D.C. Mun. Regs. tit. 26-A, § 2699
For the purposes of this chapter, the following words and phrases shall have the meanings ascribed:
Activities of daily living - at least bathing, continence, dressing, eating, toileting, and transferring.
Acute condition - condition where the individual is medically unstable. Such an 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 - a program for six (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.
Applicant - has the same meaning as set forth in section 2(1) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(1) (2001)).
Bathing - 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.
Certificate - has the same meaning as set forth in section 2(2) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(2) (2001)).
Cognitive impairment - 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.
Commissioner - the Commissioner of the Department of Insurance, Securities, and Banking.
Continence - 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 - putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.
Eating - 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.
Group long-term care insurance - has the same meaning as set forth in section 2(4) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(4) (2001)).
Hands-on assistance - physical assistance (minimal, moderate, or maximal) without which the individual would not be able to perform the activities of daily living.
Home health care services - medical and nonmedical services provided to ill, disabled, or infirm persons in their residences. Such services may include homemaker services, assistance with activities of daily living, and respite care services.
Incidental - as used in section 2631, that the value of the long-term care benefits provided is less than ten percent (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.
Long-term care insurance - has the same meaning as set forth in section 2(5) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(5) (2001)).
Medicare - '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.
Personal care - the provision of hands-on services to assist an individual with activities of daily living.
Policy - has the same meaning as set forth in section 2(7) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(7) (2001)).
Qualified actuary - a member in good standing of the American Academy of Actuaries.
Qualified long-term care insurance contract - has the same meaning as set forth in section 2(8) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(8) (2001)).
Similar policy forms - 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 in section 2(4)(A) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(4)(A) (2001)) are not considered similar to certificates or policies otherwise issued as long-term care insurance, but shall be considered similar to other comparable certificates with the same long-term care benefit classifications. For the 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.
Toileting - getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
Transferring - moving into or out of a bed, chair, or wheelchair.
Long-Term Care Insurance Policies
For the District Of Columbia
For the Reporting Year of _____
Due: March 1 annually
Company Name:
Address:
Phone Number:
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
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.
Under District of Columbia law, the insurance company must fill out part of the information on this worksheet and ask you to fill out the rest to help you and the company decide if you should buy this policy.
Policy Form Numbers ___
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 the District of Columbia.] [Insurers shall use the appropriate bracketed statement. Rate guarantees shall not be shown on this form.]
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 the District of Columbia or any other state.] [The company has not raised its rates for this policy form or similar policy forms in the District of Columbia 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.]
Drafting Note: A company may use the first bracketed sentence above only if it has never increased rates under any prior policy forms in the District of Columbia or any other state. The issuer shall list each premium increase it has instituted on this or similar policy forms in the District of Columbia 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.
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 went up, for example, by 20%?]
Drafting Note: The issuer is not required to use the bracketed sentence if the policy is fully paid up or is a noncancellable policy.
What is your annual income? (check one) Under $10,000 $[10-20,000]
$[20-30,000] $[30-50,000] Over $50,000
Drafting Note: The issuer may choose the numbers to put in the brackets to fit its suitability standards.
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.
Drafting Note: The projected cost can be based on federal estimates in a current year. In the above statement, the second figure equals 163% of the first figure.
What elimination period are you considering?
Number of days _ 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
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.
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 the 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: ____ (Agent) ______ (Date)
Agent's Printed Name: ]
[In order for us to process your application, please return this signed statement to [name of company] , along with your application.]
[My agent has advised me that this policy does not seem to be suitable for me. However, I still want the company to consider my application.
Signed: ____ ____
(Applicant) (Date) ]
Drafting Note: Choose the appropriate sentences depending on whether this is a direct mail or agent sale.
The company may contact you to verify your answers.
Drafting Note: 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 model may be removed.
Long-Term Care Insurance
Long-Term
Care
Insurance
Drafting Note: For single premium policies, delete this bullet; for noncancellable policies, delete the second sentence only.
Medicare
Medicaid
Shopper's
Guide
Counseling
insurance department or department on aging for more information about the senior health insurance counseling program in your state.
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, District of Columbia 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.” The District of Columbia 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.]
Drafting Note: Choose the paragraph above that applies.
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.
Drafting Note: 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] .
Long-Term Care Insurance
For the District of Columbia
For the Reporting Year of _
Due: June 30 annually
Company Name: ________
Company Address: __________
Company NAIC Number: ___________
Contact Person: ____ Phone Number: ______
Line of Business: Individual Group
The purpose of this form 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.
| D.C. 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 reported and denied for the District of Columbia 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. Examples — a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.
Potential Rate Increase Disclosure Form
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:
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:
Turn the Page
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:
The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will equal the total amount of premiums you have 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 have 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:
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| 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 |
| 29 and under | 200% |
| 30-34 | 190% |
| 35-39 | 170% |
| 40-44 | 150% |
| 45-49 | 130% |
| 50-54 | 110% |
| 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% |
Replacement and Lapse Reporting Form
For the District of Columbia
For the Reporting Year of _
Due: June 30 annually
Company Name: ________
Company Address: __________
Company NAIC Number: ___________
Contact Person: ___ Phone Number: (_) ______
The purpose of this form is to report on a District of Columbia-wide 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 ten percent (10%) of the insurer's agents with the greatest percents of replacements and lapses.
| Agent's Name | Number of Policies Sold by this Agent | Number of Policies Replaced by this Agent | Number of Replacements as Percent of Number Sold by this Agent |
|---|---|---|---|
| Agent's Name | Number of Policies Sold by this Agent | Number of Policies Lapsed by this Agent | Number of Lapses as Percent of Number Sold by this Agent |
|---|---|---|---|
Percent of Replacement Policies Sold to Total Annual Sales ____%
Percent of Replacement Policies Sold to Policies In Force (as of the end of the preceding
calendar year) ____%
Percent of Lapsed Policies to Total Annual Sales ____%
Percent of Lapsed Policies to Policies In Force (as of the end of the preceding calendar year) ____%
SOURCE: Final Rulemaking published at 52 DCR 10902 (December 16, 2005); as amended by Final Rulemaking published at 55 DCR 3759 (April 11, 2008).