Published: 2015
Key Benefits:
[Rev. 9/25/2018 2:03:11 PM]
[NAC-687B Revised Date: 9-18]
CHAPTER 687B - CONTRACTS OF INSURANCE
GENERAL PROVISIONS
687B.0002 Definitions.
687B.0005 “Commissioner” defined.
687B.001 “Division” defined.
687B.004 Procedures for filing certain forms and paying certain fees.
CONTRACTS FOR LONG-TERM CARE
687B.005 Definitions.
687B.010 “Applicant” defined.
687B.012 “Basis for continuation of coverage” defined.
687B.013 “Basis for conversion of coverage” defined.
687B.015 “Certificate” defined.
687B.019 “Converted policy” defined.
687B.021 “Exceptional increase” defined.
687B.025 “Group long-term care insurance” defined.
687B.030 “Long-term care insurance” defined.
687B.0303 “Long-term care insurance contract” defined.
687B.0306 “Partnership certificate” defined.
687B.0309 “Partnership policy” defined.
687B.033 “Qualified actuary” defined.
687B.0332 “Qualified long-term care insurance contract” or “federally tax-qualified long-term care insurance contract” defined.
687B.0335 “Qualified state long-term care insurance partnership contract” or “partnership contract” defined.
687B.034 “Similar long-term care insurance contract forms” defined.
687B.0342 “Similar organization” defined.
687B.035 Scope.
687B.040 Compliance required.
687B.045 Modification or suspension of provisions.
687B.050 Organizational requirements.
687B.051 Licensing and training requirements.
687B.052 Required reports.
687B.053 Compensation to producers for sale, renewal or replacement of contract or certificate.
687B.054 Producer not authorized to sell, solicit or negotiate except as authorized by certain statutes.
687B.055 Contracts issued in other states.
687B.056 Standards of suitability: Development; use.
687B.0565 Standards of suitability: Procedure when applicant does not meet standards or declines to provide information.
687B.057 Standards of suitability: Annual report to Commissioner.
687B.0575 Standards of suitability: Insurer to provide form regarding long-term care insurance.
687B.058 Partnership program notice.
687B.0585 Required disclosures regarding rate revisions.
687B.059 Insurer to submit disclosures regarding rate revisions and actuarial certification to Commissioner for approval.
687B.060 Right to return individual contracts or certificates; notice of right.
687B.0655 Requirements for long-term care insurance sold in conjunction with another insurance product.
687B.066 Provision for reinstatement in event of lapse of coverage.
687B.067 Applications: Questions; required statements; required information for applicants 80 years of age or older.
687B.068 Right to copy of application or enrollment form.
687B.0681 Designation of person to receive notice of lapse or termination of coverage.
687B.0682 Verification of enrollment in group policy; satisfaction of any requirement for signature of insured.
687B.0683 Delivery of contract or certificate.
687B.0684 Delivery of policy summary or contract summary.
687B.0685 Offer of nonforfeiture benefit required.
687B.0686 Requirements for nonforfeiture benefits; contingent benefit upon lapse.
687B.0687 Applicability of provisions regarding nonforfeiture benefits and contingent benefit upon lapse.
687B.0689 Rescission or denial of claim upon showing of misrepresentation material to acceptance for coverage; field issuance of contract or certificate.
687B.069 Record of rescissions.
687B.070 Certificate of insurance: Contents.
687B.075 Outline of coverage: Format; delivery; contents.
687B.076 Offer to purchase protection from inflation required.
687B.077 Requirements for marketing.
687B.0775 Approval of advertisement by Commissioner.
687B.078 Restriction on use of certain terms in marketing.
687B.079 Prohibition of certain marketing practices.
687B.080 Definition of terms in contracts.
687B.081 Notification of availability of new series of contracts.
687B.082 Notification regarding partnership status.
687B.0825 Activities of daily living and cognitive impairment to be used to measure needs of insured and to be described in contract or certificate; benefit triggers.
687B.083 Contract or certificate to condition payment of benefits on insured’s ability to perform daily activities and cognitive impairment.
687B.084 Requirements relating to qualified long-term care insurance contract.
687B.0845 Required statement as to whether contract intended to be qualified long-term care insurance contract under federal provisions.
687B.085 Terms for renewal of contracts.
687B.090 Exclusions from and limitations on coverage.
687B.095 Extension of benefits; continuation or conversion of coverage.
687B.100 Required disclosures.
687B.105 Prohibited provisions.
687B.106 Required provisions for reducing coverage and lowering premium; notice.
687B.1065 Insurer to file for approval any increase in a premium rate schedule for certain contracts.
687B.107 Insurer to request approval of any increase in premium rate schedule for contracts and certificates issued on or after October 1, 2011.
687B.1075 Exceptional increases.
687B.108 Prohibited increases in premiums.
687B.111 Coverage for preexisting conditions.
687B.112 Monthly report to certain insureds.
687B.113 Delivery of shopper’s guide to long-term care insurance.
687B.114 Responsibilities of professional, trade or occupational association which endorses or sells contracts or certificates to members.
687B.115 Filing and certification requirements for insurer issuing contract or certificate to professional, trade or occupational association.
687B.116 Limitations on conditioning of benefits.
687B.117 Restrictions on limitation or exclusion of benefits.
687B.118 Statement of limitations or conditions upon receipt of benefits.
687B.1185 Requirements for denied claims.
687B.119 Required reserves for policy, rider or endorsement.
687B.121 Evaluation of expected loss ratio.
687B.122 General requirements for converted policy.
687B.125 Replacement of contract: Questions on applications.
687B.127 Replacement of contract or certificate: Waiver of time applicable to preexisting conditions and probationary period; notice to existing insurer.
687B.130 Replacement of contract: Notice from insurer not using direct-response solicitation.
687B.135 Replacement of policy: Notice from insurer using direct-response solicitation.
687B.140 Replacement of contract: Restrictions concerning group policies for long-term care.
POLICIES SUPPLEMENTARY TO MEDICARE
General Provisions
687B.200 Definitions.
687B.2002 “1990 standardized benefit plan to supplement Medicare” or “1990 standardized benefit plan” defined.
687B.2003 “2010 standardized benefit plan to supplement Medicare” or “2010 standardized benefit plan” defined.
687B.201 “Applicant” defined.
687B.2014 “Certificate” defined.
687B.2015 “Creditable coverage” defined.
687B.2018 “Eligible organization” defined.
687B.202 “Employee welfare benefit plan” defined.
687B.2024 “Issuer” defined.
687B.2028 “Medicare” defined.
687B.203 “Medicare Advantage organization” defined.
687B.2034 “Medicare Advantage plan” defined.
687B.2036 “Medicare Part D” defined.
687B.2037 “Medicare select issuer” defined.
687B.2039 “PACE program” defined.
687B.204 “Policy to supplement Medicare” defined.
687B.2045 “Standardized benefit plan” defined.
687B.205 Applicability of provisions.
687B.2053 Eligible persons: Description; prohibited actions by insurers.
687B.2054 Eligible persons: Subsequent enrollment deemed to be initial enrollment under certain circumstances.
687B.2055 Eligible persons: Notification required upon occurrence of certain events.
687B.2056 Guaranteed issue periods for eligible persons; special enrollment period.
687B.2057 Policies to supplement Medicare to which eligible persons are entitled.
687B.206 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment; required policy or certificate; outpatient prescription drug coverage.
687B.2062 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment, enrollment and subsequent disenrollment; required policy or certificate.
687B.2064 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain enrollment and subsequent disenrollment; required policy or certificate.
687B.2068 Policy to supplement Medicare offered to new enrollees or certificate offered to new enrollees: Prohibition against denial of application, placement of condition on issuance or effectiveness, or discrimination in pricing under certain conditions by issuer.
687B.207 Coverage if application is submitted before or during first 6-month period in which person is both 65 years of age or older and enrolled under Medicare Part B; availability of coverage to all qualified applicants.
687B.209 Termination of or disenrollment from plan, certificate or policy to supplement Medicare: Requirements for written notification.
687B.212 Filing and approval of policy forms and certificate forms.
687B.213 Availability and discontinuance of policy forms and certificate forms.
687B.215 Definitions and terms used in policy or certificate.
687B.220 Exclusions from and limitations on coverage and benefits; duplication of benefits provided by Medicare; benefits for outpatient prescription drugs.
687B.223 Prohibitions regarding genetic information and genetic testing.
687B.225 Minimum standards for coverage: Policy or certificate advertised, solicited or issued for delivery before July 16, 1992.
687B.226 Minimum standards for coverage: Policy or certificate advertised, solicited, delivered, issued for delivery or renewed on or after July 16, 1992, and before July 30, 1992.
687B.227 Policy or certificate advertised, solicited, delivered or issued for delivery or renewed on or after July 30, 1992, and effective before June 1, 2010: General requirements.
687B.2273 Policy or certificate advertised, solicited, delivered or issued for delivery on or after June 1, 2010: General requirements.
687B.229 Filing and approval of rates, rating schedule and supporting documentation required.
687B.230 Rates: Calculation of aggregate benefits; standards for ratios of loss; filing requirements; adjustments; hearing on certain requested increases.
687B.235 Calculation and payment of refunds and credits.
687B.240 Provision for renewal or continuation; acceptance of riders and endorsements; prohibited standards for payment of benefits; disclosure and dissemination of information.
687B.243 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Notice required before termination of policy or certificate.
687B.245 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Designation of person to receive notice of lapse or waiver of designation.
687B.247 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Provision for reinstatement of coverage.
687B.250 Outline of coverage; assistance in understanding health insurance.
687B.255 Elicitation and dissemination of information regarding existing coverage and its replacement; inclusion of certain statements and questions in application.
687B.258 Replacement of existing coverage: Limitations on time periods for preexisting conditions, waiting periods, elimination periods and probationary periods.
687B.260 Policy to supplement Medicare or certificate issued before January 1, 1992: Replacement with standardized benefit plan.
687B.263 Termination and replacement of coverage under group policy.
687B.265 Notice of modifications to policy or certificate; compliance with certain notice requirements.
687B.269 Notice required that certain policies of insurance are not supplementary to Medicare; disclosure of extent to which policy or certificate duplicates coverage of Medicare.
687B.273 Standards of practice for marketing.
687B.275 Compensation of agents and other representatives and producers.
687B.280 Review of proposed advertising.
687B.282 Recommendations for purchase or replacement; sale of multiple policies or certificates; issuance of policy or certificate to person enrolled in Medicare Part C.
687B.283 Annual reporting of multiple policies or certificates.
687B.286 Compliance with certain provisions of Social Security Act regarding notice and payment of claims.
Standardized Benefit Plans
687B.290 Availability; minimum benefits.
687B.295 General requirements.
687B.300 Standardized Benefit Plan A.
687B.302 Standardized Benefit Plan B.
687B.304 Standardized Benefit Plan C.
687B.306 Standardized Benefit Plan D.
687B.308 Standardized Benefit Plan E.
687B.311 Standardized Benefit Plan F or High Deductible Benefit Plan F.
687B.313 Standardized Benefit Plan G.
687B.315 Standardized Benefit Plan H.
687B.317 Standardized Benefit Plan I.
687B.319 Standardized Benefit Plan J or High Deductible Benefit Plan J.
687B.320 Standardized Benefit Plan K.
687B.321 Standardized Benefit Plan L.
687B.322 Standards for policies to supplement Medicare or certificates effective on or after June 1, 2010.
687B.323 Requirements regarding policies to supplement Medicare or certificates effective on or after June 1, 2010.
687B.325 Coverage for short-term services provided to person recovering at home.
687B.330 Provision of new or innovative benefits.
Medicare Select Policies and Certificates
687B.340 Definitions.
687B.342 “Complaint” defined.
687B.344 “Grievance” defined.
687B.346 “Medicare select issuer” defined.
687B.348 “Medicare select policy” and “Medicare select certificate” defined.
687B.350 “Network provider” defined.
687B.352 “Provision for a restricted network” defined.
687B.354 “Service area” defined.
687B.356 Compliance with regulations required before advertising.
687B.358 Authorization to offer and approval to issue.
687B.360 Filing and contents of proposed plan of operation.
687B.362 Proposed changes to plan of operation; update of list of network providers.
687B.364 Payment for covered services provided by persons other than network providers.
687B.366 Full payment required for covered services not available through network provider.
687B.368 Written disclosure of provisions, restrictions and limitations.
687B.370 Procedures for hearing complaints and resolving grievances; annual report regarding grievance procedure.
687B.372 Availability of certain policies and certificates offered by Medicare select issuer.
687B.374 Provision for continuation of coverage; availability of policies to supplement Medicare as continuation of coverage.
687B.376 Compliance with requests for data for evaluation of Medicare select program.
REQUIREMENTS FOR DELIVERY
687B.405 Delivery of certificates to policyholder of group insurance.
687B.415 Delivery of other policies, memoranda or certificates of insurance.
CANCELLATION OF POLICIES
687B.520 Refunds to third parties.
687B.530 Notice to agent.
NOTICE OF TERMINATION TO EMPLOYEE LEASING COMPANIES
687B.550 Definitions.
687B.552 “Client company” defined.
687B.554 “Employee leasing company” defined.
687B.556 “Health maintenance organization” defined.
687B.558 “Insurer” defined.
687B.560 “Producer of insurance” defined.
687B.562 Disclosure of names and addresses of client companies; confidentiality.
687B.564 Notice of cancellation or failure to renew policy or contract.
MISCELLANEOUS POLICIES
687B.630 Health policy, contract or plan that includes grace period for payment of premiums.
687B.640 Medical examination required by insurer; standard set of criteria to be applied consistently to each insured.
POLICIES THAT DUPLICATE BENEFITS PROVIDED UNDER MEDICARE
687B.700 Notice of duplication for policy which provides reimbursement upon both expense-incurred and fixed-indemnity basis.
687B.706 Notice of duplication for certain policies which provide reimbursement in fixed dollar amounts per day.
687B.711 Notice of duplication for policy which provides reimbursement in fixed dollar amounts for specified diseases or other specified impairments.
687B.716 Notice of duplication for policy which provides reimbursement for expenses incurred for accidental injury only.
687B.720 Notice of duplication for policy which provides reimbursement for expenses incurred for specified diseases and other specified impairments.
687B.725 Notice of duplication for policy which provides reimbursement for expenses incurred for specified limited services.
687B.730 Notice of duplication for policy not described in NAC 687B.700 to 687B.725, inclusive.
687B.735 Payment of benefits that are covered under other policies.
ADEQUACY OF NETWORK PLANS
687B.750 Definitions.
687B.752 “Carrier” defined.
687B.754 “Council” defined.
687B.756 “Covered person” defined.
687B.758 “Network plan” defined.
687B.760 “Provider of health care” defined.
687B.762 “Qualified health plan” defined.
687B.764 Applicability: Network plans issued by certain smaller carriers.
687B.766 Applicability: Generally.
687B.768 Requirements and standards for determining adequacy. [Effective through December 31, 2018.]
687B.768 Requirements and standards for determining adequacy. [Effective January 1, 2019.]
687B.770 Network Adequacy Advisory Council: Establishment; membership; vacancy; meetings.
687B.772 Network Adequacy Advisory Council: Recommendations for additional or alternative standards for determining adequacy; determination by Commissioner; effective date of new requirements.
687B.776 Application for approval to issue network plan: Additional data and documentation required.
687B.778 Update of directory of providers of health care; public availability of directory.
687B.780 Change to network plan resulting in failure to meet standards or requirements: Carrier required to notify Commissioner; description of cause and impact of change; summary of measures to bring plan in compliance.
687B.782 Change to network plan resulting in failure to meet standards or requirements: Submission of corrective action plan by carrier; requirement to ensure covered persons receive covered services; exception.
687B.784 Change to network plan resulting in failure to meet standards or requirements: Authority of Commissioner to determine inadequacy of plan; submission of statement of network capacity for certain plans.
POLICIES OF LIABILITY INSURANCE
687B.800 Policy sold by short-term lessor of motor vehicle: Deemed primary coverage; filing requirements.
POLICIES OF MOTOR VEHICLE INSURANCE
687B.850 Chargeable accidents: Restrictions on authority of insurer; filing and use of definition.
GENERAL PROVISIONS
NAC 687B.0002 Definitions. As used in this chapter, unless the context otherwise requires, the words and terms defined in NAC 687B.0005 and 687B.001 have the meanings ascribed to them in those sections.
(Supplied in codification)
NAC 687B.0005 “Commissioner” defined. (NRS 679B.130) “Commissioner” means the Commissioner of Insurance.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88) — (Substituted in revision for NAC 687B.020)
NAC 687B.001 “Division” defined. (NRS 679B.130) “Division” means the Division of Insurance of the Department of Business and Industry.
(Added to NAC by Comm’r of Insurance, eff. 5-27-92)
NAC 687B.004 Procedures for filing certain forms and paying certain fees. (NRS 679B.130, 679B.136, 687B.120)
1. Any form required to be filed pursuant to the provisions of NRS 687B.120 must be filed in accordance with the System for Electronic Rate and Form Filing developed and implemented by the National Association of Insurance Commissioners.
2. Any fee required when filing a rate, rule or form pursuant to NRS 680B.010 must be paid using the Electronic Funds Transfer function within the System for Electronic Rate and Form Filing.
(Added to NAC by Comm’r of Insurance by R115-02, eff. 3-18-2003; A by R129-06, 9-18-2006; R097-10, 12-16-2010, eff. 12-31-2010)
CONTRACTS FOR LONG-TERM CARE
NAC 687B.005 Definitions. (NRS 679B.130) As used in NAC 687B.005 to 687B.140, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.010 to 687B.0342, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91; 12-15-94; R121-07, 9-18-2008, eff. 10-1-2008)
NAC 687B.010 “Applicant” defined. (NRS 679B.130) “Applicant” means:
1. In the case of an individual long-term care insurance contract, the person who seeks to contract for benefits.
2. In the case of a group long-term care insurance contract, the proposed certificate holder.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.012 “Basis for continuation of coverage” defined. (NRS 679B.130) “Basis for continuation of coverage” means a provision that maintains coverage under the existing group long-term care insurance contract, subject only to the continued timely payment of premiums, when such coverage would otherwise terminate.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011) — (Substituted in revision for NAC 687B.031)
NAC 687B.013 “Basis for conversion of coverage” defined. (NRS 679B.130) “Basis for conversion of coverage” means a provision that a person:
1. Whose coverage under the group long-term care insurance contract would otherwise terminate, or whose coverage has been terminated for any reason, including discontinuance of the group long-term care insurance contract in its entirety or with respect to an insured class; and
2. Who has been continuously insured under the group long-term care insurance contract and any group long-term care insurance contract which it replaced for at least the 6 months immediately preceding the date of termination,
Ê is entitled to the issuance of a converted policy by the insurer under whose group long-term care insurance contract he or she is covered, without evidence of insurability.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011) — (Substituted in revision for NAC 687B.032)
NAC 687B.015 “Certificate” defined. (NRS 679B.130) “Certificate” means any certificate issued under a group long-term care insurance contract which is delivered or issued for delivery in this State.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.019 “Converted policy” defined. (NRS 679B.130) “Converted policy” means an individual long-term care insurance contract providing benefits identical to, or benefits determined by the Commissioner to be substantially equivalent to, or in excess of, those provided under the group long-term care insurance contract from which conversion is made.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.021 “Exceptional increase” defined. (NRS 679B.130) “Exceptional increase” means an increase which is filed by an insurer as exceptional and for which the Commissioner determines the need for the premium rate increase is justified:
1. Because of changes in laws or regulations applicable to long-term care insurance coverage in this State; or
2. Because of increased and unexpected utilization that affects the majority of insurers of similar products.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.025 “Group long-term care insurance” defined. (NRS 679B.130) “Group long-term care insurance” means a long-term care insurance contract which is delivered or issued for delivery in this State to:
1. One or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or both, for employees or former employees, or both, or for members or former members, or both, of the labor organizations;
2. Any professional, trade or occupational association for its members or former or retired members, or any combination thereof, if the association:
(a) Is composed of persons who are or were actively engaged in the same profession, trade or occupation; and
(b) Has been maintained in good faith for purposes other than obtaining insurance;
3. An association or trust, or the trustee of a fund, established, created or maintained for the benefit of members of one or more associations; or
4. Any other group, if the Commissioner finds that:
(a) The issuance of the long-term care insurance contract to that group is not contrary to the best interests of the public;
(b) The issuance of the long-term care insurance contract would result in economies of acquisition or administration; and
(c) The benefits are reasonable in relation to the premiums charged.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.030 “Long-term care insurance” defined. (NRS 679B.130)
1. “Long-term care insurance” means any group or individual insurance advertised, marketed, offered or designed to provide coverage for not less than 12 consecutive months for each person covered by the insurance on an expense-incurred, indemnity, prepaid or other basis, for necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services provided in a setting other than an acute care unit of a hospital.
2. The term includes insurance that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity.
3. The term does not include insurance which is offered primarily to provide:
(a) Basic coverage to supplement Medicare;
(b) Basic coverage for hospital expenses;
(c) Basic coverage for medical-surgical expenses;
(d) Indemnity coverage for confinement in a hospital;
(e) Coverage for major medical expenses;
(f) Coverage to protect income received for or to protect assets in the event of a disability, unless the conditions set forth in paragraph (b) of subsection 6 of NAC 687B.035 are met;
(g) Coverage for accidents only;
(h) Coverage for specified diseases or accidents; or
(i) Limited benefit health coverage.
4. The term does not include a life insurance policy that:
(a) Accelerates the death benefit specifically for one or more of the following qualifying events:
(1) Terminal illness;
(2) Medical conditions requiring extraordinary medical intervention; or
(3) Medical conditions requiring permanent institutional confinement; and
(b) Provides the option of a lump-sum payment for those benefits where neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0303 “Long-term care insurance contract” defined. (NRS 679B.130)
1. “Long-term care insurance contract” means:
(a) An insurance policy or contract, or any portion thereof; or
(b) A rider or endorsement to a policy of life insurance, a policy of disability income insurance or an annuity contract, or any portion thereof,
Ê which is delivered or issued for delivery in this State, by an insurer or similar organization, and which provides direct or supplemental coverage for long-term care insurance.
2. The term includes:
(a) A qualified long-term care insurance contract.
(b) A qualified state long-term care insurance partnership contract.
3. As used in this section, “insurance policy or contract” has the meaning ascribed to it in NAC 686A.627 and includes a subscriber agreement.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0306 “Partnership certificate” defined. (NRS 679B.130) “Partnership certificate” means a certificate issued under a group partnership contract.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0309 “Partnership policy” defined. (NRS 679B.130) “Partnership policy” means an insurance policy delivered or issued for delivery in this State that is a “partnership contract” as defined in NAC 687B.0335.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.033 “Qualified actuary” defined. (NRS 679B.130) “Qualified actuary” means a person who is qualified to sign a statement of actuarial opinion pursuant to the “Qualification Standards for Actuaries Issuing Statements of Actuarial Opinion in the United States,” approved by the Board of Directors of the American Academy of Actuaries.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0332 “Qualified long-term care insurance contract” or “federally tax-qualified long-term care insurance contract” defined. (NRS 679B.130) “Qualified long-term care insurance contract” or “federally tax-qualified long-term care insurance contract” means:
1. Any individual insurance contract or group insurance contract that meets the requirements of 26 U.S.C. § 7702B(b);
2. The portion of any life insurance contract which provides long-term care insurance coverage by rider, endorsement or as part of the contract and which satisfies the requirements of 26 U.S.C. §§ 7702B(b) and 7702B(e); or
3. The portion of any annuity contract which provides long-term care insurance coverage by rider, endorsement or as part of the contract and which satisfies the requirements of 26 U.S.C. § 7702B(b) and section 844 of the Pension Protection Act of 2006, Public Law 109-280.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0335 “Qualified state long-term care insurance partnership contract” or “partnership contract” defined. (NRS 679B.130) “Qualified state long-term care insurance partnership contract” or “partnership contract” means a qualified long-term care insurance contract that:
1. Provides coverage for insureds who are residents of Nevada on the date that coverage under the contract first becomes effective;
2. Is issued on or after January 1, 2007;
3. Satisfies all the requirements of 42 U.S.C. § 1396p(b)(1)(C)(iii)(I) to 1396p(b)(1)(C)(iii)(IV), inclusive;
4. Is filed with and approved by the Commissioner as a partnership contract;
5. Is issued by an insurer who complies with the provisions of 42 U.S.C. § 1396p(b)(1)(C)(iii)(VI); and
6. Is sold by a producer who has received training in and has demonstrated an understanding of partnership contracts and how partnership contracts relate to public and private coverage for long-term care.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008)
NAC 687B.034 “Similar long-term care insurance contract forms” defined. (NRS 679B.130)
1. “Similar long-term care insurance contract forms” means all long-term care insurance contracts and certificates issued by an insurer within the same classification of long-term care benefits as the long-term care insurance contract form being considered.
