; provided, however, that the certificateholder has been notified of the replacement.

 

1)         Do you have another long-term care insurance policy or certificate in force (including health care service contract, health maintenance organization contract)?

 

2)         Did you have another long-term care insurance policy or certificate in force during the last 12 months?

 

A)        If so, with which company?

 

B)        If that policy lapsed, when did it lapse?

 

3)         Are you covered by Medicaid?

 

4)         Do you intend to replace any of your medical or health insurance coverage with this policy (certificate)?

 

b)         Insurance producers shall list any other health insurance policies they have sold to the applicant.

 

1)         List policies sold which are still in force.

 

2)         List policies sold in the past 5 years which are no longer in force.

 

c)         Solicitations Other than Direct Response.  Upon determining that a sale will involve replacement, an insurer, other than an insurer using direct response solicitation methods, or its insurance producer, shall furnish the applicant, prior to issuance or delivery of the individual long-term care insurance policy, a notice regarding replacement of accident and sickness or long-term care coverage.  One copy of such notice shall be retained by the applicant and an additional copy signed by the applicant shall be retained by the insurer.  The required notice shall be provided as set forth in Exhibit A of this Part.

 

d)         Direct Response Solicitations.  Insurers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness or long-term care coverage to the applicant upon issuance of the policy.  The required notice shall be provided as set forth in Exhibit B of this Part.

 

e)         Where replacement is intended, the replacing insurer shall provide written notice to the existing insurer of the proposed replacement.  The existing policy shall be identified by the insurer, name of insured and policy number or address including zip code.  Notice shall be made within 5 working days from the date the application is received by the insurer or the date the policy issued, whichever is sooner.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.95  Reporting Requirements

 

All insurers shall:

 

a)         Maintain records for each insurance producer of that producer's amount of replacement sales as a percent of the producer's total annual sales and the amount of lapses of long-term care insurance policies sold by the insurance producer as a percent of the producer's total sales. 

 

b)         Report annually by June 30 the 10% of its insurance producers with the greatest percentages of lapses and replacements as measured by subsection (a) as provided in Exhibit K.

 

c)         Report annually by June 30 the number of lapsed policies as a percent of its total annual sales and as a percent of its total number of policies in force as of the end of the preceding calendar year as provided in Exhibit K.

 

d)         Report annually by June 30 the number of replacement policies sold as a percent of its total annual sales and as a percent of its total number of policies in force as of the preceding calendar year as provided in Exhibit K.

 

e)         Report annually by June 30, for qualified long-term care insurance contracts, the number of claims denied for each class of business, expressed as a percentage of claims denied, as provided by Exhibit I.

 

f)         For purposes of this Section:

 

1)         "Policy" means only long-term care insurance;

 

2)         Subject to subsection (f)(3), "claim" means a request for payment of benefits under an in force policy regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met;

 

3)         "Denied" means the insurer refuses to pay a claim for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition; and

 

4)         "Report" means on a Statewide basis.

 

g)         Reports required under this Section shall be filed with the Director.

 

h)         Annual Rate Certification Requirements

 

1)         This subsection (h) applies to any long-term care policy issued in this State on or after July 1, 2018.

 

2)         The submission requirements required by Section 2012.97 shall apply subsequent to initial rate filings for individual long-term care insurance policies made under this Section 2012.95.

 

3)         The actuarial certification required pursuant to Section 2012.97(c) must be based on calendar year data and submitted annually no later than May 1 of each year starting in the second year following the year in which the initial rate schedules are first used.

 

4)         The actuarial memorandum required pursuant to Section 2012.97(d) must be submitted at least once every 3 years with the certification.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.97  Annual Rate Certification Requirements

 

a)         This Section applies to any long-term care policy issued in this State on or after July 1, 2018.

 

b)         The annual rate certifications required by subsection (c) and the memorandum required by subsection (d), shall be filed in accordance with the filing requirements in Section 2012.95. 

 

c)         An annual actuarial certification prepared, dated and signed by a member of the American Academy of Actuaries who provides the information shall be included and shall provide at least the following information:

 

1)         A statement of the sufficiency of the current premium rate schedule including:

 

A)        For the rate schedules currently marketed,

 

i)          The premium rate schedule continues to be sufficient to cover anticipated costs under moderately adverse experience and that the premium rate schedule is reasonably expected to be sustainable over the life of the form with no future premium increases anticipated; or

 

ii)         If the above statement cannot be made, a statement that margins for moderately adverse experience may no longer be sufficient.  In this situation, the insurer shall provide to the Director, within 60 days of the date the actuarial certification is submitted to the Director, a plan of action, including a time frame, for the re-establishment of adequate margins for moderately adverse experience so that the ultimate premium rate schedule would be reasonably expected to be sustainable over the future life of the form with no future premium increases anticipated. Failure to submit a plan of action to the Director within 60 days or to comply with the time frame stated in the plan of action constitutes grounds for the Director to withdraw or modify its approval of the form for future sales pursuant to Section 143 of the Illinois Insurance Code.

 

B)        For the rate schedules that are no longer marketed,

 

i)          That the premium rate schedule continues to be sufficient to cover anticipated costs under best estimate assumptions; or

 

ii)         That the premium rate schedule may no longer be sufficient. In this situation, the insurer shall provide to the Director, within 60 days of the date the actuarial certification is submitted to the Director, a plan of action, including a time frame, for the re-establishment of adequate margins for moderately adverse experience.

 

2)         A description of the review performed that led to the statement.

 

d)         An actuarial memorandum dated and signed by a member of the American Academy of Actuaries who prepares the information shall be prepared to support the actuarial certification and provide at least the following information:

 

1)         A detailed explanation of the data sources and review performed by the actuary prior to making the statement in subsection (c)(1).

 

2)         A complete description of experience assumptions and their relationship to the initial pricing assumptions.

 

3)         A description of the credibility of the experience data. 

 

4)         An explanation of the analysis and testing performed in determining the current presence of margins. 

 

(Source:  Added at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.100  Filing Requirement

 

Prior to an insurer offering group long-term care insurance to a resident of this State pursuant to Section 351A-2 of the Code, it shall file with the Director evidence that the group policy or certificate thereunder has been approved by a state that has adopted the National Association of Insurance Commissioners' model legislation on Long-Term Care Insurance and attendant regulations, 2301 McGee Street, Suite 800, Kansas City, Missouri 64108 (2000) (no subsequent dates or editions).

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.110  Loss Ratio

 

a)         This Section shall apply to all long-term care insurance policies or certificates, except those covered under Sections 2012.64, 2012.112 and 2012.113.

 

b)         Notice of Rate Schedule Increase

 

1)         An insurer shall provide notice of a pending premium rate schedule increase, including an exceptional increase, to the Director at least 30 days prior to the notice to the policyholders. The notice shall include:

 

A)        An actuarial memorandum documenting that benefits under the long-term care insurance policies are reasonable in relation to premiums by demonstrating that the expected loss ratio meets the requirements in subsection (c), calculated in a manner that provides for adequate reserving of the long-term care insurance.  In evaluating the expected loss ratio, due consideration shall be given to all relevant factors, including:

 

i)          Statistical credibility of incurred claims experience and earned premiums;

 

ii)         The period for which rates are computed to provide coverage;

 

iii)        Experienced and projected trends;

 

iv)        Concentration of experience within early policy duration;

 

v)         Expected claim fluctuation;

 

vi)        Experience refunds, adjustments or dividends;

 

vii)       Renewability features;

 

viii)      Interest;

 

ix)        Experimental nature of the coverage;

 

x)         Product features such as long elimination periods (period between when the claim arises and insured is eligible to receive benefits), high deductibles and high maximum limits.

 

B)        A statement that, upon approval of the requested amount, the insurer agrees to not implement future rate increases on each subject policy for 3 years from the date of implementation of a single rate increase for each policy form.

 

C)        In lieu of a single increase, the insurer may request a series of scheduled rate increases that are actuarially equivalent to the single amount requested by the insurer over the lifetime of the policy.  The entire series would be reviewed and considered at one time as part of the current rate increase filing.  After implementation of the first increase, the insurer is subject to the 3-year monitoring provision in Section 2012.112(d), but the Director is allowed to require modification of later increases that were not appropriate based on the experience following the initial rate increase.  When determining the rate comparison for new business, forms subject to a series of increases shall not be included.  

 

D)        A statement indicating whether the increase or series of scheduled increases triggers the offering of a contingent benefit upon lapse.  The insurer shall offer a contingent benefit upon lapse for any increase, whether a single increase or a series of scheduled increases, that would trigger the offering of the contingent benefit upon lapse as defined in Section 2012.127(d).  The insurer shall notify policyholders and certificate holders of the contingent benefit upon lapse, in conjunction with the implementation of a rate increase.  If the rate increase is approved as a series of scheduled increases and the sum of all scheduled increases would ultimately trigger the offering of the contingent benefit upon lapse, the insurer will be required to include the contingent benefit upon lapse and the notification at the time of each scheduled increase.

 

E)        The premium increase notification letter to policyholders at the time of the premium rate increase for informational purposes.  The insurer shall clearly disclose to policyholders the following elements:

 

i)          The amount of the premium rate increase requested and implementation schedule (e.g., single premium increase applied or phased in through a series of premium increases);

 

ii)         Available benefit reduction/rate increase mitigation actions;

 

iii)        Clear disclosure addressing the guaranteed renewable nature of the policy/coverage and that the insured should understand that premium rates may increase again in the future; and

 

iv)        Offer of contingent benefit upon lapse, if applicable.

 

2)         At the request of the insurer, the Director may also consider other options that may be made available to insureds that may mitigate the impact of the rate increases on the insured population or alternative actuarial methodologies relating to the rate increase.  The insurer shall provide an explanation and demonstration on how the methodology is actuarially justified and/or how the new mitigation option may reasonably benefit insureds.  No alternative method/approach may be used until it has been accepted by the Director.

 

c)         Loss Ratio

 

1)         The expected loss ratio shall be at least:

 

A)        the greater of 60% or the lifetime loss ratio used in the original pricing, applied to the current rate schedule on July 1, 2018; plus

 

B)        Either:

 

i)          80% applied to any premium increase that is filed after that date on an individual policy form; or

 

ii)         75% applied to any premium increase that is filed on a group policy form.

 

2)         All present and accumulated values used to determine rate increases shall use the maximum valuation interest rate for contract reserves as specified in 50 Ill. Adm. Code 2004 (Accident and Health Reserves). The actuary shall disclose as part of the actuarial memorandum the use of any appropriate averages.

 

d)         Subsections (b) and (c) shall not apply to life insurance policies that accelerate benefits for long-term care.  A life insurance policy that funds long-term care benefits entirely by accelerating the death benefit is considered to provide reasonable benefits in relation to premiums paid, if the policy complies with all of the following provisions:

 

1)         The interest credited internally to determine cash value accumulations, including long-term care, if any, is guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;

 

2)         The portion of the policy that provides life insurance benefits meets the nonforfeiture requirements of Section 229.2 of the Code;

 

3)         The policy meets the disclosure requirements of Sections 351A-9.1 and 351A-9.2 of the Code;

 

4)         Any policy illustration that meets the applicable requirements of 50 Ill. Adm. Code 1406;

 

5)         An actuarial memorandum is filed with the Department that includes:

 

A)        A description of the basis on which the long-term care rates were determined;

 

B)        A description of the basis for the reserves;

 

C)        A summary of the type of policy, benefits, renewability, general marketing method, and limits on ages of issuance;

 

D)        A description and a table of each actuarial assumption used.  For expenses, an insurer must include percent of premium dollars per policy and dollars per unit of benefits, if any;

 

E)        A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives;

 

F)         The estimated average annual premium per policy and the average issue age;

 

G)        A statement as to whether underwriting is performed at the time of application.  The statement shall indicate whether underwriting is used and, if used, the statement shall include a description of the type or types of underwriting used, such as medical underwriting or functional assessment underwriting.  Concerning a group policy, the statement shall indicate whether the enrollee or any dependent will be underwritten and when underwriting occurs; and

 

H)        A description of the effect of the long-term care policy provision on the required premiums, nonforfeiture values and reserves on the underlying life insurance policy, both for active lives and those in long-term care claim status.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.112  Premium Rate Schedule Increases

 

a)         This Section shall apply as follows:

 

1)         Except as provided in subsection (a)(2), this Section applies to any long-term care policy or certificate issued in this State on or after January 1, 2003 and prior to July 1, 2018.

 

2)         For certificates issued on or after July 1, 2002 and before July 1, 2018, under a group long-term care insurance policy as defined in Section 351A-1(e)(1) of the Code, if the policy was in force prior to July 1, 2002, the provisions of this Section shall apply on the policy anniversary following July 1, 2003.

 

b)         An insurer shall provide notice of a pending premium rate schedule increase, including an exceptional increase, to the Director at least 30 days prior to the notice to the policyholders and shall include:

 

1)         Information required by Section 2012.62.

