LONG-TERM CARE INSURANCE ACT
415-D:5 Disclosure and Performance Standards for Long-Term Care Insurance; Rulemaking.
The commissioner may adopt rules, under RSA 541-A, that include standards for:
I. Full and fair disclosure, that set forth the manner, content, and required disclosures for the sale of long-term care insurance policies and certificates, terms of renewability, initial and subsequent conditions of eligibility, non-duplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, continuation or conversion, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, recurrent conditions, and definitions of terms.
II. No long-term care insurance policy may:
(a) Be cancelled, nonrenewed or otherwise terminated on the grounds of the age or deterioration of the mental or physical health of the insured individual or certificate holder.
(b) Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, 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.
(d) Be misleading or unreasonably confusing in connection with either the purchase of long-term care insurance or the settlement of claims.
(e) Be contrary to the health care needs of the public.
(f) Be so limited in scope as to be of no significant economic value to the holders of such policy.
(g) Be issued if not specifically authorized by statute.
(h) In the opinion of the commissioner, be unjust, unfair, and unfairly discriminatory to the policyholder, certificate holder, subscriber or any other person insured under the policy or certificate, or the beneficiary.
III. (a) No long-term care insurance policy or certificate shall use a definition of preexisting condition that is more restrictive than the following: "Preexisting condition" means a condition for which medical advice or treatment was recommended by, or received from a provider of health care services, within 6 months preceding the effective date of coverage of an insured person.
(b) No long-term care insurance policy or certificate may exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within 6 months following the effective date of coverage of an insured person.
(c) The commissioner may extend the limitation periods set forth in subparagraphs (a) and (b) as to specific age group categories in specific policy forms upon findings that the extension is in the best interest of the public.
(d) The definition of "preexisting condition" does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that insurers established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in subparagraph (b) expires. No long-term care insurance policy or certificate may exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subparagraph (b).
IV. (a) No long-term care insurance policy may be delivered or issued for delivery in this state if such policy:
(1) Conditions eligibility for any benefits on a prior hospitalization requirement;
(2) Conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care; or
(3) Conditions eligibility for any benefits other than waiver of premium, post-confinement, post-acute care, or recuperative benefits on a prior institutionalization requirement.
(b) A long-term care insurance policy containing post-confinement, post-acute care, or recuperative benefits shall clearly label in a separate paragraph of the policy or certificate entitled "Limitations or Conditions on Eligibility for Benefits" such limitations or conditions, including any required number of days of confinement.
(c) A long-term care insurance policy or rider that conditions eligibility of noninstitutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than 30 days.
(d) No long-term care insurance policy or rider that provides benefits only following institutionalization shall condition such benefits upon admission to a facility for the same or related conditions within a period of less than 30 days after discharge from the institution.
(e) The commissioner may adopt rules establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term care insurance policies is contained in the rule.
Source. 2003, 180:1, eff. Aug. 23, 2003.