2. A long-term care insurance contract or certificate delivered to any group described in subsection 1 of NAC 687B.025 shall be deemed not similar to other long-term care insurance contracts and certificates, except that such a contract or certificate shall be deemed similar to other comparable long-term care insurance contracts and certificates with the same long-term care benefit classification.
3. For the purpose of determining whether long-term care insurance contract forms are similar, the long-term care benefits provided by long-term care insurance contracts and certificates must be classified as:
(a) Institutional long-term care benefits only;
(b) Noninstitutional long-term care benefits only; or
(c) Comprehensive long-term care benefits.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0342 “Similar organization” defined. (NRS 679B.130) “Similar organization” means a company other than an insurer that is authorized to offer long-term care insurance contracts pursuant to the provisions of chapter 695A, 695B, 695C or 695F of NRS.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008)
NAC 687B.035 Scope. (NRS 679B.130)
1. Except as otherwise provided in this subsection, the provisions of NAC 687B.005 to 687B.140, inclusive, apply to a long-term care insurance contract delivered or issued for delivery in this State on or after November 21, 1988. The provisions of NAC 687B.113, 687B.116 and 687B.118 apply to a long-term care insurance contract delivered or issued for delivery in this State on or after January 11, 1991.
2. The provisions of NAC 687B.005 to 687B.140, inclusive, do not supersede the obligations of entities subject to them to comply with other applicable regulations insofar as they do not conflict with the provisions of NAC 687B.005 to 687B.140, inclusive.
3. Applicable regulations governing contracts of insurance which supplement Medicare do not apply to long-term care insurance contracts.
4. Except as otherwise provided in subsection 6, a contract of insurance which is not advertised, marketed or offered as long-term care insurance or nursing home insurance is not required to comply with the provisions of NAC 687B.005 to 687B.140, inclusive.
5. NAC 688B.010 and 689B.010 to 689B.080, inclusive, do not apply to long-term care insurance contracts.
6. Except as otherwise expressly provided in NAC 687B.005 to 687B.140, inclusive, the provisions of NAC 687B.005 to 687B.140, inclusive, apply to:
(a) Any long-term care insurance contract, including a qualified long-term care insurance contract, partnership contract, annuity contract and life insurance policy that accelerates benefits for long-term care delivered or issued for delivery in this State on or after October 1, 2011, by insurers and all similar organizations.
(b) 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 the normal retirement age for Social Security unless benefits are designated to replace lost income or pay for specific expenses other than long-term care services.
7. Notwithstanding any other provision of NAC 687B.005 to 687B.140, inclusive, any product advertised, marketed or offered as long-term care insurance is subject to the provisions of NAC 687B.005 to 687B.140, inclusive.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.040 Compliance required. (NRS 679B.130) A policy of insurance, rider or endorsement may not be advertised, marketed or offered as long-term care insurance or insurance which provides coverage for care received in a nursing home unless it complies with the provisions of NAC 687B.005 to 687B.140, inclusive.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91; R121-07, 9-18-2008, eff. 10-1-2008; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.045 Modification or suspension of provisions. (NRS 679B.130) The Commissioner may, upon receiving a written request therefor and after an administrative hearing, issue an order to modify or suspend any provision of NAC 687B.005 to 687B.140, inclusive, with respect to a specific long-term care insurance contract or certificate upon a written finding that:
1. The modification or suspension would be in the best interest of the insureds;
2. The purposes to be achieved would not be effectively or efficiently achieved without the modification or suspension; and
3. One of the following:
(a) The modification or suspension is necessary to the development of an innovative and reasonable approach for insuring long-term care;
(b) The long-term care insurance contract or certificate is to be issued to residents of a life care or continuing care retirement community or some other residential community for the elderly, and the modification or suspension is reasonably related to the special needs or nature of that community; or
(c) The modification or suspension is necessary to permit long-term care insurance to be sold as part of, or in conjunction with, another policy of insurance.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.050 Organizational requirements. (NRS 679B.130)
1. Before advertising, marketing or offering a group long-term care insurance contract within this State, the insurer of an association shall file evidence with the Commissioner that it has complied with NAC 679B.036, and that the association has:
(a) At the outset, at least 100 members;
(b) Been organized and maintained in good faith for purposes other than that of obtaining insurance;
(c) Been in active existence for at least 1 year; and
(d) A constitution and bylaws which provide that:
(1) The association holds regular meetings not less than annually to further the purposes of the members;
(2) Except for credit unions, the association collects dues or solicits contributions from members; and
(3) The members have voting privileges and are represented on the governing board and committees.
2. Forty-five days after filing the evidence required by subsection 1, the association shall be deemed to satisfy those organizational requirements, unless the Commissioner finds otherwise.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.051 Licensing and training requirements. (NRS 679B.130)
1. A person may not sell, solicit or negotiate long-term care insurance unless the person:
(a) Is licensed as a producer of insurance for health insurance;
(b) Has successfully completed an initial course of training consisting of at least 8 hours; and
(c) Successfully completes ongoing courses of training as specified in subsection 2.
2. During each 24-month period, except for the initial 24-month period, a person described in subsection 1 must successfully complete an ongoing course of training consisting of at least 4 hours.
3. The training required by subsections 1 and 2:
(a) Must consist of topics relating to long-term care insurance, long-term care services and, if applicable, qualified state long-term care insurance partnership programs, including, but not limited to:
(1) 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, including Medicaid;
(2) Available long-term care services and providers;
(3) Changes or improvements in long-term care services or providers;
(4) Alternatives to the purchase of private long-term care insurance;
(5) The effect of inflation on benefits and the importance of inflation protection; and
(6) Consumer suitability standards and guidelines.
(b) May not include training that is specific to any insurer or company product or that includes any sales or marketing information, materials or training other than those required by state or federal law.
4. A course of training that meets the requirements of subsection 3 may be approved as a continuing education course for licensure pursuant to NAC 683A.330 if the course satisfies the requirements of NAC 683A.335.
5. The satisfaction of the training requirements of this section in any other state shall be deemed to satisfy the training requirements in this State.
6. An insurer subject to the provisions of this section shall:
(a) Obtain verification that a producer of insurance receives the training required pursuant to subsections 1 and 2 before the producer of insurance is permitted to sell, solicit or negotiate the insurer’s long-term care insurance;
(b) Maintain records of verification of training subject to this State’s record retention requirements; and
(c) Make all verifications of training available to the Commissioner upon request.
7. An insurer that provides qualified state long-term care insurance partnership contracts shall:
(a) On or before March 1 of each year, provide certification to the Commissioner that all partnership contracts issued by the insurer during the immediately preceding calendar year were sold by producers who have received adequate training, as described in subsection 3, and 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; and
(b) Maintain records with respect to the training of its producers concerning the sale of partnership contracts that will allow the Commissioner to provide adequate assurances to the Division of Health Care Financing and Policy of the Department of Health and Human Services that the producers have received adequate training and 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. The insurer shall maintain the records of attendance and examination scores or certificates of completion pursuant to NAC 683A.340 for 4 years and shall make the records available to the Commissioner upon request.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.052 Required reports. (NRS 679B.130)
1. An insurer shall maintain records for each agent which:
(a) Specify the amount of replacement sales by the agent as a percentage of the total annual sales by the agent; and
(b) Specify the amount of lapses in policies sold by the agent as a percentage of the total annual sales by the agent.
2. On or before June 30 of each year, an insurer shall provide to the Commissioner the names of its agents in this State who, as measured by the records maintained pursuant to subsection 1, rank in the top 10 percent of all its agents in this State with the highest percentages of:
(a) Replacement sales in this State; and
(b) Lapses in policies sold by the agent in this State.
3. On or before June 30 of each year, an insurer shall report to the Commissioner the number of lapsed policies issued by the insurer in this State as a percentage of the total annual sales of the insurer in this State and as a percentage of the total number of policies issued by the insurer in this State which are in force on December 31 of the immediately preceding calendar year in this State.
4. On or before June 30 of each year, an insurer shall report to the Commissioner the number of replacement policies issued by the insurer in this State as a percentage of the total annual sales of the insurer in this State and as a percentage of the total number of policies issued by the insurer in this State which are in force on December 31 of the immediately preceding calendar year in this State.
5. On or before June 30 of each year, an insurer shall report to the Commissioner, for qualified long-term care insurance contracts issued by the insurer in this State, the number of claims denied in this State for each class of business, expressed as a percentage of all claims denied in this State.
6. An insurer or similar organization that issues partnership contracts or partnership certificates in this State shall report to the Department of Health and Human Services, using a form prescribed by the Department and including the amount of any benefits that have been provided under the contract or certificate, when:
(a) A partnership contract or partnership certificate is terminated;
(b) Benefits are provided under a partnership contract or partnership certificate; or
(c) The Commissioner or the Department of Health and Human Services requests a report.
7. An insurer shall use:
(a) Form NDOI-946, which is available from the Division, to satisfy the reporting requirements of subsections 2, 3 and 4; and
(b) Form NDOI-948, which is available from the Division, to satisfy the reporting requirements of subsection 5.
8. Reported replacement and lapse rates may not be used as a sole basis for adverse action against an insurer or agent, but may be used as a method to review agent activities regarding the sale of long-term care insurance.
9. Any report made pursuant to this section must be made on the basis of statewide information.
10. As used in this section:
(a) “Claim” means a request for payment of benefits under a policy regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met.
(b) “Denied” means the refusal of an insurer to pay a claim for any reason other than:
(1) Failure of the insured to meet an applicable waiting period; or
(2) An applicable preexisting condition.
(c) “Policy” means a policy of long-term care insurance.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.053 Compensation to producers for sale, renewal or replacement of contract or certificate. (NRS 679B.130)
1. An insurer or similar organization may pay compensation to a producer for the sale of a long-term care insurance contract or certificate on the basis of a set schedule. The amount of the compensation paid for the replacement of a long-term care insurance contract or certificate must be made in accordance with the renewal schedule of the replacing insurer unless the long-term care insurance contract or certificate cannot be renewed by the original insurer.
2. The compensation provided by the insurer or similar organization for the renewal of a replacement long-term care insurance contract in subsequent years by the replacing insurer must be the same compensation schedule as provided by the replacing insurer unless the original insurer cannot renew the long-term care insurance contract or certificate.
3. If long-term care insurance is provided as part of an annuity contract, life insurance policy, disability income insurance policy or rider or endorsement, the requirements of this section apply only to the compensation attributable to the long-term care insurance provided by the policy.
4. As used in this section, “compensation” has the meaning ascribed to it in NAC 683A.708.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R053-09, 10-27-2009; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.054 Producer not authorized to sell, solicit or negotiate except as authorized by certain statutes. (NRS 679B.130) A producer is not authorized to sell, solicit or negotiate with respect to long-term care insurance except as authorized by chapter 683A of NRS.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.055 Contracts issued in other states. (NRS 679B.130)
1. No group long-term care insurance may be offered to a resident of this State under a group long-term care insurance contract issued in another state to a group described in subsection 4 of NAC 687B.025, unless this State or another state having statutory and regulatory requirements for long-term care insurance substantially similar to those adopted in this State, has made a determination that those requirements have been met.
2. Before an insurer or similar organization offers group long-term care insurance to a resident of this State pursuant to this section, it shall file with the Commissioner evidence that the group long-term care insurance contract or certificate issued pursuant thereto has been approved by a state having statutory and regulatory requirements for long-term care insurance substantially similar to those adopted in this State.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.056 Standards of suitability: Development; use. (NRS 679B.130)
1. The provisions of this section do not apply to a policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care.
2. Every insurer or other organization that markets or offers long-term care insurance contracts or certificates in this State shall:
(a) Develop standards of suitability to determine whether the purchase or replacement of long-term care insurance is appropriate for the needs of an applicant;
(b) Train its agents in the use of the standards of suitability; and
(c) Maintain a copy of the standards of suitability and make the standards available for inspection upon request by the Commissioner.
3. An insurer shall use the standards of suitability developed pursuant to subsection 2 in determining whether it is appropriate to issue long-term care insurance to an applicant.
4. An agent shall use the standards of suitability developed by the insurer pursuant to subsection 2 in marketing long-term care insurance.
5. To determine whether an applicant meets the standards of suitability developed pursuant to subsection 2 for the purchase or replacement of long-term care insurance, the insurer and its agents shall develop policies and procedures that take into consideration:
(a) The ability of the applicant to pay for the proposed coverage;
(b) Any other pertinent financial information relating to the proposed purchase;
(c) The goals or needs of the applicant with respect to long-term care and the advantages and disadvantages of insurance to meet those goals or needs; and
(d) The values, benefits and costs of the existing insurance of the applicant, if any, as compared to the values, benefits and costs of the proposed purchase or replacement.
6. The insurer and its agents shall make reasonable efforts to obtain the information required pursuant to subsection 5, including, without limitation, presenting to the applicant at or before the time of application the worksheet described in subsection 9. The insurer may request that the applicant provide additional information to comply with the standards of suitability.
7. An insurer shall not consider an application unless the applicant completes the worksheet described in subsection 9 and returns the completed worksheet to the insurer, except that the insurer may consider an application without receiving a completed worksheet if the applicant is offered the coverage through a sale of group long-term care insurance to employees and their spouses.
8. An insurer and its agents shall not sell or disseminate outside the company any information obtained from a worksheet described in subsection 9.
9. An insurer shall provide to each applicant form NDOI-949, which is available from the Division, or a “Long-Term Care Insurance Personal Worksheet” which must contain a statement, set out conspicuously and in not less than 12-point type, that is substantially in the format of form NDOI-949.
10. An insurer shall file with the Commissioner a copy of the worksheet described in subsection 9.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0565 Standards of suitability: Procedure when applicant does not meet standards or declines to provide information. (NRS 679B.130)
1. If an insurer determines that an applicant does not meet the standards of suitability developed pursuant to NAC 687B.056, or if the applicant declines to provide any information required by NAC 687B.056, the insurer may:
(a) Reject the application; or
(b) Mail a letter to the applicant using form NDOI-950, which is available from the Division, or containing a statement that is substantially in the format of form NDOI-950.
2. If an applicant declines to provide any financial information required pursuant to NAC 687B.056, the insurer may use any other method to verify the intent of the applicant.
3. The insurer shall include in the file of the applicant:
(a) The returned letter described in paragraph (b) of subsection 1; or
(b) A record of the alternative method of verification of the intent of the applicant.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.057 Standards of suitability: Annual report to Commissioner. (NRS 679B.130) On or before April 1 of each year, for the preceding calendar year, an insurer shall report to the Commissioner using form NDOI-947, which is available from the Division:
1. The number of applications for long-term care insurance received by the insurer from residents of this State;
2. The number of applicants who declined to provide information on the worksheet described in subsection 9 of NAC 687B.056;
3. The number of applicants who did not meet the standards of suitability developed by the insurer pursuant to NAC 687B.056; and
4. The number of applicants who chose to purchase long-term care insurance after receiving the letter described in paragraph (b) of subsection 1 of NAC 687B.0565.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011; R081-16, 11-2-2016)
NAC 687B.0575 Standards of suitability: Insurer to provide form regarding long-term care insurance. (NRS 679B.130) When an insurer or its agent provides the worksheet described in subsection 9 of NAC 687B.056 to an applicant, the insurer or its agent shall provide to the applicant a form entitled “Things You Should Know Before You Buy Long-Term Care Insurance,” which must be printed in not less than 12-point type and which must contain a statement in substantially the following form, set out conspicuously in the following format:
THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG-TERM CARE INSURANCE
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Long-Term Care Insurance
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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 in other community settings. Since policies can vary in coverage, you should read this policy and make sure you understand what it covers before you purchase the policy.
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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.
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The personal worksheet includes questions designed to help you and the company determine whether this policy is suitable for your needs.
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Medicare
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Medicare does not pay for most long-term care.
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Medicaid
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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.
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Many people become eligible for Medicaid after they have used up their own financial resources by paying for long-term care services.
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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.
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Your choice of long-term care services may be limited if you are receiving Medicaid. To learn more about Medicaid, contact the Division of Health Care Financing and Policy of the Department of Health and Human Services.
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Shopper’s Guide
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Make sure the insurance company or agent gives you a copy of a booklet entitled “A Shopper’s Guide to Long-Term Care Insurance” by the National Association of Insurance Commissioners. 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 be refunded any premium you have paid if you are dissatisfied for any reason or choose not to purchase the policy.
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Counseling |
Free counseling and additional information about long-term care insurance are available through the Nevada State Health Insurance Advisory Program of the Aging and Disability Services Division of the Department of Health and Human Services. Contact the Aging and Disability Services Division for more information about the Nevada State Health Insurance Advisory Program.
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Facilities |
Some policies of long-term care insurance provide for benefit payments in certain facilities only if they are licensed or certified, such as in assisted living facilities. However, not all states regulate these facilities in the same way. Also, many people move to a different state from where they purchased their policy of long-term care insurance. 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 Nevada. |
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008)
NAC 687B.058 Partnership program notice. (NRS 679B.130)
1. The provisions of this section apply to any qualified state long-term care insurance partnership contract.
2. An insurer or agent soliciting or offering to sell a long-term care insurance contract that is intended to qualify as a partnership contract shall provide to each prospective applicant a partnership program notice. The partnership program notice must:
(a) Outline the requirements and benefits of a partnership contract.
(b) Be provided with the required outline of coverage.
(c) Be in the following form, unless a similar form is filed with, and approved by, the Commissioner:
PARTNERSHIP PROGRAM NOTICE
Important Consumer Information Regarding the Nevada Long-Term Care Insurance Partnership Program
Some long-term care insurance contracts or certificates sold in Nevada may qualify for the Nevada Long-Term Care Insurance Partnership Program (the “Partnership Program”). The Partnership Program is a partnership between state government and private insurance companies to assist individuals in planning their long-term care needs. 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 contracts or certificates that qualify as partnership contracts or partnership certificates may protect the policyholder’s or certificate holder’s assets through a feature known as “asset disregard” under Nevada’s Medicaid program.
ASSET DISREGARD means that an amount of the policyholder’s or certificate holder’s assets equal to the amount of long-term care insurance benefits received under a qualified partnership contract or partnership 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 contract or partnership certificate without affecting the person’s eligibility for Medicaid. All other Medicaid eligibility criteria will apply, and special rules may apply to persons whose home equity exceeds $500,000. Asset disregard is not available under a long-term care insurance contract or certificate that is not a partnership contract or partnership certificate. Therefore, you should consider if asset disregard is important to you, and whether a partnership contract or partnership certificate meets your needs. THE PURCHASE OF A PARTNERSHIP CONTRACT DOES NOT AUTOMATICALLY QUALIFY YOU FOR MEDICAID.
WHAT ARE THE REQUIREMENTS FOR A PARTNERSHIP CONTRACT OR PARTNERSHIP CERTIFICATE? In order for a long-term care insurance contract or certificate to qualify as a partnership contract or partnership certificate, it must, among other requirements:
· Be issued to a person on or after January 1, 2007;
· Cover a person who was a Nevada resident when coverage first became effective under the long-term care insurance contract or certificate;
· Be a federally tax-qualified long-term care insurance contract;
· Meet stringent consumer protection standards; and
· Meet the following inflation requirements:
o For persons 60 years of age or younger – provide compound annual inflation protection;
o For persons 61 to 75 years of age – provide some level of inflation protection; and
o For persons 76 years of age and older – no purchase of inflation protection is required.
If you apply and are approved for long-term care insurance coverage, your insurer will provide you with written documentation as to whether or not your long-term care insurance contract or certificate qualifies as a partnership contract or partnership certificate.
WHAT COULD DISQUALIFY A LONG-TERM CARE INSURANCE CONTRACT OR CERTIFICATE AS A PARTNERSHIP POLICY? Certain types of changes to a partnership contract or partnership certificate could affect whether or not such a contract or certificate continues to be a partnership contract or partnership certificate. If you purchase a partnership contract or partnership certificate and later decide to make ANY changes, you should first consult with your insurer 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 long-term care insurance contract or certificate as a partnership policy or partnership certificate, you would not receive beneficial treatment of your long-term care insurance contract or certificate under the Medicaid program of that state. The information contained in this disclosure is based on current Nevada and federal law. These laws may be subject to change. Any change in law could reduce or eliminate the beneficial treatment of your long-term care insurance contract or certificate under Nevada’s Medicaid program.
3. A partnership contract delivered or issued for delivery in Nevada must be accompanied by a partnership status disclosure notice. The partnership status disclosure notice must:
(a) Explain the benefits associated with a partnership contract;
(b) Indicate that the long-term care insurance contract is, at the time of issuance, intended to be a qualified state long-term care insurance partnership contract;
(c) Include a statement which indicates that the insured does not automatically qualify for Medicaid by purchasing this partnership policy; and
(d) Be in the following form, unless a similar form is filed with, and approved by, the Commissioner:
PARTNERSHIP STATUS DISCLOSURE NOTICE
Important Information Regarding Your Long-Term Care Insurance Contract’s or Certificate’s Long-Term Care Insurance Partnership Status
This disclosure notice is issued in conjunction with your long-term care insurance contract.
Some long-term care insurance contracts or certificates sold in Nevada qualify for the Nevada 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 contracts or certificates that qualify as partnership policies or partnership certificates may be entitled to special treatment and, in particular, an “asset disregard” under Nevada’s Medicaid program.
ASSET DISREGARD means that an amount of the policyholder’s or certificate holder’s assets equal to the amount of long-term care insurance benefits received under a qualified partnership contract or partnership certificate will be disregarded for the purposes 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 or partnership certificate without affecting the person’s eligibility for Medicaid. All other Medicaid eligibility criteria will apply, and special rules may apply to persons whose home equity exceeds $500,000. Asset disregard is NOT available under a long-term care insurance contract or certificate that is not a partnership contract or partnership certificate. THE PURCHASE OF A PARTNERSHIP CONTRACT DOES NOT AUTOMATICALLY QUALIFY YOU FOR MEDICAID.
PARTNERSHIP CONTRACT OR PARTNERSHIP CERTIFICATE STATUS. Your long-term care insurance contract or certificate is intended to qualify as a partnership contract or partnership certificate under the Nevada Long-Term Care Insurance Partnership Program as of your contract’s or certificate’s effective date.
WHAT COULD DISQUALIFY YOUR LONG-TERM CARE INSURANCE CONTRACT OR CERTIFICATE AS A PARTNERSHIP CONTRACT OR PARTNERSHIP CERTIFICATE? If you make any changes to your long-term care insurance contract or certificate, such changes could affect whether your long-term care insurance contract or certificate continues to be a partnership contract or partnership certificate. BEFORE YOU MAKE ANY CHANGES, YOU SHOULD CONSULT WITH YOUR INSURER 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 long-term care insurance contract or certificate as a partnership contract or partnership certificate, you would not receive beneficial treatment of your long-term care insurance contract or certificate under the Medicaid program of that state. The information contained in this Notice is based on current state and federal law. These laws may be subject to change. Any change in law could reduce or eliminate the beneficial treatment of your long-term care insurance contract or certificate under Nevada’s Medicaid program.
ADDITIONAL INFORMATION. If you have questions regarding your long-term care insurance contract or certificate, please contact your insurer. If you have questions regarding current laws governing Medicaid eligibility, you should contact the Nevada Medicaid office.
4. A partnership contract or partnership certificate must not be delivered or issued for delivery in Nevada unless filed with and approved by the Commissioner.
5. Any long-term care insurance contract submitted for certification as a partnership contract must be accompanied by an Issuer Certification Form and a Partnership Certification Form. Unless a similar form is filed with and approved by the Commissioner:
(a) Form NDOI-951 must be used as, or provide substantially the format for, the Issuer Certification Form; and
(b) Form NDOI-952 must be used as, or provide substantially the format for, the Partnership Certification Form.
6. Insurers requesting to make use of a previously approved long-term care insurance contract form as a qualified state long-term care insurance partnership contract must submit to the Commissioner an Issuer Certification Form signed by an officer of the insurance company. An Issuer Certification Form is required for each long-term care insurance contract form submitted for partnership qualification.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0585 Required disclosures regarding rate revisions. (NRS 679B.130)
1. For any long-term care insurance contract or certificate issued in this State on or after October 1, 2008, other than a long-term care insurance contract or certificate for which no applicable increases in premium rates or rate schedules can be made, the insurer shall provide to the applicant:
(a) A statement that the long-term care insurance contract or certificate may be subject to rate increases in the future;
(b) An explanation of potential future premium rate revisions, and the options available to the applicant in the event of a premium rate revision;
(c) The premium rate or rate schedules applicable to the applicant that will be in effect until a request is made for an increase;
(d) A general explanation for applying adjustments to premium rates or rate schedules that must include:
(1) A description of when such adjustments will be effective; and
(2) A statement that the applicant must be provided with a revised premium rate or rate schedule if the premium rate or rate schedule is changed;
(e) Except as otherwise provided in subsection 3, information relating to each increase in premium rates on the long-term care insurance contract form or similar long-term care insurance contract forms during the previous 10 years for this State or any other state, including, without limitation, information that identifies:
(1) The long-term care insurance contract forms for which premium rates have increased;
(2) The calendar years when the long-term care insurance contract form was available for purchase; and
(3) The amount or percentage of each rate increase which may be expressed as a percentage of the premium rate before the increase or as minimum and maximum percentages if the rate increase is variable by rating characteristics; and
(f) Any additional explanatory information related to rate increases that the insurer chooses to provide.