 

2)         Certification by a qualified actuary that:

 

A)        If the requested premium rate schedule increase is implemented and the underlying assumptions that reflect moderately adverse conditions are realized, no further premium rate schedule increases are anticipated;

 

B)        The premium rate filing is in compliance with the provisions of this Section;

 

C)        The insurer may request a premium rate schedule increase less than what is required under this Section. The Director may approve that premium rate schedule increase without submission of the certification in subsection (b)(2)(A) if:

 

i)          the actuarial memorandum discloses the premium rate schedule increase necessary to make the certification required under subsection (b)(2)(A);

 

ii)         the premium rate schedule increase filing satisfies all other requirements of this Section; and

 

iii)        the premium rate increase filing is, in the opinion of the Director, in the best interest of policyholders.

 

3)         An actuarial memorandum justifying the rate schedule change request that includes:

 

A)        Lifetime projections of earned premiums and incurred claims based on the filed premium rate schedule increase; and the method and assumptions used in determining the projected values, including reflection of any assumptions that deviate from those used for pricing other forms currently available for sale;

 

i)          Annual values for the 5 years preceding and the 3 years following the valuation date shall be provided separately;

 

ii)         The projections shall include the development of the lifetime loss ratio, unless the rate increase is an exceptional increase;

 

iii)        The projections shall demonstrate compliance with subsection (c); and

 

iv)        For exceptional increases, the projected experience should be limited to the increases in claims expenses attributable to the approved reasons for the exceptional increase; and in the event the Director determines, as provided in the definition of "Exceptional Increase" found in Section 2012.30, that offsets may exist, the insurer shall use appropriate net projected experience;

 

B)        Disclosure of how reserves have been incorporated in this rate increase whenever the rate increase will trigger the contingent benefit upon lapse;

 

C)        Disclosure of the analysis performed to determine why a rate adjustment is necessary, which pricing assumptions were not realized and why, and what other actions taken by the company have been relied on by the actuary;

 

D)        A statement that policy design, underwriting and claims adjudication practices have been taken into consideration;

 

E)        In the event that it is necessary to maintain consistent premium rates for new certificates and certificates receiving a rate increase, the insurer will need to file composite rates reflecting projections of new certificates.

 

4)         A statement that renewal premium rate schedules are not greater than new business premium rate schedules except for differences attributable to benefits, unless sufficient justification is provided to the Director.

 

5)         A statement that, upon approval of the requested amount, the insurer agrees to not implement future rate increases on each subject policy for three years from the date of implementation of a single rate increase for each policy form.

 

6)         In lieu of a single increase, the insurer may request a series of scheduled rate increases that are actuarially equivalent to the single amount requested by the insurer over the lifetime of the policy.  The entire series would be reviewed and considered at one time as part of the current rate increase filing.  However, after implementation of the first increase, the insurer is subject to the three-year monitoring provision in subsection (d), but the Director is allowed to require modification of later increases that were not appropriate based on the experience following the initial rate increase.  When determining the rate comparison for new business, forms subject to a series of increases shall not be included.  

 

7)         The insurer shall file with the Director the premium increase notification letter to policyholders at the time of the premium rate increase for informational purposes.  The insurer shall clearly disclose to policyholders the following elements:

 

A)        The amount of the premium rate increase requested and the implementation schedule (e.g., single premium increase applied or phased in a series of premium increases);

 

B)        Available benefit reduction/rate increase mitigation actions;

 

C)        Clear disclosure addressing the guaranteed renewable nature of the policy/coverage and that the insured should understand that premium rates may increase again in the future; and

 

D)        Offer of contingent benefit upon lapse, if applicable.

 

8)         Sufficient information for review and approval by the Director of the premium rate schedule increase.

 

c)         All premium rate schedule increases shall be determined in accordance with the following requirements:

 

1)         Exceptional increases shall provide that 70% of the present value of projected additional premiums from the exceptional increase will be returned to policyholders in benefits;

 

2)         Premium rate schedule increases shall be calculated such that the sum of the accumulated value of incurred claims, without the inclusion of active life reserves, and the present value of future projected incurred claims, without the inclusion of active life reserves, will not be less than the sum of the following:

 

A)        The accumulated value of the initial earned premium times the greater of:

 

i)          58%; or

 

ii)         the originally filed loss ratio;

 

B)        85% of the accumulated value of prior premium rate schedule increases on an earned basis;

 

C)        The present value of future projected initial earned premiums times the greater of:

 

i)          58%; or

 

ii)         the originally filed loss ratio; and

 

D)        85% of the present value of future projected premiums not in subsection (c)(2)(C) on an earned basis;

 

3)         In the event that a policy form has both exceptional and other increases, the values in subsections (c)(2)(B) and (D) will also include 70% for exceptional rate increase amounts;

 

4)         All present and accumulated values used to determine rate increases shall use the maximum valuation interest rate for contract reserves as specified in 50 Ill. Adm. Code 2004 (Accident and Health Reserves).  The actuary shall disclose as part of the actuarial memorandum the use of any appropriate averages; and

 

5)         The present value of future projected incurred claims calculated in subsection (c)(2) shall be on a best estimate basis.

 

d)         For each rate increase that is implemented, the insurer shall file for review and approval by the Director updated projections, as defined in subsection (b)(3)(A), annually for the next 3 years and include a comparison of actual results to projected values.  The Director may extend the period to greater than 3 years if actual results are not consistent with projected values from prior projections.  For group insurance policies that meet the conditions in subsection (k), the projections required by this subsection (d) shall be provided to the policyholder in lieu of filing with the Director.

 

e)         If any premium rate in the revised premium rate schedule is greater than 200% of the comparable rate in the initial premium schedule, lifetime projections, as defined in subsection (b)(3)(A), shall be filed for review and approval by the Director every 5 years following the end of the required period in subsection (d).  For group insurance policies that meet the conditions in subsection (k), the projections required by this subsection (e) shall be provided to the policyholder in lieu of filing with the Director.

 

f)         If the Director has determined that the actual experience following a rate increase does not adequately match the projected experience and that the current projections under moderately adverse conditions demonstrate that incurred claims will not exceed proportions of premiums specified in subsection (c), the Director:

 

1)         May require the insurer to implement any of the following:

 

A)        Premium rate schedule adjustments; or

 

B)        Other measures to reduce the difference between the projected and actual experience.

 

2)         Should give consideration to subsection (b)(3)(E) when determining whether the actual experience adequately matches the projected experience.

 

g)         If the majority of the policies or certificates to which the increase is applicable are eligible for the contingent benefit upon lapse, the insurer shall file:

 

1)         A plan, subject to the Director's approval, for improved administration or claims processing designed to eliminate the potential for further deterioration of the policy form requiring further premium rate schedule increases, or both, or to demonstrate that appropriate administration and claims processing have been implemented or are in effect; otherwise the Director may impose the condition in subsection (h); and

 

2)         The original anticipated lifetime loss ratio, and the premium rate schedule increase that would have been calculated according to subsection (c) of this Section had the greater of the original anticipated lifetime loss ratio or 58% been used in the calculations described in subsections (c)(2)(A) and (c)(2)(C).

 

h)         Significant Adverse Lapsation

 

1)         For a rate increase filing that meets the following criteria, the Director shall review, for all policies included in the filing, the projected lapse rates and past lapse rates during the 12 months following each increase to determine if significant adverse lapsation has occurred or is anticipated:

 

A)        The rate increase is not the first rate increase requested for the specific policy form or forms;

 

B)        The rate increase is not an exceptional increase; and

 

C)        The majority of the policies or certificates to which the increase is applicable is eligible for the contingent benefit upon lapse.

 

2)         In the event significant adverse lapsation has occurred, is anticipated in the filing or is evidenced in the actual results as presented in the updated projections provided by the insurer following the requested rate increase, the Director may determine that a rate spiral exists.  Following the determination that a rate spiral exists, the Director may require the insurer to offer, without underwriting, to all in force insureds subject to the rate increase the option to replace existing coverage with one or more reasonably comparable products being offered by the insurer or its affiliates.

 

A)        The offer shall:

 

i)          Be subject to the approval of the Director;

 

ii)         Be based on actuarially sound principles, but not be based on attained age; and

 

iii)        Provide that maximum benefits under any new policy accepted by an insured shall be reduced by comparable benefits already paid under the existing policy.

 

B)        The insurer shall maintain the experience of all the replacement insureds separate from the experience of insureds originally issued the policy forms.  In the event of a request for a rate increase on the policy form, the rate increase shall be limited to the lesser of:

 

i)          The maximum rate increase determined based on the combined experience; and

 

ii)         The maximum rate increase determined based only on the experience of the insured's originally issued form plus 10%.

 

i)          If the Director determines that the insurer has exhibited a persistent practice of filing inadequate initial premium rates for long-term care insurance, the Director may, in addition to the provisions of subsection (h), prohibit the insurer from either of the following:

 

1)         Filing and marketing comparable coverage for a period of up to 5 years; or

 

2)         Offering all other similar coverages and limiting marketing of new applications to the products subject to recent premium rate schedule increases.

 

j)          Subsections (a) through (i) shall not apply to policies for which the long-term care benefits provided by the policy are "Incidental", as defined in Section 2012.30, if the policy complies with all of the following provisions:

 

1)         The interest credited internally to determine cash value accumulations, including long-term care, if any, is guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;

 

2)         The portion of the policy that provides insurance benefits other than long-term care coverage meets the nonforfeiture requirements as applicable in any of the following:

 

A)        Section 229.2 of the Code;

 

B)        Section 229.4 of the Code;

 

3)         The policy meets the disclosure requirements of Sections 351A-9.1 and 9.2 of the Code;

 

4)         The portion of the policy that provides insurance benefits other than long-term care coverage meets the requirements as applicable in the following:

 

A)        Policy illustrations as required by 50 Ill. Adm. Code 1406;

 

B)        Disclosure requirements in 50 Ill. Adm. Code 1551;

 

5)         An actuarial memorandum is filed with the Director that includes:

 

A)        A description of the basis on which the long-term care rates were determined;

 

B)        A description of the basis for the reserves;

 

C)        A summary of the type of policy, benefits, renewability, general marketing method, and limits on ages of issuance;

 

D)        A description and a table of each actuarial assumption used.  For expenses, an insurer must include percent of premium dollars per policy and dollars per unit of benefits, if any;

 

E)        A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives;

 

F)         The estimated average annual premium per policy and the average issue age;

 

G)        A statement as to whether underwriting is performed at the time of application.  The statement shall indicate whether underwriting is used and, if used, the statement shall include a description of the type or types of underwriting used, such as medical underwriting or functional assessment underwriting.  Concerning a group policy, the statement shall indicate whether the enrollee or any dependent will be underwritten and when underwriting occurs; and

 

H)        A description of the effect of the long-term care policy provision on the required premiums, nonforfeiture values and reserves on the underlying insurance policy, both for active lives and those in long-term care claim status.

 

k)         At the request of the insurer, the Director may also consider other options that may be made available to insureds that may mitigate the impact of the rate increases on the insured population or alternative actuarial methodologies relating to the rate increase.  The insurer shall provide an explanation and demonstration on how that methodology is actuarially justified and/or how the new mitigation option may reasonably benefit insureds.  No alternative method/approach may be used until it has been accepted by the Director.

 

l)          Subsections (f) and (h) shall not apply to group insurance policies as defined in Section 351A-1(e)(1) of the Code if:

 

1)         The policies insure 250 or more persons and the policyholder has 5,000 or more eligible employees of a single employer; or

 

2)         The policyholder, and not the certificate holders, pays a material portion of the premium, which shall not be less than 20% of the total premium for the group in the calendar year prior to the year a rate increase is filed.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.113  Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings

 

a)         This Section shall apply as follows:

 

1)         Except as provided in subsection (a)(2), this Section applies to any long-term care policy or certificate issued in this State on or after July 1, 2018.

 

2)         For certificates issued on or after July 1, 2018, under a group long-term care insurance policy as defined in Section 351A-1(e)(1) of the Code, which was in force prior to July 1, 2018, the provisions of this Section shall apply on the policy anniversary following January 1, 2019.

 

b)         An insurer shall provide notice of a pending premium rate schedule increase, including an exceptional increase, to the Director at least 30 days prior to the notice to the policyholders and shall include:

 

1)         Information required by Section 2012.62;

 

2)         Certification by a qualified actuary that:

 

A)        If the requested premium rate schedule increase is implemented and the underlying assumptions, which reflect moderately adverse conditions, are realized, no further premium rate schedule increases are anticipated;

 

B)        The premium rate filing is in compliance with the provisions of this Section;

 

C)        The insurer may request a premium rate schedule increase less than what is required under this Section and the Director may approve that premium rate schedule increase, without submission of the certification in subsection (b)(2)(A), if:

 

i)          the actuarial memorandum discloses the premium rate schedule increase necessary to make the certification required under subsection (b)(2)(A);

 

ii)         the premium rate schedule increase filing satisfies all other requirements of this Section; and

 

iii)        the premium rate schedule increase filing is, in the opinion of the Director, in the best interest of policyholders;

 

3)         An actuarial memorandum justifying the rate schedule change request that includes:

 

A)        Lifetime projections of earned premiums and incurred claims based on the filed premium rate schedule increase and the method and assumptions used in determining the projected values, including reflection of any assumptions that deviate from those used for pricing other forms currently available for sale.

