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WACs > Title 284 > Chapter 284-54 > Section 284-54-350











284-54-300    

284-54-500







No agency filings affecting this section since 2003







WAC 284-54-350









Form to be used—Long-term care insurance disclosure form.









No later than January 1, 1996, the disclosure form shall be substantially as follows:

(Company Name)
Disclosure Form
Long-term Care Insurance


The decision to buy a new long-term care policy is very important. It should be carefully considered.
The following data give you some general tips and furnish you with a summary of benefits available under our policy.
Your long-term care policy provides thirty days (sixty days for direct response insurers) within which you may decide without cost whether you wish to keep it. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available under your policy.
If you now have insurance which provides benefits for long-term care, read your policy carefully. Look for what is said about renewing it. See if it contains waiting periods before benefits are paid. Note how it covers preexisting conditions (health conditions you already have). Compare these features with similar ones in any new policy. Use this information to measure the value of any insurance or health care plans you now have.

DON'T BUY MORE INSURANCE THAN YOU REALLY NEED. One policy that meets your needs is usually less expensive than several limited policies.
If you are eligible for state medical assistance coupons (medicaid), you should not purchase a long-term care insurance policy.
After you receive your policy, make sure you have received the coverage you thought you bought. If you are not satisfied with the policy, you may return it within thirty days (sixty days for direct response insurer) for a full refund of premium.

LTC DISCLOSURE FORM

1. INSTITUTIONAL CARE    

     

What levels of care are covered by the policy? YES   NO

Does the policy provide benefits for these levels of care?    

Skilled Nursing Care?      

Intermediate Nursing Care?      

Custodial/Personal Care?      

(By state law, all long-term care policies in Washington State must cover all
three of the above levels of care.)
   

     

Where can care be received and be covered under the policy?    

Does the policy pay for care in any licensed facility?      

If no, define the restrictions on where care can be obtained:  

Is the alternative plan of care benefit available with institutional part of policy?   If yes, see section 2  

Does the alternative plan of care benefit include home care?   If yes, see section 2  

Does the alternative plan of care benefit include structural home improvements?      

     

2. HOME/COMMUNITY BASED CARE    

     

What types of care are covered by the policy?    

Does the policy provide home care benefit for:    

Check all that apply    

Adult day care      

Adult day health care      

Chore services      

Home health aides      

Homemaker services      

Hospice      

Hygiene/personal care      

Laboratory services      

Meals/nutrition services      

Medical equipment/supplies      

Prescription drugs      

Physician/nursing services      

Respite care      

Social workers      

Therapies (List)      

Transportation      

Other:                                
     

Are these separate or post-confinement benefits? Separate   Post - Confinement  

Where can home/community-based care be received?      

Check all that apply      

Adult day care centers      

Alternative care facilities      

Assisted living facilities      

Boarding homes      

Community centers      

Congregate care facilities      

Multiple family residences      

Single family residences      

Other:                               
     

Does the alternative plan of care benefit include home care?      

Does the alternative plan of care benefit include structural improvements?      

Must the alternative plan of care be pre-certified?
If yes, by whom?                           

     

       

3. BOTH INSTITUTIONAL AND COMMUNITY-BASED CARE      

       

What is the maximum daily benefit amount for: YES/NO/COMMENTS

Institutional/nursing home care?  

Home/Community Based Care?  

Are there limits on the number of days (or visits) per year for which
benefits will be paid for:
     

Institutional/nursing home care?  

Home/Community based care?  

What are the dollar limits the policy will pay during the policyholder's lifetime for:  

Institutional/Nursing home care?  

Home/Community based care?  

Total lifetime limit?  

What basic features and benefits does the policy offer?      

Is the policy guaranteed renewable?      

Can you purchase additional increments of coverage? If yes:  

When can additional coverage be purchased?  

How much can be purchased?  

When is additional coverage no longer available for purchase?  

Does the policy have inflation protection?      

If yes, what is the % amount of the increase?  