2. In addition to the requirements of subsection 1, if an insurer or similar organization acquires a block of long-term care insurance contract forms from a nonaffiliated insurer or similar organization and:
(a) The premium rates for the block of long-term care insurance contract forms increase within 24 months after the block of long-term care insurance contract forms is acquired, the nonaffiliated insurer or similar organization shall provide a statement of the increase in premium rates to the applicant; and
(b) At any time after the acquisition the acquiring insurer files for a rate increase, subsequent to the rate increase described in paragraph (a), on the block of long-term care insurance contract forms, the acquiring insurer shall make all disclosures required by paragraph (e) of subsection 1 and provide a statement of the increase in premium rates to the applicant.
3. The provisions of paragraph (e) of subsection 1 do not apply to:
(a) Any increase in premium rates for any block of long-term care insurance contract forms acquired by the insurer from a nonaffiliated insurer if the increases occurred before the acquisition or not later than 24 months after the acquisition; or
(b) Any increase in premium rates for long-term care insurance contracts acquired by the insurer from a nonaffiliated insurer if the increases occurred before the acquisition or not later than 24 months after the acquisition.
4. The insurer shall provide the information required by subsection 1 to the applicant:
(a) At the time of application; or
(b) If the method of application does not allow for delivery of the long-term care insurance contract or certificate at the time of application, not later than the time of delivery of the long-term care insurance contract or certificate.
5. An applicant must sign an acknowledgment that the insurer provided the information required by subsection 1:
(a) At the time of application; or
(b) If the method of application does not allow for the signing of the acknowledgment at the time of application, not later than the time of delivery of the long-term care insurance contract or certificate.
6. An insurer shall use forms NDOI-949 and NDOI-953, available from the Division, to comply with the requirements of this section.
7. An insurer shall provide notice of any increase in a premium rate schedule to all affected policyholders or certificate holders not less than 60 days before the effective date of the increase. The notice must include, without limitation, the information required by subsection 1.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.059 Insurer to submit disclosures regarding rate revisions and actuarial certification to Commissioner for approval. (NRS 679B.130)
1. The provisions of this section do not apply to:
(a) A long-term care insurance contract issued before October 1, 2008;
(b) A policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care; or
(c) An annuity contract or a rider or endorsement to an annuity contract that contains benefits for long-term care.
2. An insurer shall not offer for sale any form of long-term care insurance in this State unless, not later than 45 days before the offer for sale, the insurer submits to the Commissioner and the Commissioner approves:
(a) A copy of the disclosures described in NAC 687B.0585; and
(b) An actuarial certification that includes, without limitation:
(1) 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 long-term care insurance contract with no anticipated future premium increases;
(2) A statement that the long-term care insurance contract design and the coverage provided by the long-term care insurance contract have been reviewed and taken into consideration;
(3) A statement that the underwriting and claims adjudication processes have been reviewed and taken into consideration;
(4) A complete description of the basis for contract reserves that are anticipated to be held under the long-term care insurance contract, which must include, without limitation:
(I) Sufficient detail or sample calculations so as to provide a complete and accurate depiction of the amount of reserves to be held;
(II) A statement that the assumptions used for reserves contain reasonable margins for adverse experience;
(III) A statement that the net valuation premium for renewal years does not increase, except for attained-age ratings if such increases are authorized; and
(IV) 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 any situations in which this does not occur;
(5) A statement that the premium rate schedule is not less than the premium rate schedule for existing similar long-term care insurance contract forms available from the insurer, except for reasonable differences attributable to benefits, or a comparison of the premium rate schedules for similar long-term care insurance contract forms that are currently available from the insurer with an explanation of the differences;
(6) An actuarial demonstration that benefits are reasonable in relation to premiums, which must include:
(I) Premium and claims experience on similar long-term care insurance contract forms adjusted for any premium or benefit differences;
(II) Relevant and credible data from other studies; or
(III) A combination of premium and claims experience on similar long-term care insurance contract forms and relevant and credible data from other studies; and
(7) A statement that the actuarial certification was made by a qualified actuary.
3. For the purposes of sub-subparagraph (IV) of subparagraph (4) of paragraph (b) of subsection 2, an aggregate distribution of anticipated issues may be used if the underlying gross premiums maintain a reasonably consistent relationship in accordance with generally accepted standards of actuarial practice. If the gross premiums for certain age groups appear to be inconsistent, the Commissioner may request a demonstration by the insurer that gross premiums maintain a reasonably consistent relationship based on a standard age distribution in accordance with generally accepted standards of actuarial practice.
4. Any additional information requested by the Commissioner for the purposes of approval pursuant to subsection 2 is not subject to the requirement that the information be submitted not later than 45 days before the long-term care insurance is offered for sale.
5. An initial filing for long-term care insurance must display the issue date clearly on the first page of the long-term care insurance contract or on the schedule of benefits page.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.060 Right to return individual contracts or certificates; notice of right. (NRS 679B.130)
1. An applicant for long-term care insurance may return the long-term care insurance contract or certificate within 30 days after its delivery and have the premium refunded if, after examining the long-term care insurance contract or certificate, he or she is not satisfied for any reason.
2. Except as otherwise provided in subsection 5, a long-term care insurance contract or certificate must contain a notice prominently printed on the first page or attached thereto stating in substance that the applicant may return the long-term care insurance contract or certificate within 30 days after its delivery and have the premium refunded if, after examining the long-term care insurance contract or certificate, he or she is not satisfied for any reason.
3. If an application for long-term care insurance is denied, any premium paid by the applicant must be refunded.
4. Any refund pursuant to this section must be made within 30 days after the return of the long-term care insurance contract or certificate or the denial of the application, as applicable.
5. Subsection 2 does not apply to a certificate issued pursuant to a long-term care insurance contract issued to a group described in subsection 1 of NAC 687B.025.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0655 Requirements for long-term care insurance sold in conjunction with another insurance product. (NRS 679B.130) Long-term care insurance sold in conjunction with another insurance product, including, but not limited to, life insurance or an annuity must:
1. Be issued as a separate rider that complies with the provisions of NAC 687B.005 to 687B.140, inclusive; or
2. Be incorporated directly into the policy or contract of another insurance product, including, but not limited to, a policy of life insurance or an annuity contract, and comply with the provisions of NAC 687B.005 to 687B.140, inclusive, as well as the provisions of any other statute or regulation that apply to the other insurance product. For a policy or contract sold pursuant to this subsection, except for those provisions relating to premium rates and premium rate increases which shall apply separately to each insurance product, if there is a conflict between a provision required for the long-term care insurance and a provision required for the other insurance product, the provision which is more generous to the consumer shall apply to all aspects of the policy or contract.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.066 Provision for reinstatement in event of lapse of coverage. (NRS 679B.130)
1. A long-term care insurance contract or certificate must include a provision which provides that, in the event of a lapse in coverage, coverage will be reinstated if:
(a) The insured provides proof of cognitive impairment or loss of functional capacity before the grace period contained in the long-term care insurance contract or certificate expires;
(b) The insured requests reinstatement of coverage within 5 months of the date of termination of coverage; and
(c) The insured pays any premiums which are past due.
2. For the purposes of subsection 1, the standard of proof of cognitive impairment or loss of functional capacity must not be more stringent than any criteria regarding cognitive impairment or loss of functional capacity used in the long-term care insurance contract or certificate to determine eligibility for benefits.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.067 Applications: Questions; required statements; required information for applicants 80 years of age or older. (NRS 679B.130)
1. An application for a long-term care insurance contract or certificate that is not guaranteed issue must contain clear and unambiguous questions designed to ascertain the condition of the applicant’s health.
2. If an application for a long-term care insurance contract or certificate contains a question which asks whether the applicant has had medication prescribed by a physician, the applicant must be required to list any medication that has been prescribed. If an insurer knows, or should know, at the time of application that a medication listed by the applicant on the application is directly related to a medical condition for which coverage would otherwise be denied, the insurer shall not later rescind the long-term care insurance contract or certificate for that condition.
3. Except for a long-term care insurance contract or certificate that is guaranteed issue:
(a) A statement in the following form must be set out conspicuously and in close proximity to the block for the applicant’s signature on an application for a long-term care insurance contract or certificate:
Caution: If your answers on this application are incorrect or untrue, [Company Name] has the right to deny benefits or rescind your policy.
(b) A statement in substantially the following form must be set out conspicuously on the long-term care insurance contract or certificate at the time of delivery:
Caution: The issuance of this [policy] [certificate] of long-term care insurance 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] [certificate]. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers is incorrect, contact the company at this address: [insert address].
(c) Prior to issuing a long-term care insurance contract or certificate to an applicant who is at least 80 years old, an insurer shall obtain one of the following:
(1) A report of a physical examination;
(2) An assessment of functional capacity;
(3) An attending physician’s statement; or
(4) Copies of medical records.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.068 Right to copy of application or enrollment form. (NRS 679B.130) An insurer shall deliver a copy of the completed application or enrollment form, whichever is applicable, to the insured no later than at the time of delivery of the long-term care insurance contract or certificate unless a copy is retained by the applicant at the time of application.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0681 Designation of person to receive notice of lapse or termination of coverage. (NRS 679B.130)
1. Except as otherwise provided in subsection 3, an insurer shall not issue an individual long-term care insurance contract in this State unless the insurer has received from the applicant:
(a) A written designation of at least one person, in addition to the applicant, who must receive notice of any lapse or termination of coverage under the policy for nonpayment of premium; or
(b) A written waiver dated and signed by the applicant stating that the applicant has chosen not to designate another person to receive notice of any lapse or termination of coverage for nonpayment of premium.
2. The designation pursuant to subsection 1 of another person to receive notice of any lapse or termination of coverage for nonpayment of premium does not constitute acceptance of any liability by the other person for services provided to the applicant. The form used for the written designation of another person to receive notice of any lapse or termination of coverage for nonpayment of premium must provide space clearly designated for listing at least one such person. The designation must include the full name and home address of each person designated by the applicant to receive notice of any lapse or termination of coverage for nonpayment of premium. If an applicant does not designate another person to receive notice of any lapse or termination of coverage for nonpayment of premium, the waiver must state, in substantially similar language: “Protection against unintended lapse. I understand that I have the right to designate at least one person other than myself to receive notice of any lapse or termination of coverage under this policy of long-term care insurance for nonpayment of premium. I understand that notice will not be given until 30 days after the date on which a premium is due and unpaid. I choose NOT to designate a person to receive this notice.” The insurer shall notify an insured of the right to change the written designation described in this section not less than once every 2 years.
3. If an insured who pays premiums for long-term care insurance through a payroll or pension deduction plan ceases to make such payments through the plan, the insurer shall comply with the requirements of subsections 1 and 2 not later than 60 days after the date on which the premiums are no longer paid through the plan. The application or enrollment form for a long-term care insurance contract or certificate for which the premium is paid through a payroll or pension deduction plan must clearly indicate the payment plan selected by the applicant.
4. An individual long-term care insurance contract must not lapse or be terminated by the insurer for nonpayment of premium unless the insurer, not less than 30 days after a premium is due and unpaid and not less than 30 days before the effective date of the lapse or termination, has given notice by first-class mail, postage prepaid, to the policyholder and to each person designated by the policyholder to receive notice pursuant to subsection 1 at the address provided by the insured for receiving notice of any lapse or termination. The notice required by this subsection shall be deemed to have been given 5 days after the date on which the insurer mails the notice.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0682 Verification of enrollment in group policy; satisfaction of any requirement for signature of insured. (NRS 679B.130)
1. For the enrollment of an insured in a long-term care insurance contract that applies to a group described in subsection 1 of NAC 687B.025, any requirement that the signature of an insured be obtained by an agent or insurer shall be deemed satisfied if:
(a) The necessary consent to enrollment is obtained from the insured by telephonic or electronic enrollment by the group policyholder or insurer;
(b) The enrollment provides necessary and reasonable safeguards to ensure the accuracy, retention and prompt retrieval of records; and
(c) The enrollment provides necessary and reasonable safeguards to ensure the confidentiality of individually identifiable and privileged information.
2. Verification of the enrollment information obtained in the manner set forth in subsection 1 must be provided to the insured.
3. Upon request, the insurer shall make available to the Commissioner any records that demonstrate the ability of the insurer to confirm enrollment and coverage amounts.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0683 Delivery of contract or certificate. (NRS 679B.130) If an insurer approves an application for long-term care insurance, the insurer shall deliver the long-term care insurance contract or certificate to the applicant not later than 30 days after the date on which the application is approved.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0684 Delivery of policy summary or contract summary. (NRS 679B.130)
1. A policy summary must be delivered to an applicant for an individual policy of life insurance at the time of policy delivery if the policy provides long-term care benefits, whether by rider, endorsement or within the policy. In the case of direct-response solicitations, the insurer shall deliver the policy summary upon the applicant’s request, or not later than the time the policy is delivered. The policy summary must 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 exclusions, reductions and limitations on benefits for long-term care;
(d) A statement that the protection against inflation required by NAC 687B.076 is not available under this policy; and
(e) If applicable to the policy type:
(1) A disclosure of the effects of exercising other rights under the policy;
(2) A disclosure of guarantees related to long-term care costs of insurance charges; and
(3) Current and projected lifetime benefits.
2. The provisions of the policy summary described in subsection 1 may be incorporated into a basic illustration required to be delivered by NAC 686A.460 to 686A.479, inclusive, or into the life insurance policy summary which is required to be delivered by NAC 686A.430.
3. A contract summary must be delivered to a prospective applicant for an individual annuity contract at the time of delivery if the contract provides long-term care benefits, whether by rider, endorsement or within the contract. In the case of direct-response solicitations, the insurer shall deliver the contract summary upon the prospective applicant’s request, or not later than the time the contract is delivered. The contract summary must include:
(a) An explanation of how the long-term care benefit interacts with other components of the contract, 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 exclusions, reductions and limitations on benefits for long-term care; and
(d) If applicable to the policy type:
(1) A disclosure of the effects of exercising other rights under the contract;
(2) A disclosure of guarantees related to long-term care costs of insurance charges; and
(3) Current and projected lifetime benefits.
4. The provisions of the contract summary described in subsection 3 may be incorporated into an illustration or into the contract summary which is required to be delivered by NAC 688A.120. An illustration or contract summary used to satisfy the requirements of this subsection must be approved by the Commissioner before use.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0685 Offer of nonforfeiture benefit required. (NRS 679B.130)
1. Except as otherwise provided in subsection 2, an insurer shall not deliver or issue for delivery in this State a long-term care insurance contract or certificate unless the policyholder or certificate holder has been offered the option to purchase a long-term care insurance contract or certificate that includes a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider or endorsement that is attached to the policy. If the policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that must be available to the policyholder or certificate holder for the period following a substantial increase in premium rates specified in NAC 687B.0686.
2. Except as otherwise provided in subsection 3, if an insurer offers a group long-term care insurance contract, the offer required by subsection 1 must be made only to the group policyholder.
3. If an insurer offers a group long-term care insurance contract to a group described in subsection 4 of NAC 687B.025, other than a continuing-care retirement community or other similar entity, the offer required by subsection 1 must be made to each certificate holder.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0686 Requirements for nonforfeiture benefits; contingent benefit upon lapse. (NRS 679B.130)
1. The provisions of this section do not apply to a policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care.
2. To satisfy the requirements of NAC 687B.0685:
(a) A long-term care insurance contract or certificate offered with nonforfeiture benefits must include the elements of the coverage, requirements for eligibility, benefit triggers and length of benefits that are the same as the coverage issued without nonforfeiture benefits;
(b) If the offer of a nonforfeiture benefit required by NAC 687B.0685 is not otherwise described in the outline of coverage or other materials provided to the applicant, the offer must be set out separately and be in writing; and
(c) The nonforfeiture benefit included in the offer must conform to the requirements of this section.
3. If the long-term care insurance contract is issued to a group described in subsection 4 of NAC 687B.025, other than to a retirement community which provides continuing care, the insurer shall make the offer required pursuant to subsection 2 to each proposed certificate holder.
4. If an applicant rejects the offer of a nonforfeiture benefit required by NAC 687B.0685, the insurer shall provide a contingent benefit upon lapse described in this section.
5. For a policy with a fixed or limited premium paying period, the insurer shall provide a contingent benefit upon lapse in accordance with subsection 9.
6. If an applicant rejects the offer of a nonforfeiture benefit required by NAC 687B.0685, for a long-term care insurance contract or certificate without nonforfeiture benefits issued on or after October 1, 2008, the insurer shall provide a contingent benefit upon lapse described in this section.
7. If a group policyholder chooses to make the nonforfeiture benefit an option to a certificate holder, the certificate must provide the nonforfeiture benefit or the contingent benefit upon lapse described in this section.
8. A contingent benefit upon lapse is triggered if an insurer increases the premium rates to a level which results in a cumulative increase of the annual premium equal to or greater than the percentage of the initial annual premium of the policyholder or certificate holder, based on the issue age of the insured, as described in the following chart entitled “Triggers for a Substantial Premium Increase (I),” and the affected long-term care insurance contract or certificate lapses within 120 days after the due date of the increased premium. The insurer shall provide notice of the rate increase to a policyholder or certificate holder not less than 60 days before the due date of the premium that includes the rate increase. The chart must be set forth as follows:
|
Triggers for a Substantial Premium Increase (I) |
|
|
Issue Age |
Percent Increase Over Initial Premium |
|
29 and under |
200 percent |
|
30-34 |
190 percent |
|
35-39 |
170 percent |
|
40-44 |
150 percent |
|
45-49 |
130 percent |
|
50-54 |
110 percent |
|
55-59 |
90 percent |
|
60 |
70 percent |
|
61 |
66 percent |
|
62 |
62 percent |
|
63 |
58 percent |
|
64 |
54 percent |
|
65 |
50 percent |
|
66 |
48 percent |
|
67 |
46 percent |
|
68 |
44 percent |
|
69 |
42 percent |
|
70 |
40 percent |
|
71 |
38 percent |
|
72 |
36 percent |
|
73 |
34 percent |
|
74 |
32 percent |
|
75 |
30 percent |
|
76 |
28 percent |
|
77 |
26 percent |
|
78 |
24 percent |
|
79 |
22 percent |
|
80 |
20 percent |
|
81 |
19 percent |
|
82 |
18 percent |
|
83 |
17 percent |
|
84 |
16 percent |
|
85 |
15 percent |
|
86 |
14 percent |
|
87 |
13 percent |
|
88 |
12 percent |
|
89 |
11 percent |
|
90 and over |
10 percent |
9. A contingent benefit upon lapse is triggered for any long-term care insurance contract with a fixed or limited premium paying period if the insurer increases the premium rates to a level which results in a cumulative increase of the annual premium equal to or greater than the percentage of the initial annual premium of the policyholder or certificate holder, based on the issue age of the insured, as described in the following chart entitled “Triggers for a Substantial Premium Increase (II),” the affected long-term care insurance contract or certificate lapses not later than 120 days after the due date of the increased premium and the ratio of the number of completed months of paid premiums divided by the number of months in the premium paying period is 0.4 or more. The provision of this benefit is in addition to the benefit described in subsection 8, and if both benefits are triggered, the insured may choose which benefit must be provided. The insurer shall provide notice of the rate increase to a policyholder or certificate holder not less than 60 days before the due date of the premium that includes the rate increase.
|
Triggers for a Substantial Premium Increase (II) |
|
|
Issue Age |
Percent Increase Over Initial Premium |
|
64 and under |
50 percent |
|
65-79 |
30 percent |
|
80 and over |
10 percent |
10. On or before the effective date of a substantial premium increase described in subsection 8, the insurer shall:
(a) Offer to reduce long-term care insurance contract 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 12 and allow the policyholder or certificate holder to accept this offer at any time during the 120-day period described in subsection 8; and
(c) Notify the policyholder or certificate holder that a default or lapse at any time during the 120-day period described in subsection 8 shall be deemed to be the selection of the offer to convert described in paragraph (b), unless the provisions of paragraph (c) of subsection 11 apply.
11. On or before the effective date of a substantial premium increase described in subsection 9, the insurer shall:
(a) Offer to reduce 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 where the amount payable for each benefit is equal to 90 percent of the amount payable immediately before the lapse multiplied by the ratio of the number of completed months of paid premiums divided by the number of months in the premium paying period and allow the policyholder or certificate holder to accept this offer at any time during the 120-day period set forth in subsection 9; and
(c) Notify the policyholder or certificate holder that a default or lapse at any time during the 120-day period set forth in subsection 9 shall be deemed to be the selection of the offer to convert described in paragraph (b) if the ratio described in paragraph (b) is 0.4 or more.
12. For the purpose of determining benefits continued as nonforfeiture benefits, including the contingent benefits upon lapse described in subsection 8 but not the contingent benefits upon lapse described in subsection 9:
(a) “Attained age rating” means a schedule of premiums starting from the issue date which increases with age of at least 1 percent per year before 50 years of age and at least 3 percent per year at and after 50 years of age.
(b) The nonforfeiture benefit must be for a shortened benefit period providing paid-up long-term care insurance after lapse. The same benefit amounts and frequency of benefits in effect at the time of lapse, but not increased thereafter, must be payable for a qualifying claim, but the lifetime maximum dollars or days of benefits must be determined as specified in paragraph (c).
(c) The standard nonforfeiture benefit must be equal to 100 percent of the sum of all premiums paid, including the premiums paid before any change in benefits. The insurer may offer additional options for shortened benefit periods if the benefits for each period are equal to or greater than the standard nonforfeiture benefit for that period, except that the minimum nonforfeiture benefit must not be less than 30 times the daily nursing home benefit in effect at the time of the lapse and is subject to the limitations of subsection 13.
(d) Except as otherwise provided in paragraph (f), the nonforfeiture benefit must begin not later than the end of the third year following the date of issue of the long-term care insurance contract or certificate.
(e) Except as otherwise provided in paragraph (f), the contingent benefit upon lapse must be effective from the date of issue of the long-term care insurance contract or certificate.
(f) For a long-term care insurance contract or certificate with attained age rating, the nonforfeiture benefit must begin on the earlier of:
(1) The end of the 10th year following the date of issue of the long-term care insurance contract or certificate; or
(2) The end of the second year following the date on which the long-term care insurance contract or certificate is no longer subject to attained age rating.
(g) Nonforfeiture benefits 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.
13. All benefits paid by an insurer while a long-term care insurance contract or certificate is not in premium-paying status and in a paid-up status must not exceed the maximum benefits which would be payable if the long-term care insurance contract or certificate remained in premium-paying status.
14. The minimum nonforfeiture benefits required by this section must be the same for group and individual long-term care insurance contracts.
15. Premiums charged for a long-term care insurance contract or certificate containing nonforfeiture benefits or a contingent benefit upon lapse are subject to the loss ratio requirements applicable to the long-term care insurance contract as a whole.
16. To determine whether the provisions of paragraph (c) of subsection 10 and paragraph (c) of subsection 11 apply, a replacing insurer that purchases or otherwise assumes a block or blocks of long-term care insurance contracts from another insurer shall calculate the percentage increase based on the initial annual premium paid by the policyholder or certificate holder when the long-term care insurance contract was first purchased by the policyholder or certificate holder.
17. An insurer shall offer a nonforfeiture benefit for any qualified long-term care insurance contract that is a level premium contract. The nonforfeiture benefit provision must:
(a) Be appropriately captioned;
(b) Provide a benefit available in the event of a default in the payment of any premiums;
(c) State that the amount of the benefit may be adjusted only as is necessary to reflect changes in claims, persistency and interest, as reflected in changes in rates for premium-paying contracts approved by the Commissioner for the same contract form; and
(d) Provide:
(1) Reduced paid-up insurance;
(2) Extended-term insurance;
(3) A shortened benefit period; or
(4) Any other similar offerings approved by the Commissioner.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0687 Applicability of provisions regarding nonforfeiture benefits and contingent benefit upon lapse. (NRS 679B.130)
1. Except as otherwise provided in this section, the provisions of NAC 687B.0686 apply to any long-term care insurance contract or certificate issued in this State on or after October 1, 2008.
2. The provisions of NAC 687B.0686 do not apply to a certificate issued on or after October 1, 2008, to a group described in subsection 1 of NAC 687B.025 under a group long-term care insurance contract which was in force on October 1, 2008.
3. The provisions of subsections 5, 9 and 11 of NAC 687B.0686 do not apply to new certificates issued to a group described in subsection 1 of NAC 687B.025 under a group long-term care insurance contract issued on or after April 1, 2009.