 

i)          Annual values for the 5 years preceding and the 3 years following the valuation date shall be provided separately;

 

ii)         The projections shall include the development of the lifetime loss ratio, unless the rate increase is an exceptional increase;

 

iii)        The projections shall demonstrate compliance with subsection (c); and

 

iv)        For exceptional increases, the projected experience should be limited to the increases in claims expenses attributable to the approved reasons for the exceptional increase. In the event the Director determines, as provided in the definition of "exceptional increase" found in Section 2012.30, that offsets may exist, the insurer shall use appropriate net projected experience;

 

B)        Disclosure of how reserves have been incorporated in this rate increase whenever the rate increase will trigger contingent benefit upon lapse;

 

C)        Disclosure of the analysis performed to determine why a rate adjustment is necessary, which pricing assumptions were not realized and why, and what other actions taken by the company have been relied on by the actuary;

 

D)        A statement that policy design, underwriting and claims adjudication practices have been taken into consideration;

 

E)        In the event that it is necessary to maintain consistent premium rates for new certificates and certificates receiving a rate increase, composite rates, filed by the insurer, reflecting projections of new certificates; and

 

F)         A demonstration that actual and projected costs exceed costs anticipated at the time of initial pricing under moderately adverse experience and that the composite margin specified in Section 2012.64(b)(2)(D) is projected to be exhausted;

 

4)         A statement that renewal premium rate schedules are not greater than new business premium rate schedules except for differences attributable to benefits, unless sufficient justification is provided to the Director; and

 

5)         Sufficient information for review and approval of the premium rate schedule increase by the Director.

 

c)         All premium rate schedule increases shall be determined in accordance with the following requirements:

 

1)         Exceptional increases shall provide that 70% of the present value of projected additional premiums from the exceptional increase will be returned to policyholders in benefits;

 

2)         Premium rate schedule increases shall be calculated such that the sum of the lesser of the accumulated value of incurred claims, without the inclusion of active life reserves, or the accumulated value of historic expected claims, without the inclusion of active life reserves, plus the present value of future projected incurred claims, projected without the inclusion of active life reserves, will not be less than the sum of the following:

 

A)        The accumulated value of the initial earned premium times the greater of:

 

i)          58%; or

 

ii)         the originally filed loss ratio;

 

B)        85% of the accumulated value of prior premium rate schedule increases on an earned basis;

 

C)        The present value of future projected initial earned premiums times the greater of:

 

i)          58%; or

 

ii)         the originally filed loss ratio; and

 

D)        85% of the present value of future projected premiums not in subsection (c)(2)(C) on an earned basis;

 

3)         In the event that a policy form has both exceptional and other increases, the values in subsections (c)(2)(B) and (D) will also include 70% for exceptional rate increase amounts;

 

4)         All present and accumulated values used to determine rate increases shall use the maximum valuation interest rate for contract reserves specified in 50 Ill. Adm. Code 2004 (Accident and Health Reserves).  The actuary shall disclose as part of the actuarial memorandum the use of any appropriate averages; and

 

5)         The present value of future projected incurred claims calculated in subsection (c)(2) shall be on a best estimate basis.

 

d)        For each rate increase that is implemented, the insurer shall file for review and approval by the Director updated projections, as defined in subsection (b)(3)(A), annually for the next 3 years and include a comparison of actual results to projected values.  The Director may extend the period to greater than 3 years if actual results are not consistent with projected values from prior projections.  For group insurance policies that meet the conditions in subsection (k), the projections required by this subsection (d) shall be provided to the policyholder in lieu of filing with the Director.

 

e)         If any premium rate in the revised premium rate schedule is greater than 200% of the comparable rate in the initial premium schedule, lifetime projections, as defined in subsection (b)(3)(A), shall be filed for review and approval by the Director every 5 years following the end of the required period in subsection (d).  For group insurance policies that meet the conditions in subsection (k), the projections required by this subsection (e) shall be provided to the policyholder in lieu of filing with the Director.

 

f)         If the Director has determined that the actual experience following a rate increase does not adequately match the projected experience, and that the current projections under moderately adverse conditions demonstrate that incurred claims will not exceed proportions of premiums specified in subsection (c), the Director:

 

1)         May require the insurer to implement any of the following:

 

A)        Premium rate schedule adjustments; or

 

B)        Other measures to reduce the difference between the projected and actual experience.

 

2)         Should give consideration to subsection (b)(3)(E) when determining whether the actual experience adequately matches the projected experience.

 

g)         If the majority of the policies or certificates to which the increase is applicable are eligible for the contingent benefit upon lapse, the insurer shall file a plan, subject to Director approval, for improved administration or claims processing designed to eliminate the potential for further deterioration of the policy form requiring further premium rate schedule increases, or both, or to demonstrate that appropriate administration and claims processing have been implemented or are in effect. Otherwise, the Director may impose the condition in subsection (h).

 

h)         Significant Adverse Lapsation

 

1)         For a rate increase filing that meets the following criteria, the Director shall review, for all policies included in the filing, the projected lapse rates and past lapse rates during the 12 months following each increase to determine if significant adverse lapsation has occurred or is anticipated:

 

A)        The rate increase is not the first rate increase requested for the specific policy form or forms;

 

B)        The rate increase is not an exceptional increase; and

 

C)        The majority of the policies or certificates to which the increase is applicable is eligible for the contingent benefit upon lapse.

 

2)         In the event significant adverse lapsation has occurred, is anticipated in the filing or is evidenced in the actual results as presented in the updated projections provided by the insurer following the requested rate increase, the Director may determine that a rate spiral exists. Following the determination that a rate spiral exists, the Director may require the insurer to offer, without underwriting, to all in force insureds subject to the rate increase, the option to replace existing coverage with one or more reasonably comparable products being offered by the insurer or its affiliates.

 

A)        The offer shall:

 

i)          Be subject to the approval of the Director;

 

ii)         Be based on actuarially sound principles, but not be based on attained age; and

 

iii)        Provide that maximum benefits under any new policy accepted by an insured shall be reduced by comparable benefits already paid under the existing policy.

 

B)        The insurer shall maintain the experience of all the replacement insureds separate from the experience of insureds originally issued the policy forms. In the event of a request for a rate increase on the policy form, the rate increase shall be limited to the lesser of:

 

i)          The maximum rate increase determined based on the combined experience; and

 

ii)         The maximum rate increase determined based only on the experience of the insureds originally issued the form plus 10%.

 

i)          If the Director determines that the insurer has exhibited a persistent practice of filing inadequate initial premium rates for long-term care insurance, the Director may, in addition to the provisions of subsection (h), prohibit the insurer from either of the following:

 

1)         Filing and marketing comparable coverage for a period of up to 5 years; or

 

2)         Offering all other similar coverages and limiting marketing of new applications to the products subject to recent premium rate schedule increases.

 

j)          Subsections (a) through (i) shall not apply to policies for which the long-term care benefits provided by the policy are "incidental", as defined in Section 2012.30, if the policy complies with all of the following provisions:

 

1)         The interest credited internally to determine cash value accumulations, including long-term care, if any, are guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;

 

2)         The portion of the policy that provides insurance benefits other than long-term care coverage meets the nonforfeiture requirements, as applicable, in either of the following:

 

A)        Section 229.2 of the Code;

 

B)        Section 229.4 of the Code;

 

3)         The policy meets the disclosure requirements of Sections 351A-9.1 and 351A-9.2 of the Code;

 

4)         The portion of the policy that provides insurance benefits other than long-term care coverage meets the requirements, as applicable, in the following:

 

A)        Policy illustrations as required by 50 Ill. Adm. Code 1406;

 

B)        Disclosure requirements in 50 Ill. Adm. Code 1551;

 

5)         An actuarial memorandum is filed with the Director that includes:

 

A)        A description of the basis on which the long-term care rates were determined;

 

B)        A description of the basis for the reserves;

 

C)        A summary of the type of policy, benefits, renewability, general marketing method, and limits on ages of issuance;

 

D)        A description and a table of each actuarial assumption used. For expenses, an insurer must include percent of premium dollars per policy and dollars per unit of benefits, if any;

 

E)        A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives;

 

F)         The estimated average annual premium per policy and the average issue age;

 

G)        A statement as to whether underwriting is performed at the time of application. The statement shall indicate whether underwriting is used and, if used, the statement shall include a description of the type or types of underwriting used, such as medical underwriting or functional assessment underwriting. Concerning a group policy, the statement shall indicate whether the enrollee or any dependent will be underwritten and when underwriting occurs; and

 

H)        A description of the effect of the long-term care policy provision on the required premiums, nonforfeiture values and reserves on the underlying insurance policy, both for active lives and those in long-term care claim status.

 

k)         At the request of the insurer, the Director may also consider other options that may be made available to insureds that may mitigate the impact of the rate increases on the insured population or alternative actuarial methodologies relating to the rate increase.  The insurer shall provide an explanation and demonstration on how the methodology is actuarially justified and/or how the new mitigation option may reasonably benefit insureds.  No alternative method/approach may be used until it has been accepted by the Director.

 

l)          Subsections (f) and (h) shall not apply to group insurance policies as defined in Section 351A-1(e)(1) of the Code if:

 

1)         The policies insure 250 or more persons and the policyholder has 5,000 or more eligible employees of a single employer; or

 

2)         The policyholder, and not the certificateholders, pays a material portion of the premium, which shall not be less than 20% of the total premium for the group in the calendar year prior to the year a rate increase is filed.

 

(Source:  Added at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.115  Filing Requirements for Advertising

 

Every insurer, as defined herein, providing long-term care insurance or benefits in this State shall comply with 50 Ill. Adm. Code 2002.180.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.120  Reserve Standards

 

a)         When long-term care benefits are provided through the acceleration of benefits under group or individual life policies or riders to such policies, policy reserves for such benefits shall be determined in accordance with Section 223 of the Code.  Claim reserves must also be established when the policy or rider is in claim status (see 50 Ill. Adm. Code 2004.40).  Reserves for policies and riders subject to this subsection should be based on the multiple decrement model utilizing all relevant decrements except for voluntary termination rates.  Single decrement approximations are acceptable if the calculation produces reserves which differ from the reserves based on the multiple decrement approach by less than 5% for each combination of issue age and duration, or are greater than the reserves based on the multiple decrement approach, or if the reserves for this line of business are less than 5% of the statutory net worth of the company.  The calculations may take into account the reduction in life insurance benefits due to the payment of long-term care benefits.  However, in no event shall the reserves for the long-term care benefit and life insurance benefit be less than the reserves for the life insurance benefit assuming no long-term care benefit.  In the development and calculation of reserves for policies and riders subject to this subsection, due regard shall be given to the applicable policy provisions, marketing methods, administrative procedures and all other considerations which have an impact on projected claim costs, including, but not limited to, the following:

 

1)         Definition of insured events

 

2)         Covered long-term care facilities

 

3)         Existence of home convalescence care coverage

 

4)         Definition of facilities

 

5)         Existence or absence of barriers to eligibility

 

6)         Premium waiver provision

 

7)         Renewability

 

8)         Ability to raise premiums

 

9)         Marketing method

 

10)         Underwriting procedures

 

11)        Claims adjustment procedures

 

12)        Waiting period

 

13)        Maximum benefit

 

14)        Availability of eligible facilities

 

15)        Margins in claim costs

 

16)        Optional nature of benefit

 

17)        Delay in eligibility for benefit

 

18)        Inflation protection provisions

 

19)        Guaranteed insurability option

 

b)         The valuation morbidity table shall be accompanied by a statement declaring it as appropriate as a statutory valuation table by a member of the American Academy of Actuaries.

 

c)         When long-term care benefits are provided other than as in subsection (a), reserves shall be determined in accordance with Section 353a of the Code.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.121  Producer Training Requirements

 

a)         Long-Term Care Training Required

 

1)         An individual may not sell, solicit or negotiate long-term care insurance unless the individual is licensed as an insurance producer for accident and health and has completed a one-time training course.  The training shall meet the requirements set forth in subsection (b). 

 

2)         An individual already licensed and selling, soliciting or negotiating long-term care insurance on July 1, 2008 may not continue to sell, solicit or negotiate long term care insurance unless the individual has completed a one-time training course, as set forth in subsection (b), by July 1, 2009.

 

3)         In addition to the one-time training course required in subsection (a)(1) and (2), an individual who sells, solicits or negotiates long-term care insurance shall complete ongoing training as set forth in subsection (b).

 

4)         The training requirements of subsection (b) may be approved as continuing education courses under Section 500-35(b)(1) of the Code.

 

b)         Minimum Education and Training Requirements

 

1)         The one-time training required by this Section shall be no less than 8 hours. The ongoing training required by this Section shall be no less than 4 hours and must be completed before each subsequent  license renewal. A producer who fails to complete the 4 hours ongoing training prior to license renewal will have 12 months from that renewal date to complete the ongoing training without having to complete the 8 hour course again.