Is the rate of increase simple or compound?  

When do increases stop?  

If policy includes inflation coverage, what is the daily benefit for:      

Institutional/nursing home care.      

5 years from policy effective date?  

10 years from policy effective date?  

Home/Community based care.      

5 years from policy effective date?  

10 years from policy effective date?  

After the limits have been reached for inflation adjustments, what is the maximum
daily benefit for:
 

Institutional/nursing home care  

Home/community based care  

After the limits have been reached for inflation adjustments, what is the maximum
lifetime benefit for:
     

Institutional/nursing home care  

Home/community based care  

Is there a waiver of premium provision for:      

Institutional/nursing home care?      

Home/community based care?      

How many days of confinement in an institution are required before the waiver of
premium benefit is available?
 

How many days of confinement at home are required before the waiver of premium
benefit is available?
 

How many days of benefits must be paid before waiver is effective?  

Does the policy have a nonforfeiture benefit?      

If yes, how many years must policy be in effect before the insured benefits from
nonforfeiture values?
 

What would the benefit value be in terms of dollars after 20 years?  

What does the nonforfeiture benefit promise? (give an appropriate example showing
dollars and time limits)
 

Does the policy have a death benefit?      

If yes, specify value (in dollars of %)  

What conditions or limitations apply, if any?  

Does the policy have a restoration of benefits provision?      

If yes, give amount of benefit and minimum required # of days between benefits.  

If disability recurs, is there a new elimination or waiting period before benefits
begin again?
     

If yes, after how long?  

How long is the waiting period for preexisting conditions?  

How is the preexisting condition defined?  

When do benefits begin?      

How long is the elimination or waiting period before benefits begin for:      

Institutional/nursing home care?  

Home/community based care?  

What gatekeepers are required before benefits start?      

Doctor certification      

Case management      

If yes, by whom?  

Medical necessity      

Plan of treatment      

If yes, by whom?  

Inability to perform activities of daily living (ADLs)      

If yes, how many ADLs must fail before benefits begin?  

If the policy uses an ADL gatekeeper(s), define "inability to perform ADL."    

Is there a separate benefit qualification requirement if there is a cognitive impairment?      

Who determines a qualifying event?  

Define any separate benefit qualification requirement if there is a cognitive impairment:  

What does the policy cost?      

How often can the premium increase?  

By how much annually can the premium increase?  

Is there a discount if both spouses buy policies?      

If so, how much?  

Do you lose the discount if one spouse dies?      

       

4. ADDITIONAL POLICY INFORMATION      

Use this space to outline additional benefits, further explanations or clarifications      

       

       

5. POLICY DEFINITIONS
     

(Include definitions of policy provisions)      

WHAT DOES THE POLICY COST?

COMPANY NAME . . . . . . . .
POLICY OPTION 1
_____ 

POLICY OPTION 2
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POLICY OPTION 3
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POLICY OPTION 4
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ELIMINATION (DEDUCTIBLE)
PERIOD
BENEFIT PERIOD
$ BENEFIT FOR DAY
$ MAXIMUM BENEFIT
 

 
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Institutional/Nursing Home
 
Home Health/Community Based

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PREMIUM SUBTOTAL $ _____  _____  _____  _____ 

OPTIONAL BENEFITS
Inflation
Non Forfeiture
Spousal Discount
Death Benefit
Other _____
Other _____
Other _____

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PREMIUM TOTAL $ _____  _____  _____  _____ 

BENEFIT "TRIGGERS"
(QUALIFICATION REQUIREMENTS)
 
List _____
List _____
List _____

 
 
 
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[Statutory Authority: RCW 48.02.060, 48.84.030 and 48.84.050. WSR 95-19-028 (Order R 95-5), § 284-54-350, filed 9/11/95, effective 10/12/95. Statutory Authority: RCW 48.02.060(3), 48.30.010 and 48.84.910. WSR 87-15-027 (Order R 87-7), § 284-54-350, filed 7/9/87.]