4. Except as otherwise provided in subsections 2, 3 and 5, the provisions of subsections 5, 9 and 11 of NAC 687B.0686 apply to any long-term care insurance contract or certificate issued in this State on or after January 1, 2009.
5. Except as otherwise provided in subsections 2 and 3, the provisions of subsections 5 and 8 to 17, inclusive, of NAC 687B.0686 apply to any long-term care insurance contract or certificate which was in force on or after October 1, 2011, regardless of the date of issue.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0689 Rescission or denial of claim upon showing of misrepresentation material to acceptance for coverage; field issuance of contract or certificate. (NRS 679B.130)
1. For a long-term care insurance contract or certificate that has been in force for less than 6 months, an insurer may rescind the long-term care insurance contract 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.
2. For a long-term care insurance contract or certificate that has been in force for not less than 6 months but less than 2 years, an insurer may rescind the long-term care insurance contract or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation which is both material to the acceptance for coverage and which pertains to the condition for which benefits are sought.
3. After a long-term care insurance contract or certificate has been in force for 2 years, it is not contestable upon the grounds of misrepresentation alone and may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured’s health.
4. A long-term care insurance contract or certificate may be field-issued if the compensation to the field issuer is not based on the number of long-term care insurance contracts or certificates issued.
5. If an insurer has paid benefits under a long-term care insurance contract or certificate, the benefit payments must not be recovered by the insurer if the long-term care insurance contract or certificate is rescinded.
6. The provisions of this section apply to policies of life insurance which accelerate benefits for long-term care except that, in the event of the death of the insured, this section does not apply to the remaining death benefit of a policy of life insurance that accelerates benefits for long-term care, and the remaining death benefits under such a policy must be governed by NRS 688A.080.
7. As used in this section, “field-issued” means issued by a producer or a third-party administrator pursuant to the underwriting authority granted to the producer or third-party administrator by an insurer, using the insurer’s underwriting guidelines.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.069 Record of rescissions. (NRS 679B.130) An insurer or other entity selling or issuing benefits for long-term care insurance shall maintain a record of all rescissions of its long-term care insurance contracts or certificates in this State or in any other state, except those which the insured voluntarily effectuated, and shall, on or before March 1 of each year, furnish this information to the Commissioner using form NDOI-929, which is available from the Division, or a similar form approved by the Commissioner.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.070 Certificate of insurance: Contents. (NRS 679B.130) A certificate issued pursuant to a group long-term care insurance contract which is delivered or issued for delivery in this State must include:
1. A description of the principal benefits and coverage provided in the group long-term care insurance contract;
2. A statement of the principal exclusions, reductions and limitations contained in the group long-term care insurance contract; and
3. A statement that the group master long-term care insurance contract determines governing contractual provisions.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.075 Outline of coverage: Format; delivery; contents. (NRS 679B.130)
1. An outline of coverage must be delivered to a prospective applicant for a long-term care insurance contract or certificate at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose. In the case of direct-response solicitations, the insurer shall deliver the outline of coverage upon the prospective applicant’s request, or not later than at the time the long-term care insurance contract is delivered.
2. The Commissioner will prescribe a standard format, including style, arrangement and overall appearance, and the content of an outline of coverage.
3. Notwithstanding the provisions of subsection 1, for a long-term care insurance contract issued to a group described in subsection 1 of NAC 687B.025, an outline of coverage need not be delivered if all the information otherwise required to be included in an outline of coverage by subsection 4 is contained in other materials relating to enrollment. These other materials must be made available to the Commissioner upon request.
4. The outline of coverage must include:
(a) A description of the principal benefits and coverage provided in the long-term care insurance contract;
(b) A statement of the principal exclusions, reductions and limitations contained in the long-term care insurance contract;
(c) A statement of the renewal provisions, including any reservation in the long-term care insurance contract of a right to change premiums and, for group coverage, specific descriptions of provisions for continuation or conversion;
(d) A statement that the outline of coverage is a summary of the long-term care insurance contract issued or applied for, and that the long-term care insurance contract should be examined to determine governing contractual provisions;
(e) A description of the terms under which the long-term care insurance contract or certificate may be returned and the premium refunded;
(f) A brief description of the relationship of the cost of care and benefits; and
(g) A statement that discloses to the policyholder or certificate holder whether the long-term care insurance contract is intended to be a federally tax-qualified long-term care insurance contract.
5. The outline of coverage must:
(a) Be a separate and complete document;
(b) Be printed in type no smaller than 10-point;
(c) Not include any material of an advertising nature; and
(d) Contain a statement in substantially the following form, set out conspicuously in the following format:
[COMPANY NAME]
[ADDRESS-CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Contract Number or Group Master Contract and Certificate Number]
[Except for a contract or certificate that is guaranteed issue, the following statement of caution, or a substantially similar statement, must appear in the outline of coverage.]
Caution: The issuance of this [contract] [certificate] of long-term care insurance 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] [will be attached to any issued contract] [will be enclosed with any issued contract]. If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your [contract] [certificate]. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers is incorrect, contact the company at this address: [Insert address].
Notice to buyer: This contract may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all limitations in the contract.
1. This contract is [an individual contract of insurance] [a group contract] which was issued in the [indicate jurisdiction in which contract was issued].
2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of the important features of the contract. You should compare this outline of coverage to outlines of coverage for other contracts available to you. This is not a contract of insurance, but only a summary of coverage. Only the individual or group contract contains governing contractual provisions. This means that the contract or group contract 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 [CONTRACT] [CERTIFICATE] CAREFULLY!
3. FEDERAL TAX CONSEQUENCES.
This [CONTRACT] [CERTIFICATE] is intended to be a federally tax-qualified long-term care insurance contract under 26 U.S.C. § 7702B(b).
OR
This [CONTRACT] [CERTIFICATE] is not intended to be a federally tax-qualified long-term care insurance contract under 26 U.S.C. § 7702B(b). Benefits received under the [CONTRACT] [CERTIFICATE] may be taxable as income.
4. TERMS UNDER WHICH THE [CONTRACT] [CERTIFICATE] MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(a) [For a long-term care insurance contract or certificate, describe one of the following permissible provisions regarding renewability of the contract or certificate:
(1) Contracts and certificates that are guaranteed renewable must contain the following statement:] RENEWABILITY: THIS [CONTRACT] [CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have the right, subject to the terms of your [contract] [certificate], to continue this [contract] [certificate] as long as you pay your premiums on time. [Company Name] cannot change any of the terms of your [contract] [certificate] on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY.
(2) [Contracts and certificates that are noncancellable must contain the following statement:] RENEWABILITY: THIS [CONTRACT] [CERTIFICATE] IS NONCANCELLABLE. This means that you have the right, subject to the terms of your [contract] [certificate], to continue this [contract] [certificate] as long as you pay your premiums on time. [Company Name] cannot change any of the terms of your [contract] [certificate] on its own and cannot change the premium you currently pay. However, if your [contract] [certificate] contains a feature to protect against inflation 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 describe the basis for continuation of coverage and basis for conversion of coverage applicable to the certificate and group contract.]
(c) [Describe the provisions regarding waiver of premium or state that there are no such provisions.]
5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.
[In bold type larger than the minimum 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 this right exists, describe clearly and concisely each circumstance under which the premium may change.]
6. TERMS UNDER WHICH THE [CONTRACT] [CERTIFICATE] MAY BE RETURNED AND PREMIUM REFUNDED.
(a) [Provide a brief description of the right to return — the “free look” provision of the contract or certificate.]
(b) [Include a statement whether the contract or certificate contains provisions for a refund or partial refund of the premium upon the death of an insured or surrender of the contract or certificate. If the contract or certificate contains such provisions, include a description of them.]
7. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the insurance company.
(a) [For agents] Neither [Company Name] nor its agents represent Medicare, the Federal Government or any state government.
(b) [For direct-response] [Company Name] is not representing Medicare, the Federal Government or any state government.
8. LONG-TERM CARE COVERAGE.
(a) Contracts of this category are designed to provide coverage for one or more necessary or medically necessary services related to diagnostic, preventative, therapeutic, rehabilitative, maintenance or personal care, 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.
(b) This contract provides coverage in the form of a fixed dollar indemnity benefit for covered long-term care expenses, subject to [limitations] [waiting periods] and [requirements regarding coinsurance] set forth in the [contract] [certificate]. [Modify this paragraph if the contract or certificate is not a contract or certificate of indemnity.]
9. BENEFITS PROVIDED BY THIS [CONTRACT] [CERTIFICATE].
(a) [Describe covered services, related deductible(s), waiting periods, elimination periods and maximums of benefits.]
(b) [Describe institutional benefits, by skill level.]
(c) [Describe noninstitutional benefits, by skill level.]
(d) Eligibility for Payment of Benefits.
[Activities of daily living and cognitive impairment must 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. If these triggers differ for different benefits, explanations 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 for an insured to be eligible for benefits, this too must be specified.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a) Preexisting conditions;
(b) Noneligible facility or provider;
(c) Noneligible levels of care (for example, unlicensed providers, care or treatment provided by a family member);
(d) Exclusions or exceptions; and
(e) Limitations.]
[This section should provide a brief, specific description of any provision in the contract or certificate which limits, excludes, restricts, reduces, delays or in any other manner operates to qualify payment of benefits for one or more necessary or medically necessary services related to diagnostic, preventative, therapeutic, rehabilitative, maintenance or personal care.]
THIS [CONTRACT] [CERTIFICATE] MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR NEEDS FOR LONG-TERM CARE.
11. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of services related to long-term care 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 level of benefits will not increase over time;
(b) Any provisions regarding automatic adjustment of benefits;
(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 screening of health will be required, the frequency and amounts of the options for upgrading and any significant restrictions or limitations; and
(e) Describe whether there will be any additional charge in premiums imposed and, if so, how the additional charge will be calculated.]
12. ALZHEIMER’S DISEASE AND OTHER ORGANIC BRAIN DISORDERS. [State that the contract or certificate provides coverage for an insured clinically diagnosed as having Alzheimer’s disease or a related degenerative and dementing illness. Specifically describe each screening of benefits or other provision in the contract or certificate that provides preconditions to the availability of benefits for such an insured.]
13. PREMIUM.
[(a) State the total annual premium for the contract.
(b) If the premium varies with an applicant’s choice among options of benefits, indicate the portion of annual premium which corresponds to each option of benefits.]
14. ADDITIONAL FEATURES.
[(a) Indicate if medical underwriting is used.
(b) Describe other important features.]
15. CONTACT THE NEVADA STATE HEALTH INSURANCE ADVISORY PROGRAM OF THE AGING AND DISABILITY SERVICES DIVISION OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES IF YOU HAVE GENERAL QUESTIONS REGARDING LONG-TERM CARE INSURANCE. CONTACT THE INSURANCE COMPANY IF YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR CONTRACT OR CERTIFICATE.
6. Text of the outline of coverage which is capitalized in the format set out in paragraph (d) of subsection 5 may be emphasized in the outline of coverage by other means which provide prominence equivalent to capitalization.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; 5-13-96; R121-07, 9-18-2008, eff. 10-1-2008; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.076 Offer to purchase protection from inflation required. (NRS 679B.130)
1. An insurer shall not offer a long-term care insurance contract unless the insurer also offers to the policyholder, in addition to any other protection from inflation, the option to purchase a long-term care insurance contract that provides for increasing levels of benefits and increasing maximum benefits at reasonable durations which account for reasonably anticipated increases in the costs of services related to long-term care covered by the long-term care insurance contract. An insurer shall offer to each policyholder, at the time of purchase, the option to purchase a long-term care insurance contract with a feature to protect against inflation that is no less favorable than one of the following:
(a) Increases levels of benefits annually in a manner so that the increases are compounded annually at a rate not less than 5 percent;
(b) Guarantees the insured the right to periodically increase levels of benefits without providing evidence of insurability or status of health so long as the option for the previous period has not been declined. The amount of the additional benefit must be no less than the difference between the existing benefit and that benefit compounded annually at a rate of at least 5 percent for the period beginning with the purchase of the existing benefit and extending until the year in which the offer is made; or
(c) Covers a specified percentage of actual or reasonable charges and does not include a maximum specified amount or limit of indemnity.
2. Except as otherwise provided in subsection 3, if the long-term care insurance contract is issued to a group, the insurer shall make the offer required by subsection 1 to the group policyholder.
3. If the long-term care insurance contract is issued to a group described in subsection 4 of NAC 687B.025, other than to a retirement community which provides continuing care, the insurer shall make the offer required pursuant to subsection 1 to each proposed certificate holder.
4. An insurer offering a long-term care insurance contract shall include the following information in or with the outline of coverage:
(a) A comparison of each level of benefits offered with a long-term care insurance contract that increases benefits over the contract period with a long-term care insurance contract that does not increase benefits. The comparison must be made through the use of graphs and must show the levels of benefits over a period of at least 20 years. All assumptions used to produce the graphs must be disclosed.
(b) Any expected increases in premiums or additional premiums to pay for automatic or optional increases in benefits.
Ê An insurer may use a reasonable hypothetical for the purpose of complying with the requirements of this subsection.
5. Increases in benefits under a long-term care insurance contract which provides for increased benefits to protect against inflation must continue without regard to an insured’s age, status regarding claims or history of claims or the length of time the person has been insured under the long-term care insurance contract.
6. An offer of protection against inflation which provides for automatic increases in benefits must include an offer of a premium which the insurer expects to remain constant and must disclose in a conspicuous manner that the premium may change in the future unless the premium is guaranteed to remain constant.
7. A long-term care insurance contract or certificate must include protection against inflation as provided in subsection 1 unless the insurer obtains a rejection of protection against inflation signed by the policyholder. A rejection must be included as a part of the application and must state:
I have reviewed the outline of coverage and the graphs that compare the benefits and premiums of this contract with and without protection against inflation. Specifically, I have reviewed Plans ........., and I reject protection against inflation.
8. In addition to the other requirements of this section for protection against inflation, a partnership contract must also:
(a) For a purchaser who has not attained 61 years of age as of the date of purchase, increase levels of benefits annually in a manner so that the increases are compounded annually at a rate:
(1) Of not less than 3 percent; or
(2) Based on changes in the Consumer Price Index for All Urban Consumers, U.S. City Average (All Items) published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year;
(b) For a purchaser who has attained 61 years of age but has not attained 76 years of age as of the date of purchase, contain some level of protection against inflation, such as simple inflation protection; and
(c) For a purchaser who has attained 76 years of age as of the date of purchase, give the purchaser an option for some level of protection against inflation.
9. A person who purchases a partnership contract may adjust the level of protection against inflation, and such a contract will maintain partnership status if the new level of protection against inflation meets the minimum requirement set forth in subsection 8 for the policyholder’s age at the time of adjustment.
10. The provisions of this section do not apply to a policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.077 Requirements for marketing. (NRS 679B.130) An insurer, health care plan or other entity who markets, directly or through its agents or other producers, long-term care insurance in this State shall:
1. Establish procedures regarding marketing to assure that any comparison of long-term care insurance contracts by its agents or other producers will be fair and accurate.
2. Establish procedures regarding marketing to assure excessive insurance is not sold or issued.
3. Display prominently by type, stamp or other appropriate means, on the first page of the outline of coverage and long-term care insurance contract, a statement in substantially the following form:
“Notice to buyer: This contract may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all limitations in the contract.”
4. Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for long-term care insurance already has a policy for accident and sickness or a long-term care insurance contract and the types and amounts of any such insurance, except that no inquiry into existing policies for accident and sickness needs to be made for a prospective applicant or enrollee for a qualified long-term care insurance contract.
5. Establish auditable procedures for verifying compliance with this section.
6. At the time of solicitation, provide a written notice to the prospective policyholder or certificate holder:
(a) Informing him or her of the availability of a program which provides counseling to elderly persons concerning health insurance; and
(b) Providing the name, address and telephone number of the program.
7. Provide an applicant with copies of forms NDOI-949 and NDOI-953.
8. Provide an explanation of the contingent benefit upon lapse provided for in subsection 8 of NAC 687B.0686 and, if applicable, the additional contingent benefit upon lapse provided to a long-term care insurance contract with a fixed or limited premium paying period provided for in subsection 9 of NAC 687B.0686.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0775 Approval of advertisement by Commissioner. (NRS 679B.130)
1. Except as otherwise provided in subsection 2, every insurer or other organization that markets or offers long-term care insurance contracts or certificates in this State shall:
(a) Provide to the Commissioner for review and approval a copy of any written, radio or television advertisement for the sale of long-term care insurance intended for use in this State; and
(b) Retain any such advertisement for at least 3 years after the date the advertisement was first used.
2. The Commissioner may exempt an advertisement from the requirements of subsection 1 if, in the opinion of the Commissioner, the provisions of subsection 1 may not be reasonably applied to the advertisement.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.078 Restriction on use of certain terms in marketing. (NRS 679B.130) An insurer, health care plan or other entity marketing long-term care insurance in this State, directly or through its agents or other producers, shall not use the terms “noncancellable” or “level premium” in reference to a long-term care insurance contract or certificate unless the long-term care insurance contract or certificate provides that the insured may continue the long-term care insurance by the timely payment of premiums during which period the insurer may not unilaterally make any change in any provision of the insurance or in the premium rate.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.079 Prohibition of certain marketing practices. (NRS 679B.130)
1. An insurer, health care plan or other entity marketing long-term care insurance in this State, directly or through its agents or other producers, shall not engage in the following acts or practices:
(a) High pressure tactics, including:
(1) Any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright or threat, whether explicit or implied; and
(2) Undue pressure to purchase or recommend the purchase of insurance.
(b) Directly or indirectly making use 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 agent or insurance company, commonly referred to as “cold lead advertising.”
(c) Knowingly making any misleading representation or incomplete or fraudulent comparison of any contract of insurance or insurer for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow or convert any contract of insurance or to take out a contract of insurance with another insurer, commonly referred to as “twisting.”
(d) Misrepresenting a material fact in selling or offering to sell a long-term care insurance contract.
2. The provisions of NRS 686A.010 to 686A.325, inclusive, apply to all long-term care insurance contracts.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.080 Definition of terms in contracts. (NRS 679B.130) A long-term care insurance contract delivered or issued for delivery in this State may not use the following terms unless the terms are defined in the long-term care insurance contract as follows:
1. “Activities of daily living” must be defined as including, without limitation, bathing, continence, dressing, eating, toileting and transferring.
2. “Acute condition” must be defined as a condition making a person medically unstable and requiring frequent monitoring of the person by providers of health care, including, but not limited to, physicians and registered nurses, in order to maintain his or her status of health.
3. “Adult day care” must be defined as a program, for six or more persons, of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired, elderly or disabled adults who can benefit from care in a group setting outside the home.
4. “Bathing” must be defined as washing oneself by sponge bath or in a tub or shower, including, without limitation, the task of getting into or out of the tub or shower.
5. “Cognitive impairment” must be defined as a deficiency in:
(a) The short or long-term memory of the person;
(b) Orientation as to person, place and time;
(c) Deductive or abstract reasoning; or
(d) Judgment as it relates to safety awareness.
6. “Continence” must be defined as:
(a) The ability of a person to maintain control of bowel and bladder function; or
(b) If a person is unable to maintain control of bowel or bladder function, the ability of a person to perform associated personal hygiene, including, without limitation, caring for a catheter or colostomy bag.
7. “Dressing” must be defined as putting on and taking off all items of clothing, including, without limitation, any necessary braces, fasteners or artificial limbs.
8. “Eating” must be defined as feeding oneself by getting food into the body, including, without limitation:
(a) From a receptacle, including, without limitation, a plate, cup or table;
(b) By feeding tube; or
(c) Intravenously.
9. “Hands-on assistance” must be defined as physical assistance without which the person would not be able to perform the activity of daily living.
10. “Home health care services” must be defined as medical and nonmedical services provided to ill, disabled or infirm persons in their residences. Covered services may include the services of a homemaker, assistance with activities of daily living and respite care.
11. “Medicare” must be defined as:
(a) “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended”;
(b) “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
(c) Any words of similar import.
12. “Mental or nervous disorder” must not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or a mental or emotional disease or disorder.
13. “Personal care” must be defined as the provision of hands-on services to assist a person with activities of daily living.
14. “Provider of services,” including, without limitation, a “skilled nursing facility,” “extended care facility,” “intermediate care facility,” “convalescent nursing home,” “personal care facility,” “specialized care provider,” “assisted living facility” and “home care agency” must be defined in relation to the services and facilities required to be available and the level of the licenses, certificates, registrations or degrees required for persons providing or supervising the services. If the definition requires that the provider be appropriately licensed, certified or registered, the definition must also set forth the 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 such services to be licensed, certified or registered or when the state licenses, certifies or registers such a provider under another name.
15. “Skilled nursing care,” “intermediate care,” “specialized care,” “assisted living care,” “home care” and any other care received must be defined in relation to the level of skill required, the nature of the care and the setting in which the care must be provided.
16. “Toileting” must be defined as:
(a) Getting to and from the toilet;
(b) Getting on and off the toilet; and
(c) Performing associated personal hygiene.
17. “Transferring” must be defined as moving into or out of a bed, chair or wheelchair.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R121-07, 9-18-2008, eff. 10-1-2008; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.081 Notification of availability of new series of contracts. (NRS 679B.130)
1. The provisions of this section do not apply to a policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care.
2. Except as otherwise provided in subsections 3, 6 and 7, an insurer shall notify each policyholder or certificate holder of the availability of any new series of long-term care insurance contracts that provides material coverage for long-term care services or providers that was not previously available through the insurer to the general public, not later than 12 months after the date the new series of long-term care insurance contracts is made available for sale in this State.
3. The notification required by subsection 2 is not required for any long-term care insurance contract or certificate issued:
(a) Before October 1, 2008; or
(b) To any policyholder or certificate holder who:
(1) Is currently eligible for benefits;
(2) Is within an elimination period;
(3) Is on a claim;
(4) Previously received benefits under the long-term care insurance contract or certificate; or
(5) Is not eligible to apply for the new coverage because of limitations under the new long-term care insurance contract relating to the issue age of the insured.
4. The insurer may require that the insured meet all eligibility requirements, including, without limitation, any underwriting requirements and payment of premiums to add any new coverage described in subsection 2.
5. The insurer shall make any new coverage described in subsection 2 available:
(a) By adding a rider or endorsement to the existing long-term care insurance contract and charging a separate premium for the rider or endorsement based on the attained age of the insured;
(b) By exchanging the existing long-term care insurance contract 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 long-term care insurance contract or certificate based on premiums paid or reserves held for the previous long-term care insurance contract or certificate;
(c) By exchanging the existing long-term care insurance contract or certificate for a new long-term care insurance contract or certificate in which:
(1) Consideration for past insured status must be recognized by setting the premium for the new long-term care insurance contract or certificate at the issue age of the insured for the long-term care insurance contract or certificate being exchanged; and
(2) The cost for the new long-term care insurance contract or certificate may recognize the difference in reserves between the new long-term care insurance contract or certificate and the original long-term care insurance contract or certificate; or
(d) By an alternative program developed by the insurer and approved by the Commissioner.
6. An insurer is not required to notify policyholders of a new proprietary long-term care insurance contract series created and filed for use in a limited distribution channel except that the insurer must notify any policyholder who purchases such a proprietary long-term care insurance contract when a new series of long-term care insurance contracts that provides material coverage for new long-term care services or providers is made available to that limited distribution channel. As used in this subsection, “limited distribution channel” means a discrete entity, including, without limitation, a financial institution or brokerage, through or for which specialized products are available that are not available for sale to the general public.
7. If the new series of long-term care insurance contracts is offered through an employer, labor organization, or professional, trade or occupational association, the insurer is only required to provide notice to the offering entity unless the policy is issued to a group described in subsection 4 of NAC 687B.025, in which case notice must be provided to each certificate holder.
8. A long-term care insurance contract or certificate issued pursuant to this section:
(a) Shall be deemed an exchange; and
(b) Is not subject to the provisions of NAC 687B.125 to 687B.135, inclusive.
9. The provisions of this section do not prohibit an insurer from offering any policy, rider, endorsement, certificate or change in coverage to any policyholder or certificate holder. The insurer may require that policyholders meet all eligibility requirements of the offered policy, rider, endorsement, certificate or change in coverage, including underwriting and the payment of the required premium to add such new services or providers.
10. Upon request, any policyholder or certificate holder may apply for any currently available coverage that includes any new services or providers described in subsection 2.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.082 Notification regarding partnership status. (NRS 679B.130)
1. Except as otherwise provided in subsection 3, after the Division approves a filing associated with the partnership status of a form, the insurer or similar organization issuing the form shall notify each policyholder and certificate holder with a long-term care insurance contract or certificate issued or delivered in this State:
(a) If the long-term care insurance contract or certificate requires no additional features to make it a partnership contract or partnership certificate, that the long-term care insurance contract or certificate is now intended to be a partnership contract or partnership certificate.