 

2)         The training required under subsection (b)(1) shall consist of topics related to long-term care insurance, long-term care services and, if applicable, qualified state long-term care insurance Partnership programs as prescribed in 42 USC 1396p, including, but not limited to:

 

A)        State and federal regulations and requirements and the relationship between qualified state long-term care insurance Partnership programs and other public and private coverage of long-term care services, including Medicaid;

 

B)        Available long-term care services and providers;

 

C)        Changes or improvements in long-term care services or providers;

 

D)        Alternatives to the purchase of private long-term care insurance;

 

E)        The effect of inflation on benefits and the importance of inflation protection; and

 

F)         Consumer suitability standards and guidelines.

 

3)         The training required by this Section shall not include training that is insurer or company product specific or that includes any sales or marketing information, materials, or training, other than those required by State or federal law.

 

c)         Verification of Training

 

1)         Insurers subject to this Part shall obtain verification that a producer receives training required by subsection (a) before a producer is permitted to sell, solicit or negotiate the insurer's long-term care insurance products, maintain records subject to the state's record retention requirements, and make that verification available to the Director upon request.

 

2)         Insurers subject to this Part shall maintain records with respect to the training of their producers concerning the distribution of their Partnership policies that will allow the state insurance department to provide assurance to the state Medicaid agency that producers have received the training contained in subsection (b)(2)(A) as required by subsection (a) and that producers have demonstrated an understanding of the Partnership policies and their relationship to public and private coverage of long-term care, including Medicaid, in this State.  These records shall be maintained in accordance with the state's record retention requirements and shall be made available to the Director upon request.

 

d)         The satisfaction of these training requirements in any state shall be deemed to satisfy the training requirements in this State.

 

(Source:  Amended at 38 Ill. Reg. 2186, effective January 2, 2014)

 

Section 2012.122  Standards for Marketing

 

a)         Every insurer, as defined herein, marketing long-term care insurance coverage in this State, directly or through its producers, shall:

 

1)         Establish marketing procedures and producer training requirements to assure that:

 

A)        Any marketing activities, including any comparison of policies, by its agents or other producers will be fair and accurate; and

 

B)        Excessive insurance is not sold or issued.

 

2)         Display prominently by type or stamp or other appropriate means on the first page of the outline of coverage and policy the following:  "NOTICE TO BUYER:  THIS POLICY MAY NOT COVER ALL THE COSTS ASSOCIATED WITH LONG-TERM CARE INCURRED BY THE BUYER DURING THE PERIOD OF COVERAGE.  THE BUYER IS ADVISED TO REVIEW CAREFULLY ALL POLICY LIMITATIONS."

 

3)         Provide copies of the disclosure forms required in Section 2012.62(c) and Exhibits F and J to the applicant.

 

4)         Inquire of a prospective applicant or enrollee for long-term care insurance, and otherwise make every reasonable effort to identify, whether the applicant or enrollee already has accident and sickness or long-term care insurance and the types and amounts of any such insurance, except that, in the case of qualified long-term care insurance contracts, an inquiry into whether a prospective applicant or enrollee for long-term care insurance has accident and sickness insurance is not required.

 

5)         Every insurer or entity marketing long-term care insurance shall establish auditable procedures for verifying compliance with this subsection (a).

 

6)         The insurer shall, at solicitation, provide written notice to the prospective policyholder and certificateholder of the Senior Health Insurance Program (SHIP) that such a program is available and the most current name, address and telephone number of the program.  The current address and toll-free telephone number is One Natural Resources Way, #100 Springfield IL 62702-1271 (800)252-8966.  The current email address is AGING.SHIP@illinois.gov.

 

7)         For long-term care health insurance policies and certificates, use the terms "noncancellable" or "level premium" only when the policy or certificate conforms to Section 2012.50(a)(3).

 

8)         Provide an explanation of the contingent benefit upon lapse provided for in Section 2012.127(d)(2) and, if applicable, the additional contingent benefit upon lapse provided to policies with fixed or limited premium paying periods in Section 2012.127(d)(3).

 

b)         In addition to the practices prohibited in Article XXVI of the Code, the following acts and practices are prohibited:

 

1)         Twisting.  Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any insurance policy or to take out a policy of insurance with another insurer.

 

2)         High pressure tactics.  Employing any method of marketing having the effect of, or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

 

3)         Cold lead advertising.  Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance producer or insurance company.

 

4)         Misrepresentation.  Misrepresenting a material fact in selling or offering to sell a long-term care insurance policy.

 

c)         With respect to the obligations set forth in this subsection, the primary responsibility of an association when endorsing or procuring long-term care insurance shall be to educate its members concerning long-term care issues in general so that its members can make informed decisions.  Associations should provide information regarding long-term care insurance policies or certificates to ensure that members of such associations receive a balanced and complete explanation of the features in the policies or certificates that are being sold by the insurer.

 

1)         The insurer shall file with this Department the following material:

 

A)        The policy and certificate;

 

B)        A corresponding outline of coverage, as referenced in Exhibit C of this Part; and

 

C)        All advertisements requested by the Department.

 

2)         The association shall disclose in any long-term care insurance solicitation:

 

A)        The specific nature and amount of the compensation arrangements (including all fees, commissions, administrative fees and other forms of financial support) that the association receives from the endorsement or sale of the policy or certificate to its members; and

 

B)        A brief description of the processes under which such policies and the insurer issuing such policies were selected.

 

3)         If the association and the insurer have interlocking directorates or trustee arrangements, the association shall disclose that fact to its members.

 

4)         The board of directors of associations shall review and approve such insurance policies as well as the compensation arrangements made with the insurer.

 

5)         With respect to long-term care insurance contracts, the association shall also:

 

A)        Engage the services of a person with expertise in long-term care insurance, not affiliated with the insurer, to conduct an examination of the policies including its benefits, features, and rates and update such examination thereafter in the event of a material change;

 

B)        Actively monitor the marketing efforts of the insurer and its agents; and

 

C)        Review and approve all marketing materials or other insurance communications used to promote sales or sent to members regarding the policies or certificates.

 

6)         No group long-term care insurance policy or certificate may be issued to an association unless the insurer files with this Department the information required in this subsection (c).

 

7)         The insurer shall not issue a long-term care policy or certificate to an association or continue to market such a policy or certificate unless the insurer certifies annually that the association has complied with the requirements set forth in this subsection (c).

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.123  Suitability

 

a)         This Section shall not apply to life insurance policies that accelerate benefits for long-term care.

 

b)         Every insurer, health care service plan or other entity marketing long-term care insurance (the "issuer") shall:

 

1)         Develop and use suitability standards to determine whether the purchase or replacement of long-term care insurance is appropriate for the needs of the applicant;

 

2)         Train its insurance producers in the use of its suitability standards; and

 

3)         Maintain a copy of its suitability standards and make them available for inspection upon request by the Director.

 

c)         To determine whether the applicant meets the standards developed by the issuer:

 

1)         The insurance producer and issuer shall develop procedures that take the following into consideration:

 

A)        The ability to pay for the proposed coverage and other pertinent financial information related to the purchase of the coverage;

 

B)        The applicant's goals or needs with respect to long-term care and the advantages and disadvantages of insurance to meet these goals or needs; and

 

C)        The values, benefits and costs of the applicant's existing insurance, if any, when compared to the values, benefits and costs of the recommended purchase or replacement.

 

2)         The issuer, and where an insurance producer is involved, the insurance producer shall make reasonable efforts to obtain the information referenced in subsection (c)(1).  The efforts shall include presentation to the applicant, at or prior to application, of the " Long-Term Care Insurance Personal Worksheet".  The personal worksheet used by the issuer shall contain, at a minimum, the information in the format contained in Exhibit F, in not less than 12 point type.  The issuer may request the applicant to provide additional information to comply with its suitability standards.  A copy of the issuer's personal worksheet shall be filed with the Director.

 

3)         A completed personal worksheet shall be returned to the issuer prior to the issuer's consideration of the applicant for coverage, except the personal worksheet need not be returned for sales of employer group long-term care insurance to employees and their spouses.

 

4)         The sale or dissemination outside the company or agency by the issuer or insurance producer of information obtained through the personal worksheet in Exhibit F is prohibited.

 

d)         The issuer shall use the suitability standards it has developed pursuant to this Section in determining whether issuing long-term care insurance coverage to an applicant is appropriate.

 

e)         Insurance producers shall use the suitability standards developed by the issuer in marketing long-term care insurance.

 

f)         At the same time as the personal worksheet is provided to the applicant, the disclosure form entitled "Things You Should Know Before You Buy Long-Term Care Insurance" shall be provided.  The form shall be in the format found in Exhibit G, in not less than 12 point type.

 

g)         If the issuer determines that the applicant does not meet its financial suitability standards, or if the applicant has declined to provide the information, the issuer may reject the application.  In the alternative, the issuer shall send the applicant a suitability letter similar to the one found in Exhibit H.  However, if the applicant has declined to provide financial information, the issuer may use some other method to verify the applicant's intent.  Either the applicant's returned letter or a record of the alternative method of verification shall be made part of the applicant's file.

 

h)         The issuer shall report annually by June 30 to the Director the total number of applications received from residents of this State, the number of those who declined to provide information on the personal worksheet, the number of applicants who did not meet the suitability standards, and the number of those who chose to confirm after receiving a suitability letter.

 

(Source:  Amended at 38 Ill. Reg. 2186, effective January 2, 2014)

 

Section 2012.124  Prohibition Against Preexisting Conditions and Probationary Periods in Replacement Policies or Certificates

 

If a long-term care insurance policy or certificate replaces another long-term care policy or certificate, the replacing insurer shall waive any time periods applicable to preexisting conditions and probationary periods in the new long-term care policy for similar benefits to the extent that similar exclusions have been satisfied under the original policy.

 

(Source:  Section 2012.126 renumbered to Section 2012.124 and amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.125  Availability of New Services or Providers

 

a)         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 that are material in nature and not previously available through the insurer to the general public.  The notice shall be provided within 12 months after the date the new policy series is made available for sale in this State.  New long-term care services or providers that are material in nature shall not include changes to policy structure or benefits or provisions that are minor in nature.  Examples of when notification need not be provided include changes in elimination periods, benefit periods and benefit amounts.

 

b)         Notwithstanding subsection (a), notification is not required for any policy issued prior to July 2008, or to any policyholder or certificateholder who is currently eligible for benefits, within an elimination period or on claim, or who previously has been in claim status, or who would not be eligible to apply for coverage due to issue age limitations under the new policy.  The insurer may require that policyholders meet all eligibility requirements, including underwriting and payment of the required premium to add new services or providers.

 

c)         The insurer shall make the new coverage available in one of the following ways:

 

1)         By adding a rider to the existing policy and charging a separate premium for the new rider based on the insured's attained age;

 

2)         By exchanging the existing policy or certificate for one with an issue age based on the present age of the insured and recognizing past insured status by granting premium credits toward the premiums for the new policy or certificate.  The premium credits shall be based on premiums paid or reserves held for the prior policy or certificate;

 

3)         By exchanging the existing policy or certificate for a new policy or certificate in which consideration for past insured status shall be recognized by setting the premium for the new policy or certificate at the issue age of the policy or certificate being exchanged.  The cost for the new policy or certificate may recognize the difference in reserves between the new policy or certificate and the original policy or certificate; or

 

4)         By an alternative program (such as underwriting concessions) developed by the insurer that meets the intent of this Section if the program is filed with and approved by the Director.

 

d)         An insurer is not required to notify policyholders of a new proprietary policy series created and filed for use in a limited distribution channel.  For purposes of this subsection, "limited distribution channel" means through a discrete entity, such as a financial institution or brokerage, for which specialized products are available that are not available for sale to the general public.  Policyholders that purchased such a proprietary policy shall be notified when a new long-term care policy series that provides coverage for new long-term care services or providers that are material in nature is made available to that limited distribution channel.

 

e)         Policies issued pursuant to this Section shall be considered exchanges and not replacements.  These exchanges shall not be subject to Sections 2012.90 and 2012.123 of this Part, and the reporting requirements of Section 2012.95(a) through (e) of this Part.

 

f)         When the policy is offered through an employer, labor organization or professional, trade or occupational association, the required notification in subsection (a) shall be made to the offering entity.  However, if the policy is issued to a group defined in Section 351A-1(e)(4) of the Code, the notification shall be made to each certificateholder.

 

g)         Nothing in this Section shall prohibit an insurer from offering any policy, rider, certificate or coverage change to any policyholder or certificateholder.  However, upon request, any policyholder may apply for currently available coverage that includes the new services or providers.  The insurer may require that policyholders meet all eligibility requirements, including underwriting and payment of the required premium to add new services or providers.

 

h)         This Section does not apply to life insurance policies or riders containing accelerated long-term care benefits.

 

i)          The provisions of this Section apply on and after January 1, 2009.

 

(Source:  Added at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.126  Right to Reduce Coverage and Lower Premiums

 

a)         Coverage Reduction Options

 

1)         Every 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 following ways:

 

A)        Reducing the maximum benefit; or

 

B)        Reducing the daily, weekly or monthly benefit amount.

 

2)         The insurer may also offer other reduction options that are consistent with the policy or certificate design or the carrier's administrative processes.