(b) If the long-term care insurance contract requires additional features to make it a partnership contract or partnership certificate, of an offer, subject to the conditions described in subsection 4, to upgrade the long-term care insurance contract or certificate with the intention to make it a partnership contract or partnership certificate.
2. The notices described in subsections 2 and 3 of NAC 687B.058 must be provided at the time of notification to the parties notified pursuant to subsection 1.
3. The requirements of subsection 1 do not apply to:
(a) A policy of life insurance or a rider to a policy of life insurance that accelerates benefits for long-term care;
(b) A disability income insurance policy or a rider to a disability income insurance policy that contains long-term care eligibility triggers;
(c) A long-term care insurance contract or certificate issued before January 1, 2007;
(d) A long-term care insurance contract or certificate issued by the insurer or similar organization but not approved by the Division as a partnership contract or certificate; or
(e) A long-term care insurance contract or certificate issued to any policyholder or certificate holder who:
(1) Is currently eligible for benefits;
(2) Is within an elimination period;
(3) Is on a claim;
(4) Previously received benefits under the long-term care insurance contract or certificate; or
(5) Is not eligible to apply for the new coverage because of limitations under the new long-term care insurance contract or certificate relating to the issue age of the insured.
4. The insurer may condition the offer described in paragraph (b) of subsection 1 on the insured meeting all eligibility requirements for any additional features that bear new risk, including, without limitation, enhancement of protection against inflation to the level identified in subsection 8 of NAC 687B.076. Eligibility requirements include, without limitation, any underwriting requirements and payment of premiums to add any new coverage.
5. The insurer shall make any new coverage pursuant to the offer described in paragraph (b) of subsection 1 available:
(a) By adding a rider or endorsement to the existing long-term care insurance contract and charging a separate premium for any new benefits provided under the rider or endorsement based on the present age of the insured; or
(b) By exchanging the existing long-term care insurance contract or certificate for one based on the age of the insured at the time the long-term care insurance contract or certificate was originally issued for all benefits provided under the existing long-term care insurance contract, and based on the present age of the insured for all new benefits that were not included in the existing long-term care insurance contract.
6. The forms associated with methods of upgrade described in subsection 5 intended for use by the insurer or similar organization must be included as part of the filing for partnership program status.
7. Not more than 18 months after the Division approves the partnership program status of a filing associated with a long-term care insurance contract or certificate, the insurer or similar organization shall complete:
(a) The conversion of all long-term care insurance contracts and certificates to partnership status as described in paragraph (a) of subsection 1; and
(b) The upgrades identified in subsection 5 for policyholders and certificate holders found eligible pursuant to subsection 4 who have accepted the offer described in paragraph (b) of subsection 1.
8. A long-term care insurance contract or certificate issued pursuant to this section:
(a) Must satisfy the requirements of NAC 687B.0335;
(b) Shall be deemed an exchange; and
(c) Is not subject to the provisions of NAC 687B.125 to 687B.135, inclusive.
9. An insurer or similar organization may upgrade any long-term care insurance contract or certificate associated with a filing approved pursuant to subsection 1 with issue dates before January 1, 2007, to partnership program status at any time in the form of an exchange. For any such exchange:
(a) The exchange must take place for a new long-term care insurance contract or certificate, as described in paragraph (b) of subsection 5.
(b) The requirements of paragraph (a) of subsection 8 must be met.
(c) The exchange offer must be made in a uniform and nondiscriminatory fashion, including, without limitation, making the offer for existing long-term care insurance contracts and certificates with an effective date on or after a justifiable date. For the purposes of this paragraph, February 8, 2006, is presumed to be a justifiable date.
(d) The applicability conditions in subsection 3, with the exception of paragraph (d) of subsection 3, apply to the exchange.
10. The provisions of this section do not:
(a) Prohibit an insurer or similar organization from offering a long-term care insurance contract or certificate to any policyholder or certificate holder. Insurers and similar organizations may require that policyholders and certificate holders meet all eligibility requirements, including underwriting and payment of required premiums.
(b) Prevent any prospective applicant from applying for the newly available partnership contract or partnership certificate approved by the Division in subsection 1.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.0825 Activities of daily living and cognitive impairment to be used to measure needs of insured and to be described in contract or certificate; benefit triggers. (NRS 679B.130)
1. Activities of daily living and cognitive impairment must be used to measure the needs of an insured for long-term care and must be described in a long-term care insurance contract or certificate in a separate paragraph that must be labeled as “Eligibility for the Payment of Benefits.” Any additional benefit triggers must also be explained and must include, without limitation, whether:
(a) Any such benefit triggers differ for different benefits; and
(b) An attending physician or other specified person is required to certify a certain level of functional dependency for the insured to be eligible for benefits.
2. The description of any benefit in a long-term care insurance contract or certificate must include an explanation of the benefit trigger.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.083 Contract or certificate to condition payment of benefits on insured’s ability to perform daily activities and cognitive impairment. (NRS 679B.130)
1. A long-term care insurance contract or certificate must condition the payment of benefits on a determination of the ability of the insured to perform activities of daily living and on the cognitive impairment of the insured. Eligibility for the payment of benefits must not be more restrictive than requiring a determination that the insured:
(a) Is unable to perform more than three of the activities of daily living; or
(b) Has a cognitive impairment.
2. For the purpose of determining the ability of an insured to perform the activities of daily living pursuant to subsection 1, such activities include, without limitation:
(a) Bathing;
(b) Continence;
(c) Dressing;
(d) Eating;
(e) Toileting;
(f) Transferring; and
(g) Any other activity of daily living defined in the long-term care insurance contract or certificate.
3. For the purposes of this section, the determination of a deficiency in the ability of the insured to perform the activities of daily living must not be more restrictive than a determination that the insured:
(a) Requires the hands-on assistance of another person to perform the prescribed activities of daily living; and
(b) If the deficiency is due to a cognitive impairment, requires supervision or verbal cues by another person to protect the insured or other persons.
4. Determinations regarding activities of daily living and cognitive impairment must be performed by a licensed health care practitioner.
5. In addition to the criteria set forth in subsections 1 to 4, inclusive, an insurer may use any other criteria for determining when benefits are payable under a long-term care insurance contract or certificate that are not more restrictive than the criteria set forth in subsection 1.
6. A long-term care insurance contract or certificate must include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.
7. Except for certificates issued on or after October 1, 2008, under a group long-term care insurance contract issued to a group described in subsection 1 of NAC 687B.025 that was in force on October 1, 2008, the provisions of this section apply to any long-term care insurance contract or certificate issued in this State on or after October 1, 2008.
8. As used in this section, “licensed health care practitioner” means a person licensed pursuant to chapters 630 to 633, inclusive, of NRS, a licensed social worker or other individual who meets the requirements prescribed by the Secretary of the Treasury pursuant to 26 U.S.C. § 7702B(c)(4).
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.084 Requirements relating to qualified long-term care insurance contract. (NRS 679B.130)
1. A qualified long-term care insurance contract must pay only for qualified long-term care services:
(a) Received by a chronically ill individual; and
(b) Provided pursuant to a plan of care prescribed by a licensed health care practitioner.
2. The payment of benefits under a qualified long-term care insurance contract must be conditioned on a certification of the inability of the insured to perform the activities of daily living for an expected period of at least 90 days because of a loss of functional capacity or severe cognitive impairment.
3. Certifications pursuant to subsection 2 regarding activities of daily living and cognitive impairment:
(a) Must be performed by a licensed health care practitioner.
(b) May be performed by a licensed health care practitioner at the direction of the insurer as is reasonably necessary with respect to a specific claim, except that if 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 because of a loss of functional capacity and the insured is receiving benefits, the certification may not be rescinded and additional certifications must not be performed until after the expiration of the 90-day period.
4. A qualified long-term care insurance contract must include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.
5. As used in this section:
(a) “Chronically ill individual” has the meaning ascribed to it in 26 U.S.C. § 7702B(c)(2).
(b) “Licensed health care practitioner” means a person licensed pursuant to chapters 630 to 633, inclusive, of NRS, a licensed social worker or other individual who meets the requirements prescribed by the Secretary of the Treasury pursuant to 26 U.S.C. § 7702B(c)(4).
(c) “Qualified long-term care services” has the meaning ascribed to it in 26 U.S.C. § 7702B(c)(1).
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008)
NAC 687B.0845 Required statement as to whether contract intended to be qualified long-term care insurance contract under federal provisions. (NRS 679B.130)
1. A qualified long-term care insurance contract must include a disclosure statement in the qualified long-term care insurance contract and in the outline of coverage that the qualified long-term care insurance contract is intended to be a qualified long-term care insurance contract under 26 U.S.C. § 7702B(b).
2. A long-term care insurance contract that is not a qualified long-term care insurance contract must include a disclosure statement in the long-term care insurance contract and in the outline of coverage that the long-term care insurance contract is not intended to be a qualified long-term care insurance contract under 26 U.S.C. § 7702B(b).
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.085 Terms for renewal of contracts. (NRS 679B.130)
1. The terms “guaranteed renewable” and “noncancellable” may not be used in any individual long-term care insurance contract without further explanatory language conforming to the disclosure requirements of NAC 687B.100.
2. No individual long-term care insurance contract may contain renewal provisions other than “guaranteed renewable” or “noncancellable.”
3. The term “guaranteed renewable” may be used only when the insured has the right to continue the long-term care insurance by the timely payment of premiums and the insurer has no unilateral rights to make any change in any provision of the long-term care insurance contract while the insurance is in force, and cannot decline to renew the long-term care insurance contract, except that the rates may be revised by the insurer on a class basis.
4. The term “noncancellable” may be used only when the insured has the right to continue the long-term care insurance 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.
5. The term “level premium” may be used only when the insurer has no right to change the premium.
6. In addition to the other requirements of this section, a qualified long-term care insurance contract must be guaranteed renewable in conformance with the provisions of 26 U.S.C. § 7702B(b)(1)(c).
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.090 Exclusions from and limitations on coverage. (NRS 679B.130)
1. A long-term care insurance contract may not be delivered or issued for delivery in this State as long-term care insurance if the long-term care insurance contract limits or excludes coverage by type of illness, treatment, medical condition or accident, except for:
(a) Preexisting conditions or diseases.
(b) Mental or nervous disorders. This exception does not allow a limitation of benefits or exclusion of coverage on the basis of Alzheimer’s Disease.
(c) Alcoholism and drug addiction.
(d) Any illness, treatment or medical condition arising out of:
(1) A war or an act of war, whether declared or undeclared.
(2) Participation in a felony, riot or insurrection.
(3) Service in the Armed Forces or units auxiliary thereto.
(4) Suicide, attempted suicide or intentionally self-inflicted injury.
(5) Aviation. This exclusion applies only to passengers who do not pay fares.
(e) Treatment provided in a governmental facility, unless otherwise required by law, services for which benefits are available under Medicare or another governmental program, except Medicaid, and treatment received pursuant to any state or federal program for workers’ compensation, employer’s liability or occupational disease.
(f) Treatment provided pursuant to any law governing no-fault insurance for motor vehicles.
(g) Services provided by a member of the insured person’s immediate family.
(h) Services for which no charge is normally made in the absence of insurance.
(i) Services or items available from or paid by another long-term care insurance contract.
(j) In the case of a qualified long-term care insurance contract, expenses for services or items to the extent that the expenses are reimbursable under Medicare or would be so reimbursable but for the application of a deductible or coinsurance amount.
2. This section does not prohibit territorial limitations.
3. Notwithstanding the provisions of subsection 2, no issuer of long-term care insurance may deny a claim because services are provided in a state other than the state in which the long-term care insurance contract or certificate was issued when the state in which services are provided:
(a) Does not license, certify or register providers as required in the long-term care insurance contract or certificate, but the provider otherwise satisfies the requirements of the long-term care insurance contract or certificate; or
(b) Licenses, certifies or registers providers under another name.
4. For the purposes of this section, “preexisting condition” means a medical condition of a person for which he or she has received treatment during the 6 months preceding the effective date of the long-term care insurance contract.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-11-90; A 1-4-91; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.095 Extension of benefits; continuation or conversion of coverage. (NRS 679B.130)
1. Any termination of long-term care insurance must be without prejudice to any benefits payable for institutionalization if the institutionalization began while the long-term care insurance was in force and continues without interruption after termination.
2. Such an extension of benefits beyond the period the long-term care insurance is 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 waiting period contained in the long-term care insurance contract or any other applicable provision of the long-term care insurance contract.
3. An insurer or similar organization issuing a group long-term care insurance contract shall include in the group long-term care insurance contract:
(a) The basis for continuation of coverage; or
(b) The basis for conversion of coverage.
4. A group long-term care insurance contract which restricts the provision of benefits and services to certain providers or facilities or which contains incentives to use certain providers or facilities may comply with subsection 3 by containing a provision for the continuation of coverage under a long-term care insurance contract which provides benefits which are substantially equivalent to the benefits of the existing group long-term care insurance contract. The Commissioner shall make a determination as to the substantial equivalency of benefits, and in doing so, may take into consideration the differences between plans with and without managed care, including, but not limited to, the arrangement of providing benefits under the plans, the availability of service under the plans, the levels of benefits under the plans and the administrative complexity of the plans.
5. As used in this section, “plan with managed care” means an arrangement for health care or assisted living designed to coordinate care of patients or to control costs through a system that provides, at a minimum, for review of the necessity and appropriateness of the allocation of health care resources and services provided or proposed to be provided to an insured, through management of cases or through use of specific networks of providers.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.100 Required disclosures. (NRS 679B.130, 679B.136)
1. An individual long-term care insurance contract must contain a provision for renewability unless the long-term care insurance contract provides that the right not to renew is reserved solely to the policyholder. Such a provision must be appropriately captioned, appear on the first page of the long-term care insurance contract, and clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the long-term care insurance contract is issued and for which it may be renewed. If the long-term care insurance contract is not of limited duration, the provision must also clearly state that the coverage is either guaranteed renewable or noncancellable, as appropriate.
2. 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 contract, all riders or endorsements added to an individual long-term care insurance contract after the date the long-term care insurance contract is issued or when the long-term care insurance contract is reinstated or renewed which reduce or eliminate benefits or coverage in the long-term care insurance contract must be agreed to in writing and signed by the insured. After the date the long-term care insurance contract is issued, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the term of the long-term care insurance contract must be agreed to in writing and signed by the insured, unless 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, the premium charged must be set forth in the long-term care insurance contract, rider or endorsement.
3. A long-term care insurance contract which provides for the payment of benefits based on standards described as “usual and customary,” “reasonable and customary” or words of similar import must include a definition and explanation of those terms in its accompanying outline of coverage.
4. If a long-term care insurance contract or certificate contains any limitations with respect to preexisting conditions, the limitations must appear as a separate paragraph of the long-term care insurance contract or certificate and be labeled as “Preexisting Condition Limitations.”
5. If a long-term care insurance contract or certificate contains any limitations or conditions with respect to eligibility other than those prohibited pursuant to NAC 687B.116, a statement concerning the limitations or conditions must appear as a separate paragraph of the long-term care insurance contract or certificate, must be labeled as “Limitations or Conditions on Eligibility for Benefits” and must include a description of the limitations or conditions, including information regarding any required number of days of confinement.
6. If a policy of life insurance or a rider or endorsement on a policy of life insurance provides accelerated benefits for long-term care, at the time of application for the policy, rider or endorsement, a statement disclosing that receipt of accelerated benefits may be taxable and that assistance should be sought from a personal tax advisor must be prominently displayed on the first page of the policy, rider or endorsement and any other related documents. When a request for payment of accelerated benefits is submitted, a copy of the statement disclosing that receipt of accelerated benefits may be taxable and that assistance should be sought from a personal tax advisor must be provided to the insured. This subsection does not apply to a qualified long-term care insurance contract.
7. If an annuity contract or a rider or endorsement on an annuity contract contains benefits for long-term care insurance, at the time of application for the contract, rider or endorsement, a statement disclosing that receipt of long-term care benefits may be taxable and that assistance should be sought from a personal tax advisor must be prominently displayed on the first page of the contract, rider or endorsement and any other related documents. When a request for payment of long-term care benefits is submitted, a copy of the statement disclosing that receipt of long-term care benefits may be taxable and that assistance should be sought from a personal tax advisor must be provided to the insured. This subsection does not apply to a qualified long-term care insurance contract.
8. An individual long-term care insurance contract, other than one for which the insurer has no right to change the premium, must include a provision stating that premium rates may change.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.105 Prohibited provisions. (NRS 679B.130) No long-term care insurance contract may:
1. Be cancelled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured or the certificate holder;
2. Contain a provision establishing a new waiting period if existing coverage is converted to or replaced by a new form within the same company, except with respect to an increase in benefits voluntarily selected by the insured or group policyholder; or
3. Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care provided in a facility than coverage for lower levels of care.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.106 Required provisions for reducing coverage and lowering premium; notice. (NRS 679B.130)
1. The provisions of this section do not apply to a policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care.
2. Each long-term care insurance contract or certificate must include a provision that allows the policyholder or certificate holder to reduce coverage and lower the premium by reducing:
(a) The maximum benefit; or
(b) The daily, weekly or monthly benefit amount.
3. In addition to the provisions of subsection 2, an insurer may include a provision that allows the policyholder or certificate holder to reduce coverage and lower the premium by offering any other option to reduce the premium that is consistent with the other provisions of the long-term care insurance contract or certificate or the administrative processes of the insurer.
4. Any provision that allows the policyholder or certificate holder to reduce coverage and lower the premium must include a description of the ways in which coverage may be reduced and the process for requesting and implementing a reduction in coverage.
5. For the purposes of reducing coverage pursuant to this section, the age of the insured used to determine the premium for the reduced coverage must be based on the age used to determine the premiums for the current amount of coverage.
6. The insurer may limit any reduction in coverage to plans or options available for that long-term care insurance contract form and to those for which benefits will be available after consideration of claims paid or payable.
7. If a long-term care insurance contract or certificate is at risk of lapsing, the insurer shall, in addition to the notice required pursuant to NAC 687B.0681, provide written notice to the policyholder or certificate holder of his or her right to reduce coverage and premiums pursuant to this section. The insurer shall provide notice to the policyholder or certificate holder before the later of:
(a) The date 20 days before the end of the grace period provided by the policy or certificate; or
(b) The date on which the premium becomes past due.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.1065 Insurer to file for approval any increase in a premium rate schedule for certain contracts. (NRS 679B.130)
1. The provisions of this section do not apply to:
(a) A long-term care insurance contract or certificate issued before October 1, 2008;
(b) A policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care;
(c) An annuity contract or a rider or endorsement to an annuity contract that contains benefits for long-term care; or
(d) A long-term care insurance contract or certificate which is subject to the provisions of NAC 687B.107.
2. An insurer shall file with the Commissioner for approval any increase in a premium rate schedule. The filing must include, without limitation:
(a) The information required by NAC 687B.0585;
(b) An actuarial memorandum prepared in accordance with all applicable standards of practice which must include:
(1) A description of the benefits provided under the affected long-term care insurance contract;
(2) An actuarial demonstration that the benefits are reasonable in relation to the premiums;
(3) An explanation of the reasons for the rate increase;
(4) The history of any previously approved rate increase, which must include the effective date of each previous rate increase and the percentage increase of each previous rate increase;
(5) A description of any actuarial assumptions and any related tables, including any changes in actuarial assumptions since the last rate increase and since the initial filing of contract rates;
(6) An analysis of the expected and the actual experience and projections for claims, premiums, loss ratios, lapses and mortality;
(7) The annual loss ratios expected at the time of the most recent premium filing and the initial rate filing, which must include a comparison of the expected and the actual loss ratios;
(8) The number of its insureds in this State and nationwide;
(9) If a reduction in benefits is offered to offset the rate increase, a complete actuarial justification that the premium changes are actuarially equivalent to the benefit reduction; and
(10) The basis for the interest rate used; and
(c) The percentage amount of the rate increase stated in the filing description of the uniform transmittal document.
3. If the insurer has fewer than 2,000 insureds nationwide, the information required pursuant to subparagraphs (6) and (7) of paragraph (b) of subsection 2 must be provided:
(a) When combined with all similar long-term care insurance contract forms; and
(b) For a specific long-term care insurance contract form.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.107 Insurer to request approval of any increase in premium rate schedule for contracts and certificates issued on or after October 1, 2011. (NRS 679B.130)
1. An insurer shall request approval of any increase in a premium rate schedule, including an exceptional increase, from the Commissioner at least 60 days before providing notice of the increase to the policyholders and shall include in the request:
(a) The information required by NAC 687B.0585;
(b) Certification by a qualified actuary that:
(1) If the requested rate increase is implemented and the underlying assumptions which reflect moderately adverse conditions are materialized, no further rate increases are anticipated; and
(2) The premium rate filing is in compliance with the provisions of this section;
(c) An actuarial memorandum justifying the rate increase that includes:
(1) Lifetime projections of earned premiums and incurred claims based on the filed rate increase which include the method and assumptions used in determining the projected values and reflection of any assumptions that deviate from those used for pricing other forms currently available for sale, including, without limitation:
(I) Separate actual and projected annual values for the 5 years before and the 3 years after the valuation date;
(II) The development of the lifetime loss ratio, unless the rate increase is an exceptional increase;
(III) A demonstration of compliance with subsection 2;
(IV) For an exceptional increase, projections that are limited to the increases in claims expenses attributable to the approved reasons for the exceptional increase; and
(V) For an exceptional increase, if the Commissioner determines that offsets may exist, projections which use the appropriate net projected experience;
(2) Disclosure of how reserves have been incorporated in this rate increase whenever the rate increase will trigger contingent benefits upon lapse;
(3) Disclosure of the analysis performed to determine why a rate increase 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;
(4) A statement that policy design, underwriting and claims adjudication practices have been taken into consideration; and
(5) If it is necessary to maintain consistent premium rates for new certificates and certificates receiving a rate increase, information concerning composite rates reflecting projections of new certificates;
(d) 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 Commissioner; and
(e) Sufficient information for review and approval of the rate increase by the Commissioner.
2. The Commissioner may approve an increase in a premium rate schedule if the Commissioner determines that:
(a) For an exceptional increase, 70 percent of the present value of projected additional premiums from the exceptional increase will be returned to the policyholders in benefits;
(b) The rate increase is 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:
(1) Fifty-eight percent of the accumulated value of the initial earned premium;
(2) Eighty-five percent of the accumulated value of previous rate increases on an earned basis;
(3) Fifty-eight percent of the present value of future projected initial earned premiums; and
(4) Eighty-five percent of the present value of future projected premiums not included in subparagraph (3) on an earned basis;
(c) If a long-term care insurance contract has an exceptional increase and any other increase, the values in subparagraphs (2) and (4) of paragraph (b) also include 70 percent for exceptional increase amounts;
(d) All present and accumulated values used to determine rate increases use the maximum valuation interest rate for contract reserves as specified in paragraph (a) of subsection 2 of NRS 681B.120 and the actuary disclosed as part of the actuarial memorandum the use of any appropriate averages; and
(e) For a request for an increase in a premium rate schedule that does not comply with subparagraph (1) of paragraph (b) of subsection 1:
(1) The premium rate filing is in compliance with all other provisions of this section;
(2) The insurer provided the Commissioner with justification for the request and provided any additional information that the Commissioner may require in order to appropriately review and approve the rate increase; and
(3) The insurer complied with any additional conditions that the Commissioner may require for approval of the request for an increase in a premium rate schedule.
3. For each rate increase that is implemented, the insurer shall file updated projections, as described in subparagraph (1) of paragraph (c) of subsection 1, for approval by the Commissioner annually for each of the 3 years following the increase and must include a comparison of actual results to projected values. The Commissioner may extend this period beyond 3 years if actual results are not consistent with projected values from previous projections. For group long-term care insurance contracts that meet the conditions of subsection 11, the projections required by this subsection must be provided to the policyholder in lieu of filing with the Commissioner.
4. If any premium rate in the revised premium rate schedule is greater than 200 percent of the comparable rate in the initial premium schedule, lifetime projections, as described in subparagraph (1) of paragraph (c) of subsection 1, must be filed for approval by the Commissioner every 5 years following the end of the required period in subsection 3. For group long-term care insurance contracts that meet the conditions of subsection 11, the projections required by this subsection must be provided to the policyholder in lieu of filing with the Commissioner.
5. If the Commissioner determines that the actual experience following a rate increase does not adequately match the projected experience and that current projections under moderately adverse conditions demonstrate that incurred claims will not exceed the proportions of premiums specified in subsection 2, the Commissioner may require the insurer to implement:
(a) An adjustment to the premium rate schedule; or
(b) Other measures to reduce the difference between the projected experience and the actual experience.
Ê In determining whether the actual experience adequately matches the projected experience, the Commissioner will consider the provisions of subparagraph (5) of paragraph (c) of subsection 1, if applicable.