 

3)         In the event the reduction in coverage involves the reduction or elimination of the inflation protection provision, the insurer shall allow the policyholder to continue the benefit amount in effect at the time of the reduction.

 

b)         The provision shall include a description of the ways in which coverage may be reduced and the process for requesting and implementing a reduction in coverage.

 

c)         The premium for the reduced coverage shall:

 

1)         Be based on the same age and underwriting class used to determine the premium for the coverage currently in force; and

 

2)         Be consistent with the approved rate table.

           

d)         The insurer may limit any reduction in coverage to plans or options available for that policy form and to those for which benefits will be available after consideration of claims paid or payable.

 

e)         If a policy or certificate is about to lapse, the insurer shall provide a written reminder to the policyholder or certificateholder of his or her right to reduce coverage and premiums in the notice required by Section 2012.55(a)(3).

 

f)         This Section does not apply to life insurance policies or riders containing accelerated long-term care benefits.

 

g)         The requirements of this Section shall apply to any long-term care policy issued in this State on or after July 2009.

 

            h)         A premium increase notice required by Section 2012.62(e) shall include:

 

            1)         An offer to reduce policy benefits provided by the current coverage, consistent with the requirements of this Section;

 

                        2)         A disclosure stating that all options available to the policyholder may not be of equal value; and

 

            3)         In the case of a partnership policy, a disclosure that some benefit reduction options may result in a loss in partnership status that may reduce policyholder protections. 

 

i)          The requirements of subsection (h) shall apply to any rate increase implemented in this State on or after January 1, 2019.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.127  Nonforfeiture Benefit Requirement

 

a)         This Section does not apply to life insurance policies or riders containing accelerated long-term care benefits. 

 

b)         To comply with the requirement to offer a nonforfeiture benefit pursuant to Section 2012.86 of this Part:

 

1)         A policy or certificate offered with nonforfeiture benefits shall have coverage elements, eligibility, benefit triggers and benefit length that are the same as coverage to be issued without nonforfeiture benefits.  The nonforfeiture benefit included in the offer shall be the benefit described in Section 2012.127(e); and

 

2)         The offer shall be in writing if the nonforfeiture benefit is not otherwise described in the Outline of Coverage or other materials given to the prospective policyholder.

 

c)         If the offer required to be made under Section 2012.86 is rejected, the insurer shall provide the contingent benefit upon lapse described in this Section. Even if this offer is accepted for a policy with a fixed or limited premium paying period, the contingent benefit upon lapse in subsection (d)(3) shall still apply.

 

d)         After rejection of the offer required under Section 2012.86, for individual and group policies without nonforfeiture benefits, the insurer shall provide the contingent benefit upon lapse:

 

1)         In the event a group policyholder elects to make the nonforfeiture benefit an option to the certificateholder, a certificate shall provide either the nonforfeiture benefit or the contingent benefit upon lapse.

 

2)         For policies or certificates that have reached their twentieth duration, a contingent benefit on lapse shall be triggered every time an insurer increases the premium rates.  For policies or certificates that have not reached their twentieth duration, a contingent benefit on lapse shall be triggered every time an insurer increases the premium rates to a level that results in a cumulative increase of the annual premium equal to or exceeding the percentage of the insured's initial annual premium set forth below based on the insured's issue age, and the policy or certificate lapsing within 120 days after the due date of the premium so increased.  Unless otherwise required, policyholders shall be notified at least 30 days prior to the due date of the premium reflecting the rate increase.

 

Triggers for a Substantial Premium Increase

 

Issue Age		Percent Increase Over Initial Premium
54 and under		100%
55-59		90%
60		70%
61		66%
62		62%
63		58%
64		54%
65		50%
66		48%
67		46%
68		44%
69		42%
70		40%
71		38%
72		36%
73		34%
74		32%
75		30%
76		28%
77		26%
78		24%
79		22%
80		20%
81		19%
82		18%
83		17%
84		16%
85		15%
86		14%
87		13%
88		12%
89		11%
90 and over		10%

 

3)         A contingent benefit upon lapse shall also be triggered for policies with a fixed or limited premium paying period every time an insurer increases the premium rates to a level that results in a cumulative increase of the annual premium equal to or exceeding the percentage of the insured's initial annual premium set forth below based on the insured's issue age, the policy or certificate lapsing within 120 days after the due date of the premium so increased, and the ratio in subsection (d)(5)(B) being 40% or more. Unless otherwise required, policyholders shall be notified at least 30 days prior to the due date of the premium reflecting the rate increase.  This subsection (d)(3) becomes effective January 1, 2009.

 

Triggers for a Substantial Premium Increase

 

Issue Age		Percent Increase Over Initial Premium
Under 65		50%
65-80		30%
Over 80		10%

 

This provision shall be in addition to the contingent benefit provided by subsection (d)(2) and, when both are triggered, the benefit provided shall be at the option of the insured.

 

4)         On or before the effective date of a substantial premium increase as defined in subsection (d)(2), the insurer shall:

 

A)        Offer to reduce policy benefits provided by the current coverage without the requirement of additional underwriting so that required premium payments are not increased;

 

B)        Offer to convert the coverage to a paid-up status with a shortened benefit period in accordance with the terms of subsection (e).  This option may be elected at any time during the 120-day period referenced in subsection (d)(2); and

 

C)        Notify the policyholder or certificateholder that a default or lapse at any time during the 120-day period referenced in subsection (d)(2) shall be deemed to be the election of the offer to convert in subsection (d)(4) unless the automatic option in subsection (d)(5)(C) applies.

 

5)         On or before the effective date of a substantial premium increase, as defined in subsection (d)(3), the insurer shall:

 

A)        Offer to reduce policy benefits provided by the current coverage without the requirement of additional underwriting so that required premium payments are not increased;

 

B)        Offer to convert the coverage to a paid-up status when the amount payable for each benefit is 90% of the amount payable in effect immediately prior to lapse times the ratio of the number of completed months of paid premiums divided by the number of months in the premium paying period.  This option may be elected at any time during the 120-day period referenced in subsection (d)(3); and

 

C)        Notify the policyholder or certificateholder that a default or lapse at any time during the 120-day period referenced in subsection (d)(3) shall be deemed to be the election of the offer to convert in subsection (d)(5)(B) if the ratio is 40% or more.

 

6)         For policies issued prior to July 1, 2002, the insurer shall provide these benefits without amending the contract or certificate to include them.

 

e)         Benefits continued as nonforfeiture benefits, including contingent benefits upon lapse in accordance with subsection (d)(2), but not subsection (d)(3), are described as follows:

 

1)         For purposes of this Section, attained age rating is defined as a schedule of premiums starting from the issue date which increases age at least 1% per year prior to age 50, and at least 3% per year beyond age 50.

 

2)         For purposes of this Section, the nonforfeiture shall be a shortened benefit period providing paid-up traditional long-term care insurance coverage after lapse.  The same benefits (amounts and frequency in effect at the time of lapse but not increased thereafter) will be payable for a qualifying claim, but the lifetime maximum dollars or days of benefits shall be determined as specified in subsection (e)(3).

 

3)         The standard nonforfeiture credit will be equal to 100% of the sum of all premiums paid, including the premiums paid prior to any changes in benefits.  The insurer may offer additional shortened benefit period options, as long as the benefits for each duration equal or exceed the standard nonforfeiture credit for that duration. However, the minimum nonforfeiture credit shall not be less than 30 times the daily nursing home benefit at the time of lapse.  In either event, the calculation of the nonforfeiture credit is subject to the limitation of subsection (f) of this Section.

 

4)         No policy or certificate which includes a nonforfeiture benefit shall begin a nonforfeiture benefit later than the end of the third year following the policy or certificate issue date except that, for a policy or certificate with attained age rating, the nonforfeiture benefit shall begin on the earlier of:

 

A)        The end of the tenth year following the policy or certificate issue date; or

 

B)        The end of the second year following the date the policy or certificate is no longer subject to attained age rating.

 

5)         Nonforfeiture credits may be used for all care and services qualifying for benefits under the terms of the policy or certificate, up to the limits specified in the policy or certificate.

 

f)         All benefits paid by the insurer while the policy or certificate is in premium paying status and in the paid up status will not exceed the maximum benefits which would have been payable if the policy or certificate had remained in premium paying status.

 

g)         There shall be no difference in the minimum nonforfeiture benefits as required under this Section for group and individual policies.

 

h)         The requirements of this Section shall apply to any long-term care policy issued in this State, and shall apply as follows:

 

1)         Except as provided in subsections (h)(2) and (3), the provisions of this Section apply to any long-term care policy issued in this State on or after July 2008.

 

2)         For certificates issued on or after July 2008, under a group long-term care insurance policy issued to one or more employers or labor organizations, or to a trust or to the trustee or trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations, which policy was in force in July 2008, the provisions of this Section shall not apply.

 

3)         The last sentence in subsection (c) and all of subsections (d)(3) and (d)(4) shall apply to any long-term care insurance policy or certificate issued in this State after January 2009, except new certificates on a group policy issued to one or more employers or labor organizations, or to a trust or to the trustee or trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations, after July 2009.

 

i)          Premiums charged for a policy or certificate containing nonforfeiture benefits or a contingent benefit on lapse shall be subject to the loss ratio requirements of Sections 2012.110, 2012.112 or Section 2012.113, whichever is applicable, treating the policy as a whole.

 

j)          To determine whether contingent nonforfeiture upon lapse provisions are triggered under subsection (d)(2) or (d)(3), a replacing insurer that purchased or otherwise assumed a block or blocks of long-term care insurance policies from another insurer shall calculate the percentage increase based on the initial annual premium paid by the insured when the policy was first purchased from the original insurer.

 

k)         A nonforfeiture benefit for qualified long-term care insurance contracts that are level premium contracts shall be offered that meets the following requirements:

 

1)         The nonforfeiture provision shall be appropriately captioned;

 

2)         The nonforfeiture provision shall provide a benefit available in the event of a default in the payment of any premiums and shall state that the amount of the benefit may be adjusted subsequent to being initially granted only as necessary to reflect changes in claims, persistency and interest as reflected in changes in rates for premium paying contracts approved by the Director for the same contract form; and

 

3)         The nonforfeiture provision shall provide at least one of the following:

 

A)        Reduced paid-up insurance;

 

B)        Extended term insurance;

 

C)        Shortened benefit period; or

 

D)        Other similar offerings approved by the Director.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

 

Section 2012.128  Standards for Benefit Triggers

 

a)         A long-term care insurance policy shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment.  Eligibility for the payment of benefits shall not be more restrictive than requiring either a deficiency in the ability to perform not more than 3 of the activities of daily living or the presence of cognitive impairment.

 

b)         Insurers may use activities of daily living to trigger covered benefits as long as they are defined in the policy.  Activities of daily living shall include but not be limited to the following, as defined in Section 2012.40 of this Part and in the policy:

 

1)         Bathing;

 

2)         Continence;

 

3)         Dressing;

 

4)         Eating;

 

5)         Toileting; and

 

6)         Transferring.

 

c)         An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however, the provisions shall not restrict, and are not in lieu of, the requirements contained in subsections (a) and (b) of this Section.

 

d)         For purposes of this Section the determination of a deficiency shall not be more restrictive than:

 

1)         Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

 

2)         If the deficiency is due to the presence of a cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured or others.

 

e)         Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.

 

f)         Long-term care insurance policies shall include a clear description of the process for appealing and resolving benefit determinations.

 

g)         The requirements set forth in this Section shall apply as follows:

 

1)         Except as provided in subsection (g)(2) of this Section, the provisions of this Section apply to a long-term care policy issued in this State.

 

2)         For certificates issued under a group long-term care insurance policy as defined in Section 351A-1(e)(1) of the Code, the provisions of this Section shall not apply.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.129  Additional Standards for Benefit Triggers for Qualified Long-Term Care

 

a)         A qualified long-term care insurance contract shall pay only for qualified long-term care services received by a chronically ill individual provided pursuant to a plan of care prescribed by a licensed health care practitioner.

 

b)         A qualified long-term care insurance contract shall condition the payment of benefits on a determination of the insured's inability to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity or to severe cognitive impairment.

 

c)         Certifications regarding activities of daily living and cognitive impairment required pursuant to subsection (b) of this Section shall be performed by the following licensed or certified professionals:  physicians, registered professional nurses, licensed social workers, or other individuals who meet requirements prescribed by the Secretary of the Treasury under the authority of Section 7702B of the IRS Code (26 USC 7702B).

 

d)         Certifications required pursuant to subsection (b) of this Section may be performed by a licensed health care practitioner at the direction of the carrier as is reasonably necessary with respect to a specific claim, except that when a licensed health care practitioner has certified that an insured is unable to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity and the insured is in claim status, the certification may not be rescinded and additional certifications may not be performed until after the expiration of the 90 day period.

 

e)         Qualified long-term care insurance contracts shall include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.130  Standard Format Outline of Coverage Requirements

 

This Section implements, interprets and makes specific the provisions of Section 351A-8 of the Code in prescribing a standard format and the content of an outline of coverage.

 

a)         The outline of coverage shall be a free-standing document, using no smaller than ten point type.

 

b)         The outline of coverage shall contain no material of an advertising nature.

 

c)         Text which is capitalized or underscored in the standard format outline of coverage may be emphasized by other means which provide prominence equivalent to such capitalization or underscoring.

 

d)         Use of the text and sequence of text of the standard format outline of coverage is mandatory unless otherwise specifically indicated.

 

e)         The standard format, including style, arrangement and overall appearance, and the content of an outline of coverage appears in Exhibit C of this Part.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.140  Requirement to Deliver Shopper's Guide

 

a)         A long-term care insurance shopper's guide in the format developed by the National Association of Insurance Commissioners, or a guide developed or approved by the Director shall be provided to all prospective applicants of a long-term care insurance policy or certificate.

 

1)         In the case of insurance producer solicitations, a producer must deliver the shopper's guide prior to the presentation of an application or enrollment form.

 

2)         In the case of direct response solicitations, the shopper's guide must be presented in conjunction with any application or enrollment form.

 

b)         Life insurance policies or riders containing accelerated traditional long-term care benefits are not required to furnish the above-referenced guide, but shall furnish the policy summary required under Section 351A-9.1 of the Code.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

 

Section 2012.145  Long-Term Care Insurance Partnership Program

 

a)         In accordance with section 6021 of the Deficit Reduction Act of 2005 (42 USC 1305) and the Illinois Long-Term Care Partnership Program Act [215 ILCS 132], in addition to the applicable provisions of this Part, the provisions of this Section shall apply to any qualified State long-term care insurance partnership policy.

 

b)         The policy provides the following inflation protections:

 

1)         If the policy is sold to an individual who has not attained age 61 as of the date of purchase, the policy shall provide compound annual inflation protection at a rate of at least 3%, or at a rate based on the changes in the Consumer Price Index for All Urban Consumers: U.S. city average as determined by the Bureau of Labor Statistics of the U.S. Department of Labor.

 

2)         If the policy is sold to an individual who has attained age 61 but has not attained age 76 as of the date of purchase, the policy shall provide inflation protection expressed in simple or compound interest annually at a rate of at least 3% or at a rate based on the changes in the Consumer Price Index for All Urban Consumers: U.S. city average as determined by the Bureau of Labor Statistics of the U.S. Department of Labor.

 

3)         If the policy is sold to an individual who has attained age 76 as of the date of purchase, the policy may, but is not required to, provide some level of inflation protection.

 

c)         Offers of Exchange

 

1)         An insurer shall offer, on a onetime basis, in writing, to all existing policyholders that were issued a long-term care policy on or after May 5, 2008, the date of the last long-term care (LTC) regulation revision, the option to exchange their existing LTC coverage for coverage that is intended to qualify under Illinois' Long-Term Care Partnership Program (LTCPP). The insurer shall provide written notification of this onetime offer within 12 months from the date on which the company begins to offer partnership coverage in this State.  The offer shall be made on a nondiscriminatory basis without regard to the age or health status of the insured and shall remain open for a minimum of 90 days from the date of mailing by the insurer.

 

2)         The mandatory offer of an exchange shall only apply to products issued by the insurer that are comparable to the type of policy form, such as group policies and individual policies, and on the policy series that the company has certified as partnership qualified. This exchange may be subject to underwriting. 

 

3)         Premiums may be adjusted based on the results of the underwriting process or the exchange may be denied by the insurer. 

 

4)         A policy received in an exchange after the effective date of Illinois' LTCPP is treated as newly issued and is eligible for qualified policy status. For purposes of applying the Medicaid rules relating to qualified LTC partnership policies, the addition of a rider, endorsement or change in schedule page for a policy may be treated as giving rise to an exchange. The effective date of the LTC partnership policy shall be the date the policy was exchanged.

 

d)         Filing Requirements for Long-Term Care Insurance Partnership Policies

 

1)         A partnership policy shall not be issued or issued for delivery in this State unless filed with and approved by the Director in accordance with the procedures set forth in Section 143 of the Code.  Any policy submitted for approval as a partnership policy shall be accompanied by a properly executed Partnership Certification Form (Exhibit M).

 

2)         Insurers requesting to make use of a previously approved policy form as a qualified State LTC partnership policy shall submit to the Director a Partnership Certification Form signed by an officer of the company. The Partnership Certification Form shall be accompanied by a copy of the policy or certificate form listed, the approval date, and a bookmark for each of the requirements listed in sections II and III of the form. A Partnership Certification Form shall be required for each policy form submitted for partnership qualification.

 

e)         Partnership Disclosure Notice

A partnership policy issued or issued for delivery in this State shall include a Partnership Disclosure Notice (Exhibit L) explaining the benefits associated with a partnership policy and indicating that, at the time issued, the policy is a qualified State LTC insurance partnership policy. The Partnership Disclosure Notice shall also include a statement indicating that, by purchasing this partnership policy, the insured does not automatically qualify for Medicaid.

 

f)         Producer Training Requirements

The training requirements for a producer to sell, solicit or negotiate LTC insurance, which includes the LTCPP, are listed in Section 2012.121.  The training requirements must be met before any producer attempts to sell, solicit or negotiate an LTC partnership policy.

 

(Source:  Added at 38 Ill. Reg. 2186, effective January 2, 2014)

 

Section 2012.150  Penalties

 

In addition to any other penalties provided by the laws of this State any insurer or any insurance producer found to have violated any requirement of this State relating to the regulation of long-term care insurance or the marketing of such insurance shall be subject to a fine of up to 3 times the amount of any commissions paid for each policy involved in the violation or up to $10,000, whichever is greater.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT A   Replacement Notice for Other Than Direct Response Solicitations

 

NOTICE TO APPLICANT REGARDING REPLACEMENT OF INDIVIDUAL ACCIDENT AND

SICKNESS OR LONG-TERM CARE INSURANCE

 

[Insurance Company Name and Address]

 

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

 

According to [your application] [information you have furnished], you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with an individual long-term care insurance policy to be issued by [Company Name] Insurance Company.  Your new policy provides 30 days within which you may decide, without cost, whether you desire to keep the policy.  For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

 

You should review this new coverage carefully, comparing it with all accident and sickness or long-term care insurance coverage you have, and terminate your policy only if, after due consideration, you find that purchase of this long-term care coverage is a wise decision.

 

STATEMENT TO APPLICANT BY AGENT [BROKER OR OTHER REPRESENTATIVE]:  (Use additional sheets as necessary)

 

I have reviewed your current medical or health insurance coverage.  I believe the replacement of insurance involved in this transaction materially improves your position.  My conclusion has taken into account the following considerations, which I call to your attention:

 

1.         Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy.  This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.

 

2.         State law provides that your replacement policy or certificate may not contain new preexisting conditions or probationary periods.  The insurer will waive any time periods applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.

 

3.         If you are replacing existing long-term care insurance coverage you may wish to secure the advice of your present insurer or its insurance producer regarding the proposed replacement of your present policy.  This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.

 

4.         If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical health history.  Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force.  After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded.

 

(Signature of Insurance Producer) [Type Name and Address of Insurance Producer]

 

The above "Notice to Applicant" was delivered to me on:

 

(Applicant's Signature)		(Date)

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

Section 2012.EXHIBIT B   Replacement Notice for Direct Response Solicitations

 

NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS OR

LONG-TERM CARE INSURANCE

 

[Insurance Company's Name and Address]

 

SAVE THIS NOTICE!  IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

 

According to [your application] [information you have furnished], you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with the long-term care insurance policy delivered herewith issued by [Company Name] Insurance Company.  Your new policy provides 30 days within which you may decide, without cost, whether you desire to keep the policy.  For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

 

You should review this new coverage carefully, comparing it will all accident and sickness or long-term care insurance coverage you now have, and terminate your present policy only if, after due consideration, you find that purchase of this long-term coverage is a wise decision.

 

1.         Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy.  This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.

 

2.         State law provides that your replacement policy or certificate may not contain new preexisting conditions or probation periods.  Your insurer will waive any time periods applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.

 

3.         If you are replacing existing long-term care insurance coverage you may wish to secure the advice of your present insurer or its insurance producer regarding the proposed replacement of your present policy.  This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.

 

4.         [To be included only if the application is attached to the policy.] If, after due consideration, you still wish to terminate you present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly.  Omissions or misstatements in the application could cause an otherwise valid claim to be denied.  Carefully check the application and write to [Company Name and Address] within 30 days if any information is not correct and complete, or if any past medical history has been left out of the application.

 

(Company Name)

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT C   Standard Format Outline of Coverage

 

[COMPANY NAME]

 

[ADDRESS − CITY & STATE]

 

[TELEPHONE NUMBER]

 

LONG-TERM CARE INSURANCE

 

OUTLINE OF COVERAGE

 

[Policy Number or Group Master Policy and Certificate Number]

 

[Except for policies or certificates which are guaranteed issue, the following caution statement, or language 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, the company has the right to deny benefits or rescind your policy.  The best time to clear up any questions is now, before a claim arises! If for any reason any of your answers are incorrect, contact the company at this address: [insert address]

 

1.         This policy is [an individual policy of insurance] ([a group policy] which was issued in the [indicate jurisdiction in which group policy was issued]).

 

2.         PURPOSE OF OUTLINE OF COVERAGE.  This outline of coverage provides a very brief description of the important features of the policy.  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 individual or group policy contains governing contractual provisions.  This means that the policy or group policy sets forth in detail the rights and obligations of both you and the insurance company.  Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR POLICY (OR CERTIFICATE) CAREFULLY!

 

3.         FEDERAL TAX CONSEQUENCES.

 

This [POLICY] [CERTIFICATE] is intended to be a federally tax-qualified long-term care insurance contract within the meaning of the Internal Revenue Code of 1986, as amended (26 USC 7702B(b)).

 

OR

 

Federal Tax Implications of this [POLICY] [CERTIFICATE].  This [POLICY] [CERTIFICATE] is not intended to be a federally tax-qualified long-term care insurance contract within the meaning of the Internal Revenue Code of 1986 as amended (26 USC 7702B(b)).  Benefits received under the [POLICY] [CERTIFICATE] may be taxable as income.

 

4.         TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE CONTINUED IN FORCE OR DISCONTINUED.

 

a)         [For long-term care health insurance policies or certificates include one of the following permissible policy renewability provisions:]

 

1)         Policies and certificates that are guaranteed renewable shall contain the following statement:  RENEWABILITY:  THIS POLICY [CERTIFICATE] IS GUARANTEED RENEWABLE.  This means you have the right, subject to the terms of your policy [certificate], to continue this policy as long as you pay your premiums on time.  [Company 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.

 

2)         Policies and certificates that are noncancellable shall contain the following statement:  RENEWABILITY:  THIS POLICY [CERTIFICATE] IS NONCANCELLABLE.  This means that you have the right, subject to the terms of your policy, to continue this policy as long as you pay your premiums on time.  [Company Name] cannot change any of the terms of your policy on its own and cannot change the premium you currently pay.  However, if your policy contains an inflation protection feature where you choose to increase your benefits, [Company Name] may increase your premium at that time for those additional benefits.

 

b)         [For group coverage, specifically include continuation/conversion provisions applicable to the certificate and group policy;]

 

c)         [Include waiver of premium provisions or state that there are no such provisions].

 

5.         TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.  [In bold type larger than the maximum type required to be used for the other provisions of the outline of coverage, state whether or not the company has a right to change the premium, and if a right exists, describe clearly and concisely each circumstance under which the premium may change.]

 

6.         TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.

 

a)         [Provide a brief description of the right to return − "free look" provision of the policy.]

 

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.]

 

7.         THIS IS NOT MEDICARE SUPPLEMENT COVERAGE.  If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the insurance company.

 

a)         [For insurance producers] Neither [insert company name] nor its insurance producers represent Medicare, the federal government or any state government.

 

b)         [For direct response] [insert company name] is not representing Medicare, the federal government or any state government.

 

8.         LONG-TERM CARE COVERAGE.  Policies of this category are designed to provide coverage for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital, such as in a nursing home, in the community or in the home.  

This policy 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.  [Modify this paragraph if the policy is not an indemnity policy.]

 

9.         BENEFITS PROVIDED BY THIS POLICY.

 

a)         [Covered services, related deductible(s), waiting periods, elimination periods and benefit maximums.]

 

b)         [Institutional benefits, by skill level.]

 

c)         [Non-institutional benefits, by skill level.]

 

d)         Eligibility for Payment of Benefits.

 

[Activities of daily living and cognitive impairment shall be used to measure an insured's need for long-term care and must be defined and described as part of the outline of coverage.]

 

[Any additional benefit triggers must also be explained in this Section.  If these benefit triggers differ for different benefits, explanation of the triggers 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.]

 

10.       LIMITATIONS AND EXCLUSIONS.

[Describe:

 

a)         Preexisting conditions;

 

b)         Non-eligible facilities/provider;

 

c)         Non-eligible levels of care (e.g., unlicensed providers, care or treatment provided 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 number 9 above.]

THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG-TERM CARE NEEDS.