6. If the majority of long-term care insurance contracts or certificates to which an increase is applicable are eligible for the contingent benefit upon lapse, the insurer shall file:
(a) The original anticipated lifetime loss ratio and the rate increase that would have been calculated according to subsection 3 had the greater of the original anticipated lifetime loss ratio or 58 percent been used in the calculations described in subparagraphs (1) and (3) of paragraph (b) of subsection 2; and
(b) A plan, subject to the approval of the Commissioner, for improved administration or claims processing designed to eliminate the potential for further deterioration of the long-term care insurance contract requiring further rate increases or to demonstrate that appropriate administration and claims processing have been implemented or are in effect. If the insurer fails to file a plan pursuant to this paragraph, the Commissioner may impose the requirements of subsection 8.
7. The Commissioner will, for all long-term care insurance contracts included in the filing, review the projected lapse rates and past lapse rates during the 12 months following each rate increase to determine if significant adverse lapsation has occurred or is anticipated if:
(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 long-term care insurance contracts or certificates to which the rate increase is applicable are eligible for the contingent benefit upon lapse.
8. If the Commissioner determines that significant adverse lapsation has occurred pursuant to subsection 7, 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 Commissioner may determine that a rate spiral exists. Following the determination that a rate spiral exists, the Commissioner may require the insurer to offer, without underwriting, to all insureds who have long-term care insurance contracts in force and who are 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. For such an offer:
(a) The offer must:
(1) Be subject to the approval of the Commissioner;
(2) Be based on actuarially sound principles but not be based on attained age; and
(3) Provide that maximum benefits under any new policy accepted by an insured will be reduced by comparable benefits already paid under the existing long-term care insurance contract; and
(b) The insurer shall maintain the experience of all the replacement insureds separate from the experience of the insureds originally issued the long-term care insurance contracts. In the event of a request for a rate increase on the long-term care insurance contracts, the rate increase must be limited to the lesser of:
(1) The maximum rate increase determined based on the combined experience; and
(2) The maximum rate increase determined based only on the experience of the insureds who were originally issued the long-term care insurance contract plus 10 percent.
9. If the Commissioner determines that the insurer has established a persistent practice of filing inadequate initial premium rates for long-term care insurance, the Commissioner may, in addition to the provisions of subsections 7 and 8, prohibit the insurer from:
(a) Filing and marketing comparable coverage for a period of up to 5 years; or
(b) Offering all other similar coverages and limiting marketing of new applications to the products subject to recent rate increases.
10. Subsections 1 to 9, inclusive, do not apply to long-term care insurance contracts for which the long-term care benefits provided by the long-term care insurance contract are incidental if:
(a) The interest credited internally to determine cash value accumulations, including long-term care, if any, is guaranteed to be not less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;
(b) The portion of the policy that provides insurance benefits other than long-term care coverage meets the nonforfeiture requirements as applicable in:
(1) NRS 688A.290 to 688A.360, inclusive, for life insurance; or
(2) NRS 688A.361 to 688A.369, inclusive, for deferred annuities;
(c) The policy meets the disclosure requirements of NAC 687B.0683, 687B.0684 and 687B.112;
(d) The portion of the policy that provides insurance benefits other than long-term care coverage meets the requirements for:
(1) Policy illustrations as required in NAC 686A.460 to 686A.479, inclusive, for life insurance; or
(2) Disclosure in NAC 688A.470 for deferred annuities; and
(e) An actuarial memorandum is filed with the Division and includes:
(1) A description of the basis on which the rates for long-term care were determined;
(2) A description of the basis for the reserves;
(3) A summary of the type of long-term care insurance contract, benefits, renewability, general marketing method and limits on ages of issuance;
(4) A description and a table of each actuarial assumption used, which includes, for expenses, the percent of premium dollars per long-term care insurance contract and dollars per unit of benefits, if any;
(5) A description and a table of the anticipated reserves for the long-term care insurance contract and additional reserves to be held in each future year for active lives;
(6) The estimated average annual premium per long-term care insurance contract and the average issue age;
(7) A description of the effect of the provisions of the long-term care insurance contract on the required premiums, nonforfeiture values and reserves on the underlying long-term care insurance contract, both for active lives and those in claim status; and
(8) A statement as to whether underwriting is performed at the time of application. The statement must indicate whether underwriting is used and, if used, the statement must include a description of the type of underwriting used, such as medical underwriting or functional assessment underwriting. For a group long-term care insurance contract, the statement must indicate whether the enrollee or any dependent will be underwritten and when underwriting occurs.
11. Subsections 5, 7 and 8 do not apply to a group long-term care insurance contract issued to a group described in subsection 1 of NAC 687B.025 if:
(a) The contract insures 250 or more persons and the policyholder has 5,000 or more eligible employees of a single employer; or
(b) The policyholder, and not the certificate holder, pays a material portion of the premium, which is not less than 20 percent of the total premium for the group in the calendar year before the year a rate increase is filed.
12. This section applies to long-term care insurance contracts and certificates issued in this State on or after October 1, 2011.
13. As used in this section, “incidental” means that the value of the long-term care benefits provided, as measured at the date of issue, is less than 10 percent of the total value of benefits provided over the life of the long-term care insurance contract.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
REVISER’S NOTE.
The regulation of the Commissioner of Insurance filed with the Secretary of State on December 16, 2010, (LCB File No. R028-10), which amended this section, contains the following provision not included in NAC:
“1. Notwithstanding the provisions of subsection 12 of section 14 of this regulation [NAC 687B.107], section 14 of this regulation [NAC 687B.107] does not apply to a long-term care insurance contract or certificate issued on or after October 1, 2011, until:
(a) Except as otherwise provided in paragraph (b), April 1, 2012.
(b) For a certificate issued on or after October 1, 2011, under a group long-term care insurance contract in force on October 1, 2011, for a group described in subsection 1 of NAC 687B.025, the date of the first anniversary of the contract to occur after October 1, 2012.
2. As used in this section:
(a) “Certificate” has the meaning ascribed to it in NAC 687B.015, as amended by section 17 of this regulation.
(b) “Group long-term care insurance” has the meaning ascribed to it in NAC 687B.025, as amended by section 19 of this regulation.
(c) “Long-term care insurance contract” has the meaning ascribed to it in section 3 of this regulation [NAC 687B.0303].”
NAC 687B.1075 Exceptional increases. (NRS 679B.130)
1. Except as otherwise provided in NAC 687B.107, an exceptional increase is subject to the same requirements as other premium rate schedule increases.
2. The Commissioner may request a review by an independent actuary or a professional actuarial body of the basis for a request that a premium rate increase be considered an exceptional increase.
3. The Commissioner, in determining whether the necessary basis for an exceptional increase exists, will also determine any potential offsets to higher claims costs.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.108 Prohibited increases in premiums. (NRS 679B.130)
1. The premium charged to an insured for long-term care insurance must not increase because of:
(a) The increasing age of the insured beyond 65 years of age; or
(b) The duration the insured has been covered under the policy.
2. The purchase of additional coverage must not be considered a premium rate increase, but, for calculation purposes, the portion of the premium attributable to the additional coverage must be added to and considered part of the initial annual premium.
3. A reduction in benefits must not be considered a premium change but, for calculation purposes, the initial annual premium must be based on the reduced benefits.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.111 Coverage for preexisting conditions. (NRS 679B.130)
1. A long-term care insurance contract or certificate, other than a long-term care insurance contract or certificate issued to a group described in subsection 1 of NAC 687B.025, may not:
(a) Define “preexisting condition” in a more restrictive manner than as a condition for which medical advice or treatment was recommended by, or received from a provider of health care within the 6 months preceding the effective date of coverage of the insured.
(b) Exclude coverage for a loss or confinement which is the result of a preexisting condition unless the loss or confinement begins within the 6 months following the effective date of coverage of the insured.
2. An insurer may use an application form designed to elicit the complete medical history of an applicant, and, on the basis of the answers on that application, underwrite a long-term care insurance contract in accordance with that insurer’s established underwriting standards. Unless otherwise provided in the long-term care insurance contract or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in paragraph (b) of subsection 1 expires. A long-term care insurance contract or certificate may not exclude or use waivers or riders of any kind to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in that paragraph.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.112 Monthly report to certain insureds. (NRS 679B.130) If an insured is receiving benefits for long-term care through the acceleration of benefits under a group or individual policy of life insurance, a rider to that policy or an annuity contract, the insurer shall provide a monthly report to the insured. The report must include, without limitation:
1. A statement of any benefits for long-term care paid during that month;
2. An explanation of any changes to the policy or contract, including, without limitation, any change to the death benefit or cash value of the policy or contract resulting from the payment of any benefits for long-term care; and
3. The amount of any remaining benefits for long-term care.
(Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008)
NAC 687B.113 Delivery of shopper’s guide to long-term care insurance. (NRS 679B.130)
1. Except as otherwise provided in this section, a shopper’s guide to long-term care insurance must be furnished to each prospective applicant. In the case of a group contract, the guide may be delivered to the policyholder for distribution to the certificate holders. The guide must be one developed and approved by the Commissioner or must be in the format developed by the National Association of Insurance Commissioners.
2. An agent who is soliciting an application for long-term care insurance in person shall furnish the prospective applicant with the shopper’s guide before giving him or her an application or enrollment form. In the case of a direct-response solicitation, the shopper’s guide must be presented in conjunction with any application or enrollment form.
3. An insurer who offers a life insurance policy, rider or endorsement that contains accelerated long-term care benefits is not required to furnish the shopper’s guide, but shall furnish the policy summary required by NAC 687B.0684 within the time provided by that section.
(Added to NAC by Comm’r of Insurance, eff. 1-4-91; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.114 Responsibilities of professional, trade or occupational association which endorses or sells contracts or certificates to members. (NRS 679B.130)
1. A professional, trade or occupational association, as described in subsection 2 of NAC 687B.025, which endorses or sells long-term care insurance to its members, shall educate its members concerning general issues involving long-term care so that its members can make informed decisions regarding the long-term care insurance.
2. The professional, trade or occupational association shall provide objective information regarding long-term care insurance contracts or certificates endorsed or sold by the association and ensure that members of the association receive a complete explanation of the features in the long-term care insurance contracts or certificates that are being endorsed or sold.
3. The professional, trade or occupational association shall disclose in any solicitation for long-term care insurance:
(a) The specific nature and amount of compensation, including all fees, commissions and other forms of financial support, that the association receives from endorsement or sale of long-term care insurance contracts or certificates to its members; and
(b) A brief description of the process under which such contracts and the insurer issuing such contracts were selected.
4. If a professional, trade or occupational association and an insurer have common ownership or management, the association shall disclose that fact to its members.
5. The board of directors of a professional, trade or occupational association which sells or endorses long-term care insurance contracts or certificates shall review and approve the long-term care insurance contracts and the agreement regarding compensation it receives from endorsement or sale of long-term care insurance contracts or certificates to its members.
6. A professional, trade or occupational association shall:
(a) Actively monitor the efforts regarding marketing of the insurer and its agents or other producers;
(b) Review and approve all marketing materials or other communications regarding long-term care insurance contracts or certificates used to promote sales or sent to members; and
(c) At the time that the association decides to endorse long-term care insurance, engage the services of a person with expertise in long-term care insurance not affiliated with the insurer to conduct an examination of the long-term care insurance contracts, including their benefits, features and rates, and update the examination thereafter in the event of material change.
Ê The provisions of this subsection do not apply to a qualified long-term care insurance contract.
7. Any insurer who offers long-term care insurance that is endorsed or sold by a professional, trade or occupational association shall file with the Division:
(a) The long-term care insurance contract or certificate;
(b) A corresponding outline of coverage; and
(c) All advertisements requested by the Division.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.115 Filing and certification requirements for insurer issuing contract or certificate to professional, trade or occupational association. (NRS 679B.130)
1. An insurer shall not issue a group long-term care insurance contract or certificate to a professional, trade or occupational association unless the insurer files with the Division any materials required by this section or NAC 687B.114.
2. An insurer shall not issue a long-term care insurance contract or certificate to a professional, trade or occupational association, or continue to market such a contract or certificate, unless the insurer certifies on or before December 31 of each year that the association has complied with the requirements set forth in NAC 687B.114.
3. Failure to comply with the requirements regarding filing and certification contained in this section constitutes an undefined unfair trade practice pursuant to NRS 686A.170.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.116 Limitations on conditioning of benefits. (NRS 679B.130)
1. A long-term care insurance contract delivered or issued for delivery in this State may not:
(a) Condition any benefit upon the hospitalization of the insured;
(b) Condition any benefit for an insured who is institutionalized upon his or her receiving a higher level of institutional care; or
(c) Condition any benefit, other than a waiver of premium or benefits for postconfinement care, postacute care or any recuperative benefit, upon the institutionalization of the insured.
2. If a long-term care insurance contract conditions coverage for noninstitutional care upon the receipt of institutional care, the required period of institutional care must not exceed 30 days.
(Added to NAC by Comm’r of Insurance, eff. 1-4-91; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.117 Restrictions on limitation or exclusion of benefits. (NRS 679B.130)
1. A long-term care insurance contract or certificate that provides benefits for services related to home health care or community care must not limit or exclude benefits:
(a) By requiring that the insured or claimant would need care in a skilled nursing facility if services related to home health care were not provided;
(b) By requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services in a home, community or institutional setting before services related to home health care are covered;
(c) By limiting eligible services provided by registered nurses or licensed practical nurses;
(d) By requiring that a nurse or therapist provide services covered by the long-term care insurance contract that can be provided by a home health aide, or other licensed or certified person providing home health care acting within the scope of his or her licensure or certification;
(e) By excluding coverage for services related to personal care provided by a home health aide;
(f) By requiring that the provision of services related to home health care be at a level of certification or licensure greater than that required by the eligible service;
(g) By requiring that the insured or claimant have an acute condition before services related to home health care are covered;
(h) By limiting benefits to services provided by agencies or providers certified by Medicare; or
(i) By excluding coverage for services related to adult day care.
2. Except as otherwise provided in subsection 3, a long-term care insurance contract or certificate that provides for services related to home health care or community care must provide total coverage for home health care or community care in an amount equivalent in dollars to at least one-half of 1 year’s benefits for care received in a nursing home pursuant to the coverage available under the long-term care insurance contract or certificate at the time covered services related to home health care or community care are being received.
3. The provisions of subsection 2 do not apply to a long-term care insurance contract or certificate issued to a resident of a retirement community which provides continuing care.
4. For the purpose of determining the maximum coverage under the terms of the long-term care insurance contract or certificate, coverage for home health care may be applied to the benefits provided in the long-term care insurance contract or certificate for care other than home health care.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.118 Statement of limitations or conditions upon receipt of benefits. (NRS 679B.130) Each long-term care insurance contract which provides coverage for postconfinement care, postacute care or recuperative services, and each certificate issued under such a contract, must contain a prominent statement of any limitations or conditions on eligibility for these benefits. The statement:
1. Must be contained in the paragraph of the long-term care insurance contract or certificate required pursuant to subsection 5 of NAC 687B.100; and
2. Must specify the length in days of any period that the insured is required to be confined in an institution as a condition of receiving these benefits.
(Added to NAC by Comm’r of Insurance, eff. 1-4-91; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.1185 Requirements for denied claims. (NRS 679B.130) If a claim under a long-term care insurance contract or certificate is denied, the issuer shall, not later than 60 days after the date of a written request by the policyholder, certificate holder or a representative thereof:
1. Provide a written explanation of the reasons for the denial; and
2. Make available all information directly related to the denial.
(Added to NAC by Comm’r of Insurance by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.119 Required reserves for policy, rider or endorsement. (NRS 679B.130)
1. When benefits for long-term care are provided through the acceleration of benefits under a group or an individual policy of life insurance or a rider or endorsement to that policy, the reserves for the benefits must be determined in accordance with the provisions of paragraph (g) of subsection 2 of NRS 681B.120. Reserves for a claim must also be established when a policy, rider or endorsement is in claim status.
2. Reserves for policies, riders and endorsements subject to the provisions of subsection 1 must be based on a multiple decrement model using all relevant decrements except those for rates for voluntary termination. An approximation based upon a single decrement model may be used if the calculation produces similar reserves as the multiple decrement model, the reserves are more conservative than the multiple decrement model or the reserves are immaterial. The calculation may take into account the reduction in benefits for life insurance as the result of payment of benefits for long-term care. However, the reserves for the benefit for long-term care and the benefit for life insurance must not be less than the reserves for the benefit for life insurance assuming no benefit for long-term care.
3. In the development and calculation of reserves for policies, riders and endorsements subject to the provisions of subsection 1, consideration must be given to the applicable provisions of the policy, marketing methods, administrative procedures and all other factors which have an impact on projected costs of claims, including, but not limited to, the following:
(a) Definition of insured events;
(b) Covered facilities for long-term care;
(c) Existence of coverage for convalescent care at home;
(d) Definition of facilities;
(e) Existence or absence of barriers to eligibility;
(f) Provisions regarding waiver of premiums;
(g) Renewability;
(h) Ability to raise premiums;
(i) Methods of marketing;
(j) Procedures regarding underwriting;
(k) Procedures regarding adjustment of claims;
(l) Waiting periods;
(m) Maximum benefits;
(n) Availability of eligible facilities;
(o) Margins in costs of a claim;
(p) Optional nature of benefits;
(q) Delay in eligibility for benefits;
(r) Provisions regarding protection against inflation; and
(s) Option of guaranteed insurability.
Ê Any valuation table for morbidity consulted in the development and calculation of reserves must be certified as appropriate as a statutory valuation table by a qualified actuary.
4. When benefits for long-term care are provided other than by the method described in subsection 1, reserves must be determined using a table that is:
(a) Established by a qualified actuary for the purpose of setting reserves; and
(b) Acceptable to the Commissioner.
5. As used in this section, “multiple decrement model” means a model in which people in a defined status at any age are subject to more than one contingency at the next age.
6. As used in this section, “single decrement model” means a model in which people in a defined status at any age are subject to only one contingency during the next age.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.121 Evaluation of expected loss ratio. (NRS 679B.130)
1. For a long-term care insurance contract or certificate to which subsection 2 does not apply, the Commissioner shall deem the benefits reasonable in relation to premiums charged if the expected loss ratio is at least 60 percent, calculated in a manner which provides for the adequate reserving of the long-term care insurance risk. In evaluating the expected loss ratio, due consideration will be given to all relevant factors, including:
(a) The statistical credibility of incurred claims experience and earned premiums;
(b) The period for which rates are computed to provide coverage;
(c) Experienced and projected trends;
(d) The concentration of experience within early contract duration;
(e) Expected claim fluctuation;
(f) Experience refunds, adjustments or dividends;
(g) Renewability features;
(h) All appropriate expense factors;
(i) Interest;
(j) The experimental nature of the coverage;
(k) Contract reserves;
(l) The mix of business by risk classification; and
(m) Product features such as long elimination periods, high deductibles and high maximum limits.
2. For a policy of life insurance or a rider or endorsement to a policy of life insurance that contains accelerated benefits for long-term care, the Commissioner shall deem the benefits reasonable in relation to the premiums charged if:
(a) The interest credited internally to determine cash value accumulations, including long-term care, 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;
(b) The portion of the policy that provides benefits for life insurance meets the nonforfeiture requirements of NRS 688A.290 to 688A.360, inclusive;
(c) The policy meets the disclosure requirements of NAC 687B.0683, 687B.0684 and 687B.112;
(d) Any policy illustration provided satisfies the requirements of NAC 686A.460 to 686A.479, inclusive; and
(e) An actuarial memorandum is filed with, and approved by, the Commissioner that includes, without limitation:
(1) A description of the basis on which the long-term care rates are determined;
(2) A description of the basis for the reserves;
(3) A summary of the type of policy, benefits, provisions for renewal, general marketing method and limits on ages of issuance;
(4) A description and a table of each actuarial assumption used and, for expenses, the percent of premium dollars per policy and dollars per unit of benefits;
(5) A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives;
(6) The estimated average annual premium per policy and the average issue age;
(7) A statement which:
(I) Must indicate whether underwriting is performed at the time of application;
(II) If underwriting is performed at the time of application, must include a description of the type or types of underwriting used; and
(III) If the policy is a policy of group long-term care insurance, must indicate whether the enrollee or any dependent will be underwritten and when such underwriting occurs; and
(8) A description of the effect of the long-term care benefits on the required premiums, nonforfeiture values and reserves on the underlying policy of life insurance, both for active lives and those in long-term care claim status.
3. For an annuity contract that pays for benefits for long-term care entirely by accessing the contract value, the Commissioner shall deem the benefits reasonable in relation to the premium charged if:
(a) The interest credited internally to determine cash value accumulations, including long-term care, are guaranteed not to be less than the minimum guaranteed interest rate for cash-value accumulations without long-term care set forth in the contract;
(b) The portion of the contract that provides benefits for long-term care meets the nonforfeiture requirements of NRS 688A.361 to 688A.369, inclusive;
(c) The contract meets the disclosure requirements of NAC 687B.075 and 687B.112; and
(d) An actuarial memorandum is filed with, and approved by, the Commissioner that includes, without limitation:
(1) A description of the basis on which the long-term care rates are determined;
(2) A description of the basis for the reserves;
(3) A summary of the type of contract, benefits, provisions for renewal, general marketing method and limits on ages of issuance;
(4) A description and a table of each actuarial assumption used and, for expenses, the percent of premium dollars per contract and dollars per unit of benefits;
(5) A description and a table of the anticipated contract reserves and additional reserves to be held in each future year for active lives;
(6) The estimated average annual premium per contract and the average issue age;
(7) A statement which:
(I) Must indicate whether underwriting is performed at the time of application; and
(II) If underwriting is performed at the time of application, must include a description of the type or types of underwriting used; and
(8) A description of the effect of the long-term care benefits on the required premiums, nonforfeiture values and reserves on the underlying annuity contract, both for active lives and those insureds who are receiving benefits for long-term care.
4. Subsections 1 and 2 do not apply to a long-term care insurance contract or certificate if NAC 687B.059 or 687B.107 applies to the long-term care insurance contract or certificate.
5. Subsection 3 applies to any annuity contract or rider or endorsement on an annuity contract which contains benefits for long-term care insurance and which was issued on or after October 1, 2008.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91; R121-07, 9-18-2008, eff. 10-1-2008; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.122 General requirements for converted policy. (NRS 679B.130)
1. A written application by an insured for a converted policy must be made, and the first premium due, if any, must be paid as directed by the insurer within 31 days of the date of termination of coverage under a group long-term care insurance contract. The converted policy must be issued effective on the day following the termination of coverage under the group long-term care insurance contract and must be renewable annually.
2. Unless the group long-term care insurance contract from which conversion is made replaced previous group coverage, the premium for the converted policy must be calculated on the basis of the insured’s age at inception of coverage under the group long-term care insurance contract from which conversion is made. If the group long-term care insurance contract from which conversion is made replaced previous group coverage, the premium for the converted policy must be calculated on the basis of the insured’s age at inception of coverage under the initial group long-term care insurance contract that was replaced.
3. Upon termination of coverage under a group long-term care insurance contract, the insurer shall provide each insured continuation of coverage or shall issue each insured a converted policy unless:
(a) Termination of group coverage resulted from the failure to make any required payment of premium or contribution when due; or
(b) Within 31 days from the date of termination of coverage, the long-term care insurance contract is replaced by a group long-term care insurance contract:
(1) Effective on the day following the date of termination of coverage.
(2) The premium for which is calculated as set forth in subsection 2.
(3) Providing benefits identical to, or benefits determined by the Commissioner to be substantially equivalent to, or in excess of, those provided by the previous long-term care insurance contract.
4. A converted policy may provide that the benefits payable under the converted policy, together with the benefits payable under the group long-term care insurance contract from which conversion is made, must not exceed those that would have been payable had the person’s coverage under the group long-term care insurance contract remained in force and effect.
5. Notwithstanding any other provision of this section, a converted policy issued to a person who at the time of conversion is covered by another long-term care insurance contract or certificate which 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 percent of incurred expenses. The provision may be included in the converted policy only if the converted policy also provides for a decrease in the premium or a refund of a part of the premium which reflects the reduction in benefits payable.
6. Notwithstanding any other provision of this section, an insured individual whose eligibility for group long-term care coverage is based upon his or her relationship to another person is entitled to continuation of coverage under the group long-term care insurance contract upon termination of the qualifying relationship by death or dissolution of marriage.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.125 Replacement of contract: Questions on applications. (NRS 679B.130) Application forms for individual long-term care insurance contracts must include the following questions designed to elicit information as to whether the proposed long-term care insurance contract is intended to replace any other contract for accident and sickness or long-term care insurance contract presently in force:
TO BE COMPLETED BY THE APPLICANT
1. Do you currently have another contract or certificate of long-term care insurance in force (including a contract for health care services or a contract with a health maintenance organization)?
2. Have you had another contract or certificate of long-term care insurance in force during the last 12 months? If so, please answer questions (a) and (b).
(a) With what company was your contract or certificate?
(b) If your contract or certificate lapsed, when did it lapse?
3. Do you currently have coverage under Medicaid?
4. Do you intend to replace any of your current medical or health insurance coverage with this [contract] [certificate]?
TO BE COMPLETED BY THE AGENT
1. Have you sold any other contract of health insurance to this applicant? If so, please answer questions 2 and 3.
2. List each contract you have sold to the applicant that is still in force.
3. List each contract you have sold to the applicant within the past 5 years that is no longer in force.
A supplementary application or other form to be signed by the applicant and, if the coverage is sold by an agent, the agent, containing such questions may be used. For a replacement long-term care insurance contract issued to a group described in subsection 1 of NAC 687B.025, the questions may be modified only to the extent necessary to elicit information about contracts for health insurance or long-term care insurance contracts other than the group long-term care insurance contract being replaced, if the certificate holder has been notified of the replacement.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.127 Replacement of contract or certificate: Waiver of time applicable to preexisting conditions and probationary period; notice to existing insurer. (NRS 679B.130)
1. If a long-term care insurance contract or certificate replaces another long-term care insurance contract or certificate, the insurer replacing the long-term care insurance contract or certificate shall waive any period of time applicable to preexisting conditions and probationary periods in the new long-term care insurance contract or certificate for similar benefits to the extent that similar periods have been satisfied under the original long-term care insurance contract or certificate.
2. Where replacement of the long-term care insurance contract or certificate is intended, the insurer replacing the long-term care insurance contract or certificate shall notify, in writing, the existing insurer of the proposed replacement. The insurer replacing the long-term care insurance contract or certificate shall identify the existing long-term care insurance contract or certificate by the name of the insurer, the name of the insured and either the number of the long-term care insurance contract or certificate or the address of the insured, including the zip code. The written notice must be given not less than 5 working days before the date the application is received by the insurer or the date the long-term care insurance contract is issued, whichever is sooner.
3. If a life insurance policy that accelerates benefits for long-term care replaces the coverage of a long-term care insurance contract, the insurer shall comply with the provisions of NAC 687B.125 to 687B.140, inclusive. If a life insurance policy that accelerates benefits for long-term care replaces the coverage of a life insurance policy, the insurer shall comply with the replacement requirements of NAC 686A.510 to 686A.570, inclusive. If a life insurance policy that accelerates benefits for long-term care replaces another life insurance policy that accelerates benefits for long-term care, the replacing insurer shall comply with both NAC 686A.510 to 686A.570, inclusive, and NAC 687B.125 to 687B.140, inclusive.
4. If an annuity contract that includes provisions for long-term care insurance replaces the coverage of a long-term care insurance contract, the insurer or similar organization shall comply with the provisions of NAC 687B.125 to 687B.140, inclusive. If an annuity contract that includes provisions for long-term care insurance replaces an annuity contract, the insurer or similar organization shall comply with the replacement requirements of NAC 686A.560, 686A.573 and 686A.577. If an annuity contract that includes provisions for long-term care insurance replaces another annuity contract that includes provisions for long-term care insurance, the replacing insurer or similar organization shall comply with NAC 686A.560, 686A.573, 686A.577 and 687B.125 to 687B.140, inclusive.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.130 Replacement of contract: Notice from insurer not using direct-response solicitation. (NRS 679B.130)
1. Upon determining that a sale will involve the replacement of a long-term care insurance contract, an insurer, other than an insurer using direct-response solicitation methods, or its agent, shall furnish the applicant, before the issuance or delivery of the individual long-term care insurance contract, a notice regarding the replacement of the policy for accident and sickness or long-term care coverage. One copy of the notice must be retained by the applicant, and an additional copy signed by the applicant must be retained by the insurer.
2. The notice required by subsection 1 must be provided using form NDOI-954, which is available from the Division, or a similar form approved by the Commissioner.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.135 Replacement of policy: Notice from insurer using direct-response solicitation. (NRS 679B.130)
1. Insurers using a direct-response solicitation shall deliver a notice regarding the replacement of a policy for accident and sickness or a long-term care insurance contract to the applicant upon issuance of the long-term care insurance contract.
2. The notice required by subsection 1 must be provided using form NDOI-955, which is available from the Division, or a similar form approved by the Commissioner.
3. The insurer shall collect and retain signed copies of the notice from the applicant. The Commissioner may waive the requirements of this subsection in certain situations, including, but not limited to, electronic enrollment.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-1-94; R028-10, 12-16-2010, eff. 10-1-2011)
NAC 687B.140 Replacement of contract: Restrictions concerning group policies for long-term care. (NRS 679B.130) If a group long-term care insurance contract is replaced by another group long-term care insurance contract issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group long-term care insurance contract on its date of termination. Coverage provided or offered to an individual by the insurer and the premium charged to persons under the new group long-term care insurance contract must not:
1. Result in an exclusion for preexisting conditions that would have been covered under the group long-term care insurance contract being replaced; or
2. Vary or otherwise depend on the status of a person’s health or disability, experience with claims or use of services related to long-term care.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)
POLICIES SUPPLEMENTARY TO MEDICARE
General Provisions
NAC 687B.200 Definitions. (NRS 679B.130, 687B.430) As used in NAC 687B.200 to 687B.330, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.2002 to 687B.2045, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; 5-13-96; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.2002 “1990 standardized benefit plan to supplement Medicare” or “1990 standardized benefit plan” defined. (NRS 679B.130, 687B.430) “1990 standardized benefit plan to supplement Medicare” or “1990 standardized benefit plan” means a policy to supplement Medicare issued on or after January 1, 1992, and with an effective date for coverage before June 1, 2010, and includes policies to supplement Medicare and certificates renewed on or after that date which are not replaced by the issuer at the request of the insured.
(Added to NAC by Comm’r of Insurance by R049-09, eff. 10-27-2009)
NAC 687B.2003 “2010 standardized benefit plan to supplement Medicare” or “2010 standardized benefit plan” defined. (NRS 679B.130, 687B.430) “2010 standardized benefit plan to supplement Medicare” or “2010 standardized benefit plan” means a policy to supplement Medicare issued with an effective date for coverage on or after June 1, 2010.
(Added to NAC by Comm’r of Insurance by R049-09, eff. 10-27-2009)
NAC 687B.201 “Applicant” defined. (NRS 679B.130, 687B.430) “Applicant” means:
1. In the case of an individual policy to supplement Medicare, the person who seeks to contract for insurance benefits.
2. In the case of a group policy to supplement Medicare, the proposed certificate holder.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2014 “Certificate” defined. (NRS 679B.130, 687B.430) “Certificate” means any certificate delivered or issued for delivery in this State under a group policy to supplement Medicare.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2015 “Creditable coverage” defined. (NRS 679B.130, 687B.430) “Creditable coverage” has the meaning ascribed to it in NRS 689A.505.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2018 “Eligible organization” defined. (NRS 679B.130, 687B.430) “Eligible organization” has the meaning ascribed to it in section 1876(b) of the Social Security Act, 42 U.S.C. § 1395mm(b).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.202 “Employee welfare benefit plan” defined. (NRS 679B.130, 687B.430) “Employee welfare benefit plan” has the meaning ascribed to it in section 3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(1).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2024 “Issuer” defined. (NRS 679B.130, 687B.430) “Issuer” means any insurance company, fraternal benefit society, nonprofit corporation for hospital, medical and dental services or health maintenance organization offering a policy to supplement Medicare which is delivered or issued for delivery in this State.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2028 “Medicare” defined. (NRS 679B.130, 687B.430) “Medicare” means the program of health insurance for aged and disabled persons established pursuant to Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395 et seq.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.203 “Medicare Advantage organization” defined. (NRS 679B.130, 687B.430) “Medicare Advantage organization” has the meaning ascribed to it in section 1859(a)(1) of the Social Security Act, 42 U.S.C. § 1395w-28(a)(1).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2034 “Medicare Advantage plan” defined. (NRS 679B.130, 687B.430) “Medicare Advantage plan” means a plan of coverage for health benefits under Medicare Part C, as defined in 42 U.S.C. §§ 1395w-28(b)(1), and includes:
1. Coordinated care plans that provide health care services, including, without limitation:
(a) Health maintenance organization plans, with or without a point-of-service provider;
(b) Plans offered by provider-sponsored organizations; and
(c) Preferred provider organization plans;
2. Medical savings account plans that are coupled with a contribution into Medicare Advantage medical savings accounts; and
3. Medicare Advantage private fee-for-service plans.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2036 “Medicare Part D” defined. (NRS 679B.130, 687B.430) “Medicare Part D” means the prescription drug benefit created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, beginning January 1, 2006.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2037 “Medicare select issuer” defined. (NRS 679B.130, 687B.430) “Medicare select issuer” has the meaning ascribed to it in NAC 687B.346.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2039 “PACE program” defined. (NRS 679B.130, 687B.430) “PACE program” means the program of all-inclusive care for the elderly established pursuant to section 1894 of the Social Security Act, 42 U.S.C. § 1395eee.
(Added to NAC by Comm’r of Insurance by R075-02, eff. 9-20-2002)
NAC 687B.204 “Policy to supplement Medicare” defined. (NRS 679B.130, 687B.430) “Policy to supplement Medicare” means a group or individual policy of insurance, or a subscriber contract, other than a policy issued pursuant to section 1876 of the Social Security Act, 42 U.S.C. § 1395mm, or pursuant to a demonstration project that is advertised, marketed or designed primarily as a supplement to the reimbursements provided under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. The term does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under section 1833(a)(1)(A) of the Social Security Act, 42 U.S.C. § 1395l(a)(1)(A).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2045 “Standardized benefit plan” defined. (NRS 679B.130, 687B.430) “Standardized benefit plan” means a benefit plan to supplement Medicare that is designated as Standardized Benefit Plan A through N, inclusive, or High Deductible Benefit Plan F or J, as set forth in NAC 687B.300 to 687B.323, inclusive.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.205 Applicability of provisions. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in NAC 687B.200 to 687B.330, inclusive, the provisions of those sections apply to any:
(a) Policy to supplement Medicare delivered or issued for delivery in this State on or after July 30, 1992.
(b) Certificate.
2. The provisions of NAC 687B.200 to 687B.330, inclusive, do not apply to any policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or any 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.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; R110-98, 2-23-99)
NAC 687B.2053 Eligible persons: Description; prohibited actions by insurers. (NRS 679B.130, 687B.430)
1. Eligible persons are those persons described in subsection 3 who seek to enroll under the policy during the period specified in NAC 687B.2056, and who submit evidence of the date of termination, disenrollment or Medicare Part D enrollment with the application for a policy to supplement Medicare.
2. With respect to eligible persons, an issuer shall not deny or condition the issuance or effectiveness of a policy to supplement Medicare described in NAC 687B.2057 that is offered and is available for issuance to new enrollees by the issuer, shall not discriminate in the pricing of such a policy to supplement Medicare because of health status, claims experience, receipt of health care or medical condition, and shall not impose an exclusion of benefits based on a preexisting condition under such a policy to supplement Medicare.
3. An eligible person is a person described in any of the following paragraphs:
(a) The person is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates or the plan ceases to provide all such supplemental health benefits to the person;
(b) The person is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Medicare Part C, and any of the following circumstances apply, or the person is 65 years of age or older and is enrolled with a PACE program, and there are circumstances similar to those described below that would permit discontinuance of the person’s enrollment with such provider if such person was enrolled in a Medicare Advantage plan:
(1) The certification of the organization or plan has been terminated;
(2) The organization has terminated or otherwise discontinued providing the plan in the area in which the person resides;
(3) The person is no longer eligible to elect the plan because of a change in the person’s place of residence or other change in circumstances specified by the Secretary of Health and Human Services, but not including termination of the person’s enrollment on the basis described in section 1851(g)(3)(B) of the Social Security Act, 42 U.S.C. § 1395w-21(g)(3)(B), where the person has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under section 1856 of the Social Security Act, 42 U.S.C. § 1395w-26, or the plan is terminated for all persons within a residence area;
(4) The person demonstrates, in accordance with guidelines established by the Secretary of Health and Human Services, that:
(I) The organization offering the plan substantially violated a material provision of the organization’s contract under Medicare Part C in relation to the person, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide such covered care in accordance with applicable quality standards; or
(II) The organization, or agent or other entity acting on the organization’s behalf, materially misrepresented the plan’s provisions in marketing the plan to the person; or
(5) The person meets such other exceptional conditions as the Secretary of Health and Human Services may provide;
(c) The person is enrolled with:
(1) An eligible organization under a contract under section 1876 of the Social Security Act, 42 U.S.C. § 1395mm (Medicare cost);
(2) A similar organization operating under demonstration project authority, effective for periods before April 1, 1999;
(3) An organization under an agreement under section 1833(a)(1)(A) of the Social Security Act, 42 U.S.C. § 1395l(a)(1)(A) (health care prepayment plan); or
(4) An organization under a Medicare Select policy,
Ê and the enrollment ceases under the same circumstances that would permit discontinuance of a person’s election of coverage under paragraph (b);
(d) The person is enrolled under a policy to supplement Medicare and the enrollment ceases because:
(1) Of the insolvency of the issuer or bankruptcy of the nonissuer organization;
(2) Of other involuntary termination of coverage or enrollment under the policy;
(3) The issuer of the policy substantially violated a material provision of the policy; or
(4) The issuer, or an agent or other entity acting on the issuer’s behalf, materially misrepresented the policy’s provisions in marketing the policy to the person;
(e) The person was enrolled under a policy to supplement Medicare and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan under Medicare Part C, any eligible organization under a contract under section 1876 of the Social Security Act, 42 U.S.C. § 1395mm (Medicare cost), any similar organization operating under demonstration project authority or any PACE program, and the subsequent enrollment is terminated by the enrollee during any period within the first 12 months of such subsequent enrollment, during which the enrollee is permitted to terminate such subsequent enrollment under section 1851(e) of the Social Security Act, 42 U.S.C. § 1395w-21(e);
(f) The person, upon first becoming eligible for benefits under Medicare Part A at the age of 65 years, enrolls in a Medicare Advantage plan under Medicare Part C or with a PACE program, and disenrolls from the plan or program by not later than 12 months after the effective date of enrollment; or
(g) The person enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a policy to supplement Medicare that covers outpatient prescription drugs, and the person terminates enrollment in the policy to supplement Medicare and submits evidence of enrollment in Medicare Part D along with the application for a policy described in subsection 5 of NAC 687B.2057.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2054 Eligible persons: Subsequent enrollment deemed to be initial enrollment under certain circumstances. (NRS 679B.130, 687B.430)
1. In the case of a person described in paragraph (e) of subsection 3 of NAC 687B.2053, or deemed to be so described pursuant to this subsection, whose enrollment with an organization or provider described in paragraph (e) of subsection 3 of NAC 687B.2053 is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (e) of subsection 3 of NAC 687B.2053.
2. In the case of a person described in paragraph (f) of subsection 3 of NAC 687B.2053, or deemed to be so described pursuant to this subsection, whose enrollment with a plan or in a program described in paragraph (f) of subsection 3 of NAC 687B.2053 is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (f) of subsection 3 of NAC 687B.2053.
3. For purposes of paragraphs (e) and (f) of subsection 3 of NAC 687B.2053, no enrollment of a person with an organization or provider described in paragraph (e) of subsection 3 of NAC 687B.2053, or with a plan or in a program described in paragraph (f) of subsection 3 of NAC 687B.2053, may be deemed to be an initial enrollment under this subsection after the 2-year period beginning on the date on which the person first enrolled with such an organization, provider, plan or program.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2055 Eligible persons: Notification required upon occurrence of certain events. (NRS 679B.130, 687B.430)
1. At the time of an event described in subsection 3 of NAC 687B.2053 because of which a person loses coverage or benefits because of the termination of a contract or agreement, policy or plan, the organization that terminates the contract or agreement, the issuer terminating the policy or the administrator of the plan being terminated, respectively, shall notify the person of his or her rights under NAC 687B.2053 to 687B.2057, inclusive, and of the obligations of issuers of policies to supplement Medicare under subsections 1 and 2 of NAC 687B.2053. Such notice must be communicated contemporaneously with the notification of termination.
2. At the time of an event described in subsection 3 of NAC 687B.2053 because of which a person ceases enrollment under a contract or agreement, policy or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy or the administrator of the plan, respectively, shall notify the person of his or her rights under NAC 687B.2053 to 687B.2057, inclusive, and of the obligations of issuers of policies to supplement Medicare under subsections 1 and 2 of NAC 687B.2053. Such notice must be communicated within 10 working days of the issuer receiving notification of disenrollment.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2056 Guaranteed issue periods for eligible persons; special enrollment period. (NRS 679B.130, 687B.430)
1. In the case of a person described in paragraph (a) of subsection 3 of NAC 687B.2053, the guaranteed issue period begins on the later of:
(a) The date the person receives a notice of termination or cessation of all supplemental health benefits or, if a notice is not received, notice that a claim has been denied because of a termination or cessation; or
(b) The date that the applicable coverage terminates or ceases,
Ê and ends 63 days thereafter.
2. In the case of a person described in paragraph (b), (c), (e) or (f) of subsection 3 of NAC 687B.2053 whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the person receives a notice of termination and ends 63 days after the date the applicable coverage is terminated.
3. In the case of a person described in subparagraph (1) of paragraph (d) of subsection 3 of NAC 687B.2053, the guaranteed issue period begins on the earlier of:
(a) The date that the person receives a notice of termination, a notice of the issuer’s bankruptcy or insolvency, or other such similar notice if any; or
(b) The date that the applicable coverage is terminated,
Ê and ends on the date that is 63 days after the date the coverage is terminated.
4. In the case of a person described in paragraphs (b), (e) and (f), and subparagraphs (2) and (3) of paragraph (d), of subsection 3 of NAC 687B.2053 who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date.
5. In the case of a person described in paragraph (g) of subsection 3 of NAC 687B.2053, the guaranteed issue period begins on the date the person receives notice pursuant to section 1882(v)(2)(B) of the Social Security Act, 42 U.S.C. § 1395ss(v)(2)(B), from the Medicare supplement issuer during the 60-day period immediately preceding the initial Medicare Part D enrollment period and ends on the date that is 63 days after the effective date of the person’s coverage under Medicare Part D.
6. In the case of a person described in subsection 3 of NAC 687B.2053 but not described in subsections 1 to 5, inclusive, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date.
7. A special enrollment period is available to persons who postpone enrollment in Medicare Part B until after the age of 65 years because they are working and are enrolled in a group health insurance plan. The special enrollment period for Medicare Part B may take place anytime through their or their spouse’s current employment or during the 8 months following the month that the group health plan coverage of the employer or union ends or when the employment ends, whichever is first.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2057 Policies to supplement Medicare to which eligible persons are entitled. (NRS 679B.130, 687B.430) The policy to supplement Medicare to which eligible persons are entitled:
1. Under paragraphs (a), (b), (c) and (d) of subsection 3 of NAC 687B.2053 is a policy to supplement Medicare that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L offered by any issuer;
2. Subject to paragraph (e) of subsection 3 of NAC 687B.2053 is the same policy to supplement Medicare in which the person was most recently and previously enrolled, if available from the same issuer or, if not so available, a policy described in subsection 1;
3. After December 31, 2005, if the person was most recently enrolled in a policy to supplement Medicare with an outpatient prescription drug benefit, a policy to supplement Medicare described in this subsection is:
(a) The policy available from the same issuer but modified to remove outpatient prescription drug coverage; or
(b) At the election of the policyholder, an A, B, C, F (including F with a high deductible), K or L policy that is offered by any issuer;
4. Under paragraph (f) of subsection 3 of NAC 687B.2053 shall include any policy to supplement Medicare offered by any issuer; or
5. Under paragraph (g) of subsection 3 of NAC 687B.2053 is a policy to supplement Medicare that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the policy to supplement Medicare with outpatient prescription drug coverage.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.206 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment; required policy or certificate; outpatient prescription drug coverage. (NRS 679B.130, 687B.430)
1. A person is eligible for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees if the person provides evidence that he or she disenrolled within the previous 63 days from:
(a) An employee welfare benefit plan that:
(1) Provided health benefits to supplement the benefits provided under Medicare; and
(2) Discontinued providing substantially all such supplemental health benefits to the person.
(b) An employee welfare benefit plan that:
(1) Provided health benefits that were primary to the benefits provided under Medicare; and
(2) Discontinued providing all such health benefits to the person because the employee welfare benefit plan was terminated or the person disenrolled from the employee welfare benefit plan.
(c) A Medicare Advantage plan offered by a Medicare Advantage organization pursuant to Medicare Part C, if the person was allowed to disenroll from the Medicare Advantage plan under any of the following circumstances:
(1) The certification of the organization or the plan has been terminated, or the organization or plan has notified the person of an impending termination of its certification.
(2) The organization has terminated or otherwise discontinued providing the plan in the area in which the person resides, or has notified the person of an impending termination or discontinuance of the plan.
(3) The person was no longer eligible to elect a Medicare Advantage plan because:
(I) His or her residence changed;
(II) The Medicare Advantage plan was terminated with respect to all persons in the area where the person resided; or
(III) Other circumstances as specified by the Secretary of Health and Human Services changed. Those circumstances do not include terminating the election of the person pursuant to section 1851(g)(3)(B)(i) or (ii) of the Social Security Act, 42 U.S.C. § 1395w-21(g)(3)(B)(i) or (ii).
(4) The person demonstrated in accordance with guidelines established by the Secretary of Health and Human Services that:
(I) The Medicare Advantage organization offering the Medicare Advantage plan substantially violated a material provision of the contract of the Medicare Advantage organization under Medicare Part C with respect to the person, including, without limitation, failing to provide to an enrollee on a timely basis medically necessary care for which benefits are available under the Medicare Advantage plan or failing to provide such care in accordance with applicable quality standards; or
(II) The Medicare Advantage organization, agent or other person acting on behalf of the Medicare Advantage organization made a material misrepresentation of the provisions of the Medicare Advantage plan.
(5) The person met such other exceptional condition as provided by the Secretary of Health and Human Services.
(d) The PACE program if the person is 65 years of age or older and there are circumstances similar to those described in paragraph (c) that would permit discontinuance of the person’s enrollment with the provider if he or she were enrolled in a Medicare Advantage plan.
(e) If the person disenrolled pursuant to the same circumstances that are required to disenroll from a plan pursuant to paragraph (c), any plan offered by:
(1) An eligible organization that had a risk-sharing contract or a reasonable cost reimbursement contract with the Secretary of Health and Human Services pursuant to section 1876 of the Social Security Act, 42 U.S.C. § 1395mm;
(2) For periods before April 1, 1999, an insurer that operated pursuant to the authority of a demonstration project;
(3) An insurer that had an agreement to provide medical and other health services on a prepaid basis pursuant to section 1833(a)(1)(A) of the Social Security Act, 42 U.S.C. § 1395l(a)(1)(A); or
(4) A Medicare select issuer that had a Medicare select policy.
(f) A policy to supplement Medicare or a certificate, if the person disenrolled from that policy or certificate because:
(1) The insurer filed a voluntary petition in bankruptcy or had an involuntary petition in bankruptcy filed against it and the insurer ceased doing business in this State;
(2) The issuer was adjudicated insolvent by a court of competent jurisdiction in the state of domicile of the issuer;
(3) The insurer involuntarily terminated coverage or enrollment;
(4) The issuer of the policy or certificate substantially violated a material provision of the policy or certificate; or
(5) The issuer, an agent or other person acting on behalf of the issuer made a material misrepresentation of the provisions of the policy or certificate.
2. In lieu of using the date of termination of enrollment for purposes of this section, a person described in paragraph (c) or (d) of subsection 1 may substitute the date on which he or she was notified by the Medicare Advantage organization of the impending termination or discontinuance of the Medicare Advantage plan offered by the Medicare Advantage organization in the area in which the person resides, but only if the person disenrolls from the plan as a result of that notification. If a person makes the substitution provided in this subsection, the issuer shall accept the application of the person submitted before the date of termination or enrollment, but the coverage under this subsection must become effective only upon termination of coverage under the Medicare Advantage plan involved.
3. A person who is eligible for a policy to supplement Medicare or a certificate pursuant to subsection 1 is entitled to obtain from any issuer a policy to supplement Medicare or a certificate that has a benefit plan that is designated as Standardized Benefit Plan A, B, C, F (including F with a high deductible), K or L.
4. After December 31, 2005, a person currently enrolled in a policy to supplement Medicare with an outpatient prescription drug benefit is eligible to:
(a) Retain their current plan with outpatient prescription drug coverage;
(b) Enroll in a plan from the same issuer that is modified to exclude outpatient prescription drug coverage with the option to select Medicare Part D; or
(c) Enroll in an A, B, C, F (including F with a high deductible), K or L policy that is offered by any issuer with an option to select Medicare Part D.