 

11.       RELATIONSHIP OF COST OF CARE AND BENEFITS.  Because the cost 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 a specified amount or percentage;

 

d)         If there is such 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)         And finally, describe whether there will be any additional premium charge imposed, and how that is to be calculated.]

 

12.       ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS.

[State that the policy provides coverage for insureds clinically diagnosed as having Alzheimer's disease or related degenerative and dementing illnesses. Specifically describe each benefit screen or other policy provision which 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 among benefit options, indicate the portion of annual premium which corresponds to each benefit option.]

 

14.       ADDITIONAL FEATURES.

 

[a)        Indicate if medical underwriting is used;

 

b)         Describe other important features.]

 

15.       CONTACT THE STATE SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM IF YOU HAVE GENERAL QUESTIONS REGARDING LONG-TERM CARE INSURANCE.  CONTACT THE INSURANCE COMPANY IF YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR LONG-TERM CARE INSURANCE POLICY OR CERTIFICATE.

 

16.       GRAPHIC COMPARISON.

A graphic comparison of the benefit levels of a policy that increases benefits over the policy period with a policy that does not increase benefits.  The graphic comparison shall show benefit levels over at least a 20 year period.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT D   Rescission Reporting Format

 

RESCISSION REPORTING FORMS FOR

LONG-TERM CARE POLICIES

FOR THE STATE OF ILLINOIS

FOR THE REPORTING YEAR 20[  ]

 

Company Name:
Address:
Phone Number:

 

Due:  March 1 annually

 

Instructions:

The purpose of this form is to report all rescissions of long-term care insurance policies or certificates.  Those rescissions voluntarily effectuated by an insured are not required to be included in this report.  Please furnish one form per rescission.

 

Policy Form #	Policy and Certificate #	Name of  Insured	Date of  Policy Issuance	Date/s Claim/s Submitted	Date of Rescission

 

Detailed reason for rescission:

 

 

Signature

Name and Title (please type)

Date

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT E   Class of Insurance − Accident and Health (Repealed)

                                                           

(Source:  Repealed at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT F   Long-Term Care Insurance Personal Worksheet

 

People buy long-term care insurance for many reasons. Some don't want to use their own assets to pay for long-term care. Some buy insurance to make sure they can choose the type of care they get. Others don't want their family to have to pay for care or don't want to go on Medicaid.  But long-term care insurance may be expensive, and may not be right for everyone.

 

The company will ask you to fill out this worksheet to help you and the company decide if you should buy this policy.  By State law, the insurance company must fill out part of the information on this worksheet.

 

Premium Information

 

Policy Form Number(s)

The premium for the coverage you are considering will be

[$

per month, or

$

per year,] [a one-time single premium of

$

]

Type of Policy (noncancellable/guaranteed renewable):

The Company's Right to Increase Premiums:

 

[The company cannot raise your rates on this policy.]  [The company has a right to increase premiums on this policy form in the future, provided it raises rates for all policies in the same class in this State.] [Insurers shall use appropriate bracketed statement.  Rate guarantees shall not be shown on this form.]

 

Rate Increase History

 

The company has sold long-term care insurance since [year] and has sold this policy since [year].  [The company has never raised its rates for any long-term care policy it has sold in this State or any other state.]  [The company has not raised its rates for this policy form or similar policy forms in this State or any other state in the last 10 years.]  [The company has raised its premium rates on this policy form or similar policy forms in the last 10 years.  Following is a summary of the rate increases.]

 

[The issuer shall list each premium increase it has instituted on this or similar policy forms in this State or any other state during the last 10 years.  The list shall provide the policy form, the calendar years the form was available for sale, and the calendar year and the amount (percentage) of each increase.]

 

[The insurer shall provide minimum and maximum percentages if the rate increase is variable by rating characteristics.  The insurer may provide, in a fair manner, additional explanatory information as appropriate.]

 

Questions Related to Your Income

 

How will you pay each year's premium?
		From my Income		From my Savings/Investments				My Family will Pay
[ Have you considered whether you could afford to keep this policy if the premiums were raised substantially?]
What is your annual income?  (check one)
Under $10,000				$[10-20,000]		$[20-30,000]
$[30-50,000]				Over $50,000
How do you expect your income to change over the next 10 years? (check one)
No change				Increase		Decrease
If you will be paying premiums with money received only from your own income, a rule of thumb is that you may not be able to afford this policy if the premiums will be more than 7% of your income.
Will you buy inflation protection? (check one)					Yes		No
If not, have you considered how you will pay for the difference between future costs and your daily benefit amount?
		From my Income		From my Savings/Investments				My Family will Pay
The national average annual cost of care in [insert year] was [insert $ amount], but this figure varies across the country.  In ten years the national average annual cost would be about [insert $ amount] if costs increase 5% annually.
What elimination period are you considering?  Number of day _____ Approximate cost
$			for that period of care.
How are you planning to pay for your care during the elimination period? (check one)
		From my Income		From my Savings/Investments				My Family will Pay

 

Questions Related to Your Savings and Investments

 

Not counting your home, about how much are all of your assets (your savings and investments) worth?  (check one)
Under $20,000	$20,000-$30,000		$30,000-$50,000		Over $50,000
How do you expect your assets to change over the next ten years?  (check one)
Stay about the same		Increase		Decrease
If you are buying this policy to protect your assets and your assets are less than $30,000, you may wish to consider other options for financing your long-term care.

 

Disclosure Statement

 

The answers to the questions above describe my financial situation
Or
I choose not to complete this information
(Check one.)
I acknowledge that the carrier and/or its agent (below) has reviewed this form with me including the premium, premium rate increase history and potential for premium increases in the future.  [For direct mail situations, use the following:  I acknowledge that I have reviewed this form including their premium, premium rate increase history and potential for premium increases in the future.]  I understand the above disclosures. I understand that the rates for this policy may increase in the future. (This box must be checked).
Signed:
	(Applicant)			(Date)
[  I explained to the applicant the importance of completing this information.
Signed:
	(Insurance Producer)			(Date)
Insurance Producer's Printed Name:					]
[Choose the appropriate sentences depending on whether this is a direct mail or insurance producer sale.]
[In order for us to process your application, please return this signed statement to [name of company], along with your application.]
[My insurance producer has advised me that this policy does not appear to be suitable for me.  However, I still want the company to consider my application.]
Signed:
	(Applicant)			(Date)
The company may contact you to verify your answers.
[When the Long-Term Care Insurance Personal Worksheet is furnished to employees and their spouses under employer group policies, the text from the heading "Disclosure Statement" to the end of the page may be removed.]

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

Section 2012.EXHIBIT G   Things You Should Know Before You Buy Long-Term Care Insurance

 

Long-Term Care Insurance	·	A long-term care insurance policy may pay most of the costs for your care in a nursing home.  Many policies also pay for care at home or other community settings.  Since policies can vary in coverage, you should read this policy and make sure you understand what it covers before you buy it.
	·	[You should not buy this insurance policy unless you can afford to pay the premiums every year.]  [Remember that the company can increase premiums in the future.]  [For single premium policies, delete this bullet; for noncancellable policies, delete the second sentence only.]
	·	The personal worksheet includes questions designed to help you and the company determine whether this policy is suitable for your needs.
Medicare	·	Medicare does not pay for most long-term care
Medicaid	·	Medicaid will generally pay for long-term care if you have very little income and few assets.  You probably should not buy this policy if you are now eligible for Medicaid.
	·	Many people become eligible for Medicaid after they have used up their own financial resources by paying for long-term care services.
	·	When Medicaid pays your spouse's nursing home bills, you are  allowed to keep your house and furniture, a living allowance, and some of your joint assets.
	·	Your choice of long-term care services may be limited if you are receiving Medicaid.  To learn more about Medicaid, contact your local or State Medicaid agency.
Shopper's Guide	·	Make sure the insurance company or insurance producer gives you a copy of a book called the National Association of Insurance Commissioners' "Shopper's Guide to Long-Term Care Insurance."  Read it carefully.  If you have decided to apply for long-term care insurance, you have the right to return the policy within 30 days and get back any premium you have paid if you are dissatisfied for any reason or choose not to purchase the policy.
Counseling	·	Free counseling and additional information about long-term care insurance is available through your State's insurance counseling program.  Contact your State insurance department or Department on Aging for more information about the senior health insurance counseling program in your State.
Facilities	·	Some long-term care insurance contracts provide for benefit payments in certain facilities only if they are licensed or certified, such as in assisted living centers.  However, not all states regulate these facilities in the same way.  Also, many people move to a different state from where they purchased their long-term care insurance policy.  Read the policy carefully to determine what types of facilities qualify for benefit payments, and to determine that payment for a covered service will be made if you move to a state that has a different licensing scheme for facilities than the one in which you purchased the policy.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT H   Long-Term Care Insurance Suitability Letter

 

Dear [Applicant]:

 

Your recent application for long-term care insurance included a "personal worksheet", which asked questions about your finances and your reasons for buying long-term care insurance.  For your protection, State law requires us to consider this information when we review your application, to avoid selling a policy to those who may not need coverage.

 

[Your answers indicate that long-term care insurance may not meet your financial needs.  We suggest that you review the information provided along with your application, including the booklet "Shopper's Guide to Long-Term Care Insurance"  and the page titled "Things You Should Know Before Buying Long-Term Care Insurance."  Your State insurance department also has information about long-term care insurance and may be able to refer you to a counselor free of charge who can help you decide whether to buy this policy.]

 

[You chose not to provide any financial information for us to review.]

 

We have suspended our final review of your application.  If, after careful consideration, you still believe this policy is what you want, check the appropriate box below and return this letter to us within the next 60 days.  We will then continue reviewing your application and issue a policy if you meet our medical standards.

 

If we do not hear from you within the next 60 days, we will close your file and not issue you a policy. You should understand that you will not have any coverage until we hear back from you, approve your application and issue you a policy.

 

Please check one box and return in the enclosed envelope.

 

 Yes,  [although my worksheet indicates that long-term care insurance may not be a suitable purchase,] I wish to purchase this coverage.  Please resume review of my application.  [Delete the phrase in brackets if the applicant did not answer the questions about income.]

 

 No.  I have decided not to buy a policy at this time.

 

APPLICANT'S SIGNATURE		DATE

 

Please return to [issuer] at [address] by [date].

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT I   Claims Denial Reporting Form:  Long-Term Care Insurance

 

For the State of  Illinois For the Reporting Year of:
Company Name:											Due:  June 30 annually
Company Address:
Company NAIC Number:
Contact Person:							Phone Number:
Line of Business:					Individual			Group

 

Instructions

 

The purpose of this format is to report all long-term care claim denials under in force long-term care insurance policies.  "Denied" means a claim that is not paid for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition.

 

		State Data	Nationwide Data1
1	Total Number of Long-Term Care Claims Reported
2	Total Number of Long-Term Care Claims Denied/Not Paid
3	Number of Claims Not Paid due to Preexisting Condition Exclusion
4	Number of Claims Not Paid due to Waiting (Elimination) Period Not Met
5	Net Number of Long-Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)
6	Percentage of Long-Term Care Claims Denied of Those Reported (Line 5 Divided By Line 1)
7	Number of Long-Term Care Claims Denied due to:
8	·  Long-Term Care Services Not Covered under the Policy2
9	·  Provider/Facility Not Qualified under the Policy3
10	Benefit Eligibility Criteria Not Met4
11	·  Other

 

¹  The nationwide data may be viewed as a more representative and credible indicator where the data for claims and denied for your state are small in number.

²  Example - home health care claim filed under a nursing home only policy.

³  Example - a facility that does not meet the minimum level of care requirements or the licensing requirements as outlined in the policy.

⁴  Example - a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.

 

(Source:  Amended at 32 Ill. Reg. 7600, effective May 5, 2008)

Section 2012.EXHIBIT J   Potential Rate Increase Disclosure

 

Instructions:

 

This form provides information to the applicant regarding premium rate schedules, rate schedule adjustments, potential rate revisions, and policyholder options in the event of a rate increase.

 

Insurers shall provide all of the following information to the applicant:

 

Long-Term Care Insurance

 

Potential Rate Increase Disclosure Form

 

1.  [Premium Rate] [Premium Rate Schedules]:  [Premium rate] [Premium rate schedules] that [is] [are] applicable to you and that will be in effect until a request is made and [filed] [approved] for an increase [is] [are] [on the application] [$     ].

 

2.  The [premium] [premium rate schedule] for this policy [will be shown on the schedule page of] [will be attached to] your policy.

 

3.  Rate Schedule Adjustments:

 

The company will provide a description of when premium rate or rate schedule adjustments will be effective (e.g., next anniversary date, next billing date, etc.) (fill in the blank):

 

4.  Potential Rate Revisions:

 

This policy is Guaranteed Renewable.  This means that the rates for this product may be increased in the future.  Your rates can NOT be increased due to your increasing age or declining health, but your rates may go up based on the experience of all policyholders with a policy similar to yours.

 

If you receive a premium rate or premium rate schedule increase in the future, you will be notified of the new premium amount and you will be able to exercise at least one of the following options:

 

·          Pay the increased premium and continue your policy in force as is.

·          Reduce your policy benefits to a level such that your premiums will not increase.