5. As used in this section, “Medicare select policy” has the meaning ascribed to it in NAC 687B.348.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2062 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment, enrollment and subsequent disenrollment; required policy or certificate. (NRS 679B.130, 687B.430)
1. A person is eligible for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees if the person provides evidence that he or she:
(a) Disenrolled from such a policy or certificate;
(b) Subsequently enrolled for the first time in:
(1) A Medicare Advantage plan offered by a Medicare Advantage organization pursuant to Medicare Part C;
(2) A plan offered by an eligible organization, insurer or a Medicare select issuer listed in paragraph (e) of subsection 1 of NAC 687B.206; or
(3) Any PACE program; and
(c) Disenrolled within the previous 63 days from the subsequent plan within 12 months after the person’s enrollment as authorized pursuant to section 1851(e) of the Social Security Act, 42 U.S.C. § 1395w-21(e).
2. A person who is eligible for a policy to supplement Medicare or a certificate pursuant to subsection 1 is entitled to obtain a policy to supplement Medicare or a certificate with the same benefits as his or her original policy or certificate from the same issuer if the issuer offers the same policy or certificate or, if that policy or certificate is no longer offered, the person is entitled to obtain from any issuer a policy to supplement Medicare or a certificate that has a benefit plan that is designated as Standardized Benefit Plan A, B, C, F (including F with a high deductible), K or L.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2064 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain enrollment and subsequent disenrollment; required policy or certificate. (NRS 679B.130, 687B.430)
1. A person is eligible for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees if the person provides evidence that he or she has disenrolled within the previous 63 days from a Medicare Advantage plan offered by a Medicare Advantage organization pursuant to Medicare Part C, or from a PACE program, if he or she:
(a) Enrolled in that plan or program during the first 6-month period during which the person was both 65 years of age or older and was enrolled for benefits under Medicare Part B; and
(b) Disenrolled from the plan or program not later than 12 months after the effective date of enrollment.
2. A person who is eligible for a policy to supplement Medicare or a certificate pursuant to subsection 1 is entitled to obtain from any issuer any policy to supplement Medicare or certificate.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2068 Policy to supplement Medicare offered to new enrollees or certificate offered to new enrollees: Prohibition against denial of application, placement of condition on issuance or effectiveness, or discrimination in pricing under certain conditions by issuer. (NRS 679B.130, 687B.430) If an application for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees is submitted to an issuer by a person who is eligible for such a policy or certificate pursuant to NAC 687B.206, 687B.2062 or 687B.2064, the issuer shall not deny or condition the issuance or effectiveness of the policy or certificate or discriminate in the pricing of the policy or certificate on the basis of:
1. The health status of the applicant;
2. The claims experience of the applicant;
3. The receipt of health care by the applicant;
4. The medical condition of the applicant; or
5. A preexisting condition of the applicant.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.207 Coverage if application is submitted before or during first 6-month period in which person is both 65 years of age or older and enrolled under Medicare Part B; availability of coverage to all qualified applicants. (NRS 679B.130, 687B.430)
1. If an application for a policy to supplement Medicare or a certificate is submitted to an issuer before or during the first 6-month period during which a person is both 65 years of age or older and is enrolled for benefits under Medicare Part B, the issuer may not deny or condition the issuance or effectiveness of the policy or certificate or discriminate in the pricing of the policy or certificate on the basis of:
(a) The health status of the applicant;
(b) The claims experience of the applicant;
(c) The receipt of health care by the applicant; or
(d) The medical condition of the applicant.
2. A policy to supplement Medicare or a certificate which is available from an issuer must be made available to all qualified applicants, regardless of age.
3. Except as otherwise provided in subsection 4, the provisions of subsection 1 do not prevent the exclusion of benefits under a policy to supplement Medicare or a certificate, for the first 6 months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the 6 months before the policy or certificate became effective.
4. If an applicant submits an application to an issuer in the manner set forth in subsection 1 and, as of the date on which he or she submits the application, the applicant has not had a break of more than 63 consecutive days in his or her creditable coverage and has had an aggregate period of creditable coverage for:
(a) Six months or more, the issuer shall not exclude any benefits based on a preexisting condition of the applicant; or
(b) Less than 6 months, the issuer shall use the method of reduction set forth in 45 C.F.R. § 146.111(a)(1)(iii) to reduce the period of exclusion for a preexisting condition.
5. As used in this section, “creditable coverage” has the meaning ascribed to it in NRS 689A.505.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 8-2-94; 5-13-96; R110-98, 2-23-99)
NAC 687B.209 Termination of or disenrollment from plan, certificate or policy to supplement Medicare: Requirements for written notification. (NRS 679B.130, 687B.430)
1. Any time a plan, certificate or policy to supplement Medicare is terminated or a person disenrolls from a plan, certificate or policy to supplement Medicare, the issuer, insurer, Medicare Advantage organization, eligible organization or Medicare select issuer that offered the plan, certificate or policy shall provide written notification informing the person that:
(a) The person may be entitled to obtain a certificate or a policy to supplement Medicare pursuant to NAC 687B.206, 687B.2062 or 687B.2064; and
(b) The issuer of such a certificate or policy must comply with the provisions of NAC 687B.2068.
2. If the plan, certificate or policy was terminated, the notification required pursuant to subsection 1 must be provided with the notification of termination. If the person disenrolled from the plan, certificate or policy, the notification required pursuant to subsection 1 must be provided within 10 working days after the issuer, insurer, Medicare Advantage organization, eligible organization or Medicare select issuer received notification of the disenrollment.
3. As used in this section, “plan” means:
(a) A Medicare Advantage plan;
(b) An employee welfare benefit plan; or
(c) A plan offered by an eligible organization, insurer or a Medicare select issuer listed in paragraph (e) of subsection 1 of NAC 687B.206.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.212 Filing and approval of policy forms and certificate forms. (NRS 679B.130, 687B.120, 687B.430)
1. An issuer shall not deliver or issue for delivery in this State a policy to supplement Medicare or a certificate unless the policy form or certificate form has been filed with and approved by the Commissioner pursuant to NRS 687B.120.
2. An issuer shall file any riders or amendments to policy forms or certificate forms to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, with the commissioner in the state in which the policy or certificate was issued.
3. Except as otherwise provided in this subsection, an issuer shall not file for approval more than one policy form or certificate form for each type of policy in a standardized benefit plan to supplement Medicare. An issuer may offer, with the approval of the Commissioner, not more than four additional forms for the same type of policy in a standardized benefit plan to supplement Medicare:
(a) For the inclusion of new or innovative benefits;
(b) For the addition of a direct-response or agent-marketing method;
(c) For the addition of guaranteed issue or underwritten coverage; or
(d) To offer coverage to persons eligible for Medicare because of a disability.
4. For the purposes of this section:
(a) “Type of policy” means an individual or group policy.
(b) A policy issued as a result of any solicitation made by mail or by advertising using the mass media, including any written or broadcasted advertisement, shall be deemed to be an individual policy.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.213 Availability and discontinuance of policy forms and certificate forms. (NRS 679B.130, 687B.120, 687B.430)
1. Except as otherwise provided in subsection 2, an issuer shall make available for sale on or after July 30, 1992, any policy form or certificate form that has been previously approved by the Commissioner. A form shall be deemed available for purchase if the issuer has actively offered it for sale in the previous 12 months.
2. An issuer may discontinue a policy form or certificate form if he or she notifies the Commissioner in writing at least 30 days before he or she intends to discontinue the form. The issuer may not offer the form for sale in this State after the notice is received by the Commissioner.
3. If an issuer discontinues a policy form or certificate form, he or she may not file for approval a new form of the same type as the discontinued form for the same standardized benefit plan to supplement Medicare for 5 years after notice is given to the Commissioner pursuant to subsection 2, unless the Commissioner reduces the period of discontinuance.
4. For the purposes of this section:
(a) The sale or transfer of an issuer’s business for supplementing Medicare to another issuer shall be deemed a discontinuance of a policy form or certificate form.
(b) A change in the rating structure for a policy to supplement Medicare or a certificate shall be deemed a discontinuance of the form for that policy or certificate unless the issuer:
(1) Files with the Commissioner, in a form and manner prescribed by the Commissioner, an actuarial memorandum describing the manner in which the revised rating structure and resultant rates differ from the existing structure and existing rates; and
(2) Does not subsequently put into effect a change of rates or rating factors that cause the percentage differential between the discontinued rates and the new rates as described in the memorandum to change. The Commissioner may approve a change to a percentage differential which is in the public interest.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.215 Definitions and terms used in policy or certificate. (NRS 679B.130, 687B.430)
1. Each policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State must contain definitions or terms conforming to the requirements of this section.
2. “Accident,” “accidental injury” or “accidental means” must be defined to employ “result” language and may not include words that establish an accidental means test or use words such as “external,” “violent,” “visible wounds” or similar words of description or characterization. The definition:
(a) May not define the terms more restrictively than as the direct result of an accident, independent of disease or bodily infirmity or any other cause, that occurs while insurance coverage is in force.
(b) Unless prohibited by law, may provide that the terms do not include any injury for benefits which are provided or available under any workers’ compensation, employer’s liability or similar law, or motor vehicle no-fault plan.
3. “Benefit period” or “Medicare benefit period” may not be defined more restrictively than as defined by Medicare.
4. “Convalescent nursing home,” “extended care facility” or “skilled nursing facility” may not be defined more restrictively than as defined by Medicare.
5. “Health care expenses” means the expenses of a health maintenance organization associated with the delivery of services for health care that are analogous to the incurred losses of an issuer.
6. “Hospital” may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals. The definition must not be more restrictive than as defined by Medicare.
7. “Medicare” must be defined in the policy and certificate. The term may be defined as “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 89th 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.
8. “Medicare eligible expenses” means expenses for health care of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.
9. “Physician” may not be defined more restrictively than as defined by Medicare.
10. Except as otherwise provided in this subsection, “sickness” must not be defined more restrictively than the following:
“Sickness” means an illness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force.
The definition may be modified to exclude sicknesses or diseases for which benefits are provided under any workers’ compensation, occupational disease, employer’s liability or similar law.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 7-16-92, eff. 7-30-92; 8-2-94; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.220 Exclusions from and limitations on coverage and benefits; duplication of benefits provided by Medicare; benefits for outpatient prescription drugs. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in paragraphs (a) and (b) of subsection 2 of NAC 687B.226 and paragraphs (a) and (b) of subsection 2 of NAC 687B.227, and subparagraphs (1) and (2) of paragraph (a) of subsection 2 of NAC 687B.322, a policy or certificate may not be advertised, solicited or issued for delivery in this State as a policy to supplement Medicare if the policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
2. A policy to supplement Medicare or a certificate must not use a waiver to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.
3. A policy to supplement Medicare or a certificate must not contain benefits that duplicate the benefits provided by Medicare.
4. A policy to supplement Medicare with benefits for outpatient prescription drugs in existence before January 1, 2006, must be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
5. A policy to supplement Medicare with benefits for outpatient prescription drugs must not be issued after December 31, 2005.
6. After December 31, 2005, a policy to supplement Medicare with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:
(a) The policy is modified to eliminate outpatient prescription drug coverage for expenses of outpatient prescription drugs incurred after the effective date of the person’s coverage under a Medicare Part D plan; and
(b) Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.223 Prohibitions regarding genetic information and genetic testing. (NRS 679B.130, 687B.430)
1. An issuer of a policy to supplement Medicare or a certificate:
(a) Shall not deny or condition the issuance or effectiveness of the policy or certificate, including, without limitation, the imposition of any exclusion of benefits under the policy based on a preexisting condition, on the basis of the genetic information of a person; and
(b) Shall not discriminate in the pricing of the policy or certificate, including, without limitation, the adjustment of the premium rates, of a person on the basis of the genetic information of the person.
2. Nothing in subsection 1 shall be construed to limit the ability of an issuer of a policy to supplement Medicare or a certificate, to the extent otherwise permitted by law, from:
(a) Denying or conditioning the issuance or effectiveness of a policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant; or
(b) Increasing the premium for any policy issued to a person based on the manifestation of a disease or disorder of a person who is covered under the policy. The manifestation of a disease or disorder in one person cannot also be used as genetic information about other group members and to further increase the premium for the group.
3. An issuer of a policy to supplement Medicare or a certificate shall not request or require a person or a family member of the person to undergo a genetic test.
4. The provisions in subsection 3 must not be construed to preclude an issuer of a policy to supplement Medicare or a certificate from obtaining and using the results of a genetic test in making a determination regarding payment as defined for the purposes of applying the regulations promulgated under Part C of Title XI and section 264 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. §§ 1320d et seq., and note to 42 U.S.C. § 1320d-2, as may be revised from time to time, and consistent with the provisions of subsection 1.
5. For the purposes of carrying out subsection 4, an issuer of a policy to supplement Medicare or a certificate may request only the minimum amount of information necessary to accomplish the intended purpose.
6. Notwithstanding the provisions of subsection 3, an issuer of a policy to supplement Medicare or a certificate may request, but not require, that a person or a family member of the person undergo a genetic test if:
(a) The request is made pursuant to research that complies with 45 C.F.R. § 46.101 et seq., or equivalent federal regulations, and any applicable state or local law or regulations for the protection of human subjects in research;
(b) The issuer clearly indicates to each person, or in the case of a minor child, to the legal guardian of such child, to whom the request is made that:
(1) Compliance with the request is voluntary; and
(2) Noncompliance will have no effect on enrollment status or premium or contribution amounts;
(c) Any genetic information collected or acquired under this subsection is not used for underwriting, determination of eligibility to enroll or maintain enrollment status, premium rates, or the issuance, renewal or replacement of a policy or certificate;
(d) The issuer notifies the Secretary of the United States Department of Health and Human Services in writing that the issuer is conducting activities pursuant to the exception provided for under this subsection, including a description of the activities conducted; and
(e) The issuer complies with such other conditions as the Secretary of the United States Department of Health and Human Services may, by regulation, require for activities conducted under this subsection.
7. An issuer of a policy to supplement Medicare or a certificate shall not request, require or purchase genetic information for underwriting purposes.
8. An issuer of a policy to supplement Medicare or a certificate shall not request, require, or purchase genetic information with respect to any person before the person’s enrollment under the policy in connection with such enrollment.
9. If an issuer of a policy to supplement Medicare or a certificate obtains genetic information incidental to the requesting, requiring or purchasing of other information concerning any person, such request, requirement or purchase must not be considered a violation of the provisions of subsection 8 if such request, requirement or purchase is not in violation of the provisions of subsection 7.
10. As used in this section:
(a) “Family member” means, with respect to a person, any other person who is a first degree, second degree, third degree or fourth degree relative of the person.
(b) “Genetic information” means, with respect to any person, information about a genetic test of the person, the genetic tests of family members of the person, and the manifestation of a disease or disorder in family members of the person, and any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by the person or any family member of the person. Any reference to “genetic information” concerning a person or family member of the person who is a pregnant woman includes, without limitation, genetic information of any fetus carried by such pregnant woman, or, with respect to the person or family member utilizing reproductive technology, includes, without limitation, genetic information of any embryo legally held by the person or family member. The term does not include information about the sex or age of a person.
(c) “Genetic services” means a genetic test, genetic education and genetic counseling, including obtaining, interpreting or assessing genetic information.
(d) “Genetic test” means an analysis of human DNA, RNA, chromosomes, proteins or metabolites that detects genotypes, mutations or chromosomal changes. The term does not include:
(1) An analysis of proteins or metabolites that does not detect genotypes, mutations or chromosomal changes; or
(2) An analysis of proteins or metabolites that is directly related to a manifested disease, disorder or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the applicable field of medicine.
(e) “Issuer of a policy to supplement Medicare or a certificate” includes third-party administrator, or other person acting for or on behalf of such issuer.
(f) “Underwriting purposes” means:
(1) Rules for, or determination of, eligibility, including, without limitation, enrollment and continued eligibility for benefits under the policy;
(2) The computation of premium or contribution amounts under the policy;
(3) The application of any preexisting condition exclusion under the policy; and
(4) Other activities related to the creation, renewal or replacement of a contract of health insurance or health benefits.
(Added to NAC by Comm’r of Insurance by R049-09, eff. 10-27-2009)
NAC 687B.225 Minimum standards for coverage: Policy or certificate advertised, solicited or issued for delivery before July 16, 1992. (NRS 679B.130, 687B.430)
1. A policy of insurance or subscriber contract must not be advertised, solicited or issued for delivery in this State as a policy or certificate to supplement Medicare before July 16, 1992, if it fails to meet the standards established by this section. These are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.
2. A policy to supplement Medicare or a certificate issued for delivery in this State before July 16, 1992, must not:
(a) Deny a claim for losses incurred more than 6 months after the effective date of coverage for a preexisting condition.
(b) Define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
(c) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.
3. A policy to supplement Medicare or a certificate must provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment or coinsurance amounts. Premiums may be modified to correspond with such changes.
4. A “noncancellable,” “guaranteed renewable” or “noncancellable and guaranteed renewable” policy must not:
(a) Provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premiums; or
(b) Be cancelled or denied renewal by the insurer solely on the grounds of deterioration of health.
5. Termination of a policy to supplement Medicare or of a certificate must be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits.
6. A policy to supplement Medicare that is subject to the minimum standards adopted pursuant to the Medicare Catastrophic Coverage Act of 1988, Public Law 100-360, 102 Stat. 683, July 1, 1988, must provide at least the following benefits:
(a) Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
(b) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount.
(c) Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days.
(d) Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 90 percent of all Medicare Part A eligible expenses for hospitalization that are not covered by Medicare, subject to a lifetime maximum benefit of an additional 365 days.
(e) Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part B. Plans K and L provide for 50 percent and 75 percent coverage of the cost, respectively.
(f) Coverage for the coinsurance amount, or, for services from a hospital outpatient department paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount that is equal to the Medicare Part B deductible.
(g) Coverage under Medicare Part B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part A, subject to the Medicare deductible amount. Plans K and L provide for 50 percent and 75 percent coverage of the cost, respectively.
7. For the purposes of this section:
(a) “Medicare eligible expenses” means expenses for health care of the kind covered by Medicare, to the extent recognized as reasonable by Medicare. Payment of benefits by an insurer for such expenses may be conditioned upon the same or less restrictive conditions of payment, including determinations of medical necessity, as are applicable to Medicare claims.
(b) “Policy to supplement Medicare” means a group or individual policy of accident and sickness insurance, or a subscriber contract of one or more hospital and medical service associations or health maintenance organizations, that is advertised, marketed or designed primarily as a supplement to the reimbursement provided under Medicare for the hospital, medical or surgical expenses of one or more persons eligible for Medicare by reason of age.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92; 8-2-94; R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R066-07, 1-30-2008; R049-09, 10-27-2009)
NAC 687B.226 Minimum standards for coverage: Policy or certificate advertised, solicited, delivered, issued for delivery or renewed on or after July 16, 1992, and before July 30, 1992. (NRS 679B.130, 687B.430)
1. A policy or certificate must not be advertised, solicited, originally delivered or issued for delivery, or renewed in this State as a policy or certificate to supplement Medicare on or after July 16, 1992, and before July 30, 1992, if it fails to meet or exceed the minimum standards established by this section. These standards do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.
2. A policy to supplement Medicare or a certificate originally delivered or issued for delivery, or renewed, in this State on or after July 16, 1992, and before July 30, 1992, must not:
(a) Exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because of a preexisting condition.
(b) Define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
(c) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.
3. A policy to supplement Medicare or a certificate must provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment or coinsurance amounts. Premiums may be modified to correspond with such changes.
4. A “noncancellable,” “guaranteed renewable” or “noncancellable and guaranteed renewable” policy must not:
(a) Provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premiums; or
(b) Be cancelled or denied renewal by the insurer solely on the grounds of deterioration of health.
5. Except as otherwise authorized by the Commissioner, an issuer shall not cancel or refuse to renew a policy to supplement Medicare or a certificate for any other reason than the nonpayment of premiums or for a material misrepresentation.
6. If a group policy to supplement Medicare or a certificate is terminated by the group policyholder and is not replaced as provided in subsection 8, the issuer shall offer to each certificate holder:
(a) An individual policy to supplement Medicare currently offered by the issuer that provides comparable benefits to those contained in the terminated policy; or
(b) An individual policy to supplement Medicare that provides only those benefits as are set forth in subsection 3 of NAC 687B.322.
7. If a certificate holder is provided coverage under a group policy to supplement Medicare or a certificate and he or she terminates his or her membership in the group, the issuer shall:
(a) Offer the certificate holder an individual policy to supplement Medicare pursuant to subsection 6; or
(b) At the request of the group policyholder, continue coverage for the certificate holder under the group policy to supplement Medicare.
8. If a group policy to supplement Medicare or a certificate is replaced by another group policy to supplement Medicare or another certificate which is purchased by the same person, the issuer of the replacement policy or certificate shall offer coverage to all persons who are covered under the policy or certificate that is being replaced on the date it is terminated. The replacement policy or certificate may not provide for the exclusion of coverage for preexisting conditions that were covered under the policy or certificate that is being replaced.
9. Termination of a policy to supplement Medicare or of a certificate must be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
10. If a policy to supplement Medicare eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this section.
11. A policy to supplement Medicare that is subject to the minimum standards must provide at least the following benefits:
(a) Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
(b) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount.
(c) Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days.
(d) Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 90 percent of all Medicare Part A eligible expenses for hospitalization that are not covered by Medicare, subject to a lifetime maximum benefit of an additional 365 days.
(e) Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part B. Plans K and L provide for 50 percent and 75 percent of the cost, respectively.
(f) Coverage for the coinsurance amount, or, for services from a hospital outpatient department paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount that is equal to the Medicare Part B deductible. This coverage must include coverage for Medicare eligible expenses for drugs used by an outpatient for immune suppressive therapy.
(g) Coverage under Medicare Part B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part A, subject to the Medicare deductible amount. Plans K and L provide for 50 percent and 75 percent of the coverage of the cost, respectively.
(Added to NAC by Comm’r of Insurance, eff. 7-16-92; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R066-07, 1-30-2008; R049-09, 10-27-2009)
NAC 687B.227 Policy or certificate advertised, solicited, delivered or issued for delivery or renewed on or after July 30, 1992, and effective before June 1, 2010: General requirements. (NRS 679B.130, 687B.430)
1. A policy or certificate must not be advertised, solicited, originally delivered or issued for delivery, or renewed in this State as a policy or certificate to supplement Medicare on or after July 30, 1992, and with an effective date for coverage before June 1, 2010, if it fails to comply with the requirements set forth in this section.
2. A policy to supplement Medicare or a certificate originally delivered or issued for delivery, or renewed, in this State on or after July 30, 1992, and with an effective date for coverage before June 1, 2010, must not:
(a) Exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because of a preexisting condition.
(b) Define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment recommended by or received from a physician during the 6 months immediately preceding the effective date of coverage.
(c) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.
3. A policy to supplement Medicare or a certificate must provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment or coinsurance amounts. Premiums may be modified to correspond with such changes.
4. A policy to supplement Medicare or a certificate must not provide for the termination of coverage of a spouse solely because of the occurrence of an event specified for the termination of coverage for the insured, other than the nonpayment of premiums.
5. A policy to supplement Medicare or a certificate must be guaranteed renewable. The issuer may not cancel or refuse to renew the policy or certificate solely because of the health of the insured or for any other reason than the nonpayment of premiums or for a material misrepresentation.
6. Termination of a policy to supplement Medicare or a certificate must be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, and limited to the duration of the policy benefit period, if any, or to the payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
7. Benefits and premiums must be suspended at the request of the policyholder or certificate holder for the period, not to exceed 24 months, during which the holder has applied for and is determined to be eligible for medical assistance under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., if the holder notifies the issuer of the policy or certificate within 90 days after the date he or she becomes eligible for such assistance.
8. If benefits and premiums are suspended pursuant to subsection 7 and the policyholder or certificate holder loses his or her eligibility for assistance under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., the policy to supplement Medicare or the certificate must be automatically reinstated effective as of the date the holder is no longer eligible for assistance if he or she:
(a) Gives notice of his or her loss of eligibility to the issuer within 90 days; and
(b) Pays the premium attributable to his or her period of eligibility.
9. Benefits and premiums must be suspended at the request of the policyholder or certificate holder for any period that may be provided by federal regulation, during which the holder is entitled to benefits under section 226(b) of the Social Security Act, 42 U.S.C. § 426, and is covered under a group health plan, as that term is defined in section 1862(b)(1)(A)(v) of the Social Security Act, 42 U.S.C. § 1395y(b)(1)(A)(v). If benefits and premiums are suspended pursuant to this subsection and the policyholder or certificate holder loses coverage under the group health plan, the policy to supplement Medicare or the certificate must be automatically reinstated effective as of the date of loss of coverage if the policyholder or certificate holder provides notice of loss of coverage within 90 days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.
10. If a policy to supplement Medicare or a