·          (Subject to state law minimum standards.)

·          Exercise your nonforfeiture option if purchased.  (This option is available for purchase for an additional premium.)

·          Exercise your contingent nonforfeiture rights.*  (This option may be available if you do not purchase a separate nonforfeiture option.)

 

*  Contingent Nonforfeiture

 

If the premium rate for your policy goes up in the future and you didn't buy a nonforfeiture option, you may be eligible for contingent nonforfeiture.  Here's how to tell if you are eligible:

 

You will keep some long-term care insurance coverage, if:

 

·          Your premium after the increase exceeds your original premium by the percentage shown (or more) in the following table; and

·          You lapse (not pay more premiums) within 120 days of the increase.

 

The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will equal the total amount of premiums you've paid since your policy was first issued.  If you have already received benefits under the policy, so that the remaining maximum benefit amount is less than the total amount of premiums you've paid, the amount of coverage will be that remaining amount.

 

Except for this reduced lifetime maximum benefit amount, all other policy benefits will remain at the levels attained at the time of the lapse and will not increase thereafter.

 

Should you choose this Contingent Nonforfeiture option, your policy, with this reduced maximum benefit amount, will be considered "paid-up" with no further premiums due.

 

Example:

 

·          You bought the policy at age 65 and paid the $1,000 annual premium for 10 years, so you have paid a total of $10,000 in premium.

·          In the eleventh year, you receive a rate increase of 50%, or $500 for a new annual premium of $1,500, and you decide to lapse the policy (not pay any more premiums).

·          Your paid-up policy benefits are $10,000 (provided you have at least $10,000 of benefits remaining under your policy.)

 

Contingent Nonforfeiture Cumulative Premium Increase over Initial Premium That qualifies for Contingent Nonforfeiture   (Percentage increase is cumulative from date of original issue. It does NOT represent a one-time increase.)
Issue Age	Percent Increase Over Initial Premium
54 and under	100%
55-59	90%
60	70%
61	66%
62	62%
63	58%
64	54%
65	50%
66	48%
67	46%
68	44%
69	42%
70	40%
71	38%
72	36%
73	34%
74	32%
75	30%
76	28%
77	26%
78	24%
79	22%
80	20%
81	19%
82	18%
83	17%
84	16%
85	15%
86	14%
87	13%
88	12%
89	11%
90 and over	10%

 

[The following contingent nonforfeiture disclosure need only be included for those limited pay policies to which Section 2012.127(d)(3) and (d)(5) are applicable.]

 

In addition to the contingent nonforfeiture benefits described in this Exhibit, the following reduced paid-up contingent nonforfeiture benefit is an option in all policies that have a fixed or limited premium payment period, even if you selected a nonforfeiture benefit when you bought your policy.  If both the reduced paid up benefit AND the contingent benefit described are triggered by the same rate increase, you can choose either of the two benefits.

 

You are eligible for the reduced paid-up contingent nonforfeiture benefit when all three conditions shown below are met:

 

1.         The premium you are required to pay after the increase exceeds your original premium by the same percentage or more shown in the following chart:

 

Triggers for a Substantial Premium Increase
Issue Age		Percent Increase Over Initial Premium
Under 65		50%
65-80		30%
Over 80		10%

 

2.         You stop paying your premiums within 120 days after the premium increase took effect; AND

 

3.         The ratio of the number of months you already paid premiums is 40% or more than the number of months you originally agreed to pay.

 

If you exercise this option, your coverage will be converted to reduced paid-up status.  That means there will be no additional premiums required.  Your benefits will change in the following ways:

 

a.         The total lifetime amount of benefits your reduced paid-up policy will provide can be determined by multiplying 90% of the lifetime benefit amount at the time the policy becomes paid up by the ratio of the number of months you already paid premiums to the number of months you agreed to pay them. 

 

b.         The daily benefit amounts you purchased will also be adjusted by the same ratio. 

 

If you purchased lifetime benefits, only the daily benefit amounts you purchased will be adjusted by the applicable ratio.

 

Example:

 

·          You bought the policy at age 65 with an annual premium payable for 10 years.

 

·          In the sixth year, you receive a rate increase of 35% and you decide to stop paying premiums.

 

·          Because you have already paid 50% of your total premium payments and that is more than the 40% ratio, your paid-up policy benefits are .45 (.90 times .50) times the total benefit amount that was in effect when you stopped paying your premiums.  If you purchased inflation protection, it will not continue to apply to the benefits in the reduced paid-up policy.

 

(Source:  Amended at 42 Ill. Reg. 4867, effective February 27, 2018)

Section 2012.EXHIBIT K   Replacement and Lapse Reporting Form

 

Long-Term Care Insurance

Replacement and Lapse Reporting Form

 

For the State of
Reporting Year of

 

Company Name:					Due:  June 30 annually
Company Address:
Company NAIC Number:
Contact Person:
Phone Number:

 

Instructions

 

The purpose of this form is to report on a statewide basis information regarding long-term care insurance policy replacements and lapses.  Specifically, every insurer shall maintain records for each agent on that agent's amount of long-term care insurance replacement sales as a percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent's total annual sales.  The tables below should be used to report the 10% of the insurer's agents with the greatest percentages of replacements and lapses.

 

Listing of the 10% of Agents with the Greatest Percentage of Replacements

 

Agent's Name	Number of Policies Sold By This Agent	Number of Policies Replaced By This Agent	Number of Replacements As % of Number Sold By This Agent

 

Listing of the 10% of Agents with the Greatest Percentage of Lapses

 

Agent's Name	Number of Policies Sold By This Agent	Number of Policies Lapsed By This Agent	Number of Lapses As % of Number Sold By This Agent

 

Company Totals:

 

Percentage of Replacement Policies Sold to Total Annual Sales		%
Percentage of Replacement Policies Sold to Policies in Force (as of the end of the preceding calendar year)		%
Percentage of Lapsed Policies to Total Annual Sales		%
Percentage of Lapsed Policies to Policies in Force (as of the end of the preceding calendar year)		%

 

(Source:  Added at 32 Ill. Reg. 7600, effective May 5, 2008)

 

 

Section 2012.EXHIBIT L   Long-Term Care Insurance Partnership Disclosure Notice

 

Long-Term Care Insurance Partnership Disclosure Notice

(Company Name)

(Company Address)

 

(Policyholder/Certificateholder) Name:

(Policy/Certificate) Number/Identifier:

Effective Date:

 

Important Information Regarding Your Policy's (Certificate's)

Long-Term Care Insurance Partnership Status

 

NOTE: Please keep this notice with your long term care insurance policy (certificate)

 

Partnership Policy (Certificate) Status. Your long-term care insurance policy (certificate) is intended to qualify as a Partnership Policy (Certificate) under the Illinois Long-Term Care Partnership Program as of your Policy's (Certificate's) effective date.

 

The long-term care insurance policy (certificate) recently purchased and enclosed qualifies for the Illinois Long-Term Care Insurance Partnership Program. Insurance companies voluntarily agree to participate in the Partnership Program by offering long term care insurance coverage that meets certain state and federal requirements. Long-Term Care Insurance Policies (Certificates) that qualify as Partnership Policies (Certificates) may protect your assets through a feature known as "Asset Disregard" under Illinois' Medicaid Program.

 

Asset Disregard means that an amount of the policyholder's (certificateholder's) assets equal to the amount of long-term care insurance benefits received under a qualified Partnership Policy (Certificate) will be disregarded for the purpose of determining the insured's eligibility for Medicaid. This generally allows a person to keep assets equal to the insurance benefits received under a qualified Partnership Policy (Certificate) without affecting the person's eligibility for Medicaid. In addition, the purchase of this Partnership Policy does not automatically qualify you for Medicaid.

 

What Could Disqualify Your Policy (Certificate) as a Partnership Policy. If you make any changes to your policy (certificate), such changes could affect whether your policy (certificate) continues to be a Partnership Policy (Certificate). Before you make any changes, you should consult with (carrier name) to determine the effect of a proposed change. In addition, if you move to a state that does not maintain a Partnership Program or does not recognize your policy (certificate) as a Partnership Policy (Certificate), you would not receive beneficial treatment of your policy (certificate) under the Medicaid program of that state. The information contained in this disclosure is based on current Illinois and Federal law. These laws may be subject to change. Any change in law could reduce or eliminate the beneficial treatment of your policy (certificate) under Illinois' Medicaid Program.

 

Additional Information. If you have questions regarding long-term care insurance policies (certificates), please contact (carrier name). If you have questions regarding current laws governing Medicaid eligibility, you should contact the Illinois Department of Healthcare and Family Services.

 

(Source:  Added at 38 Ill. Reg. 2186, effective January 2, 2014)

 

 

Section 2012.EXHIBIT M   Long-Term Care Insurance Partnership Certification Form

 

Long-Term Care Insurance Partnership Certification Form

 

NOTE:  This Form must be completed and submitted with each long-term care policy or certificate form for which the insurer is seeking Partnership qualification.  A separate form must be completed for each policy form and a specimen copy of the form, including all riders and endorsements, must be attached.  A long-term care insurance policy or certificate form may not be issued in Illinois as a partnership policy or certificate unless and until this form has been submitted to and approved by the Illinois Department of Insurance.

 

Under section 1917(b)(5)(B)(iii) of the Social Security Act (42 USC 1396p(b)(5)(B)(iii)), the state insurance commissioner of a state implementing a qualified state long-term care insurance partnership ("Qualified Partnership") may certify that long-term care insurance policies (including certificates issued under a group insurance contract) covered under the Qualified Partnership meet certain consumer protection requirements, and policies so certified are deemed to satisfy those requirements.  These consumer protection requirements are set forth in section 1917(b)(5)(A) of the Social Security Act (42 USC 1396p(b)(5)(A)) and principally include certain specified provisions of the Long-Term Care Insurance Model Regulation and Long-Term Care Insurance Model Act promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000) (referred to herein as the "2000 Model Regulation" and "2000 Model Act", respectively).

 

 

I.          GENERAL INFORMATION

 

A.        Name, address and telephone number of issuer:

 

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

B.        Name, address, telephone number, and email address (if available) of an employee of issuer who will be the contact person for information relating to this form:

 

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

C.        Policy form numbers (or other identifying information, such as certificate series) for policies covered by this Issuer Certification Form:

 

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

 

Specimen copies of each of the above policy forms, including any riders and endorsements, shall be provided upon request.

 

II.        QUESTIONS REGARDING APPLICABLE PROVISIONS

 

Please answer each of the questions below with respect to the policy forms identified in section I.C above.  For purposes of answering the questions below, any provision of the 2000 Model Regulation or 2000 Model Act listed below shall be treated as including any other provision of the 2000 Model Regulation or 2000 Model Act necessary to implement the provision. 

 

NAIC Model Regulation Requirement	Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable
Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5), and the requirements of Section 6B of the 2000 Model Act relating to Section 6A
Section 6B (relating to prohibitions on limitations and exclusions), other than paragraph (7)
Section 6C (relating to extension of benefits)
Section 6D (relating to continuation or conversion of coverage)
Section 6E (relating to discontinuance and replacement of policies)
Section 7 (relating to unintentional lapse)
Section 8 (relating to disclosure), other than Sections 8F, 8G, 8H and 8I
Section 9 (relating to required disclosure of rating practices to consumer)
Section 11 (relating to prohibitions against post-claims underwriting)
Section 12 (relating to minimum standards)
Section 14 (relating to application forms and replacement coverage)
Section 15 (relating to reporting requirements)
Section 22 (relating to filing requirements for marketing)
Section 23 (relating to standards for marketing), including inaccurate completion of medical histories, other than paragraphs (1), (6) and (9) of Section 23C
Section 24 (relating to suitability)
Section 25 (relating to prohibition against pre-existing conditions and probationary periods in replacement policies or certificates)
Section 26 (relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in section 7702B(g)(4) of the Internal Revenue Code of 1986 (26 USC 7702B(g)(4))
Section 29 (relating to standard format outline of coverage)
Section 30 (relating to requirement to deliver shopper's guide)

 

NAIC Model Act Requirements	Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable
Section 6C (relating to pre-existing conditions)
Section 6D (relating to prior hospitalization)
Section 8 (relating to contingent nonforfeiture benefits)
Section 6F (relating to right to return)
Section 6G (relating to outline of coverage)
Section 6H (relating to requirements for certificates under group plans)
Section 6J (relating to policy summary)
Section 6K (relating to monthly reports on accelerated death benefits)
Section 7 (relating to incontestability period)

 

Part III.  INFLATION PROTECTION

 

Identify the policy provision or provide form number of endorsement or amendment form (and date of approval) for inflation protection coverage in compliance with 50 Ill. Adm. Code 2012.145(b)(1) through (b)(3).

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Part IV.  Certification

 

I hereby certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct and complete and the policy [certificate] satisfies the requirements necessary for a qualified State long-term care insurance partnership policy in the State of Illinois.

 

__________________                  _____________________________________________

Date                                              Name and Title of Officer of the Insurer

 

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Signature of Officer of the Insurer

 

(Source:  Added at 38 Ill. Reg. 2186, effective January 2, 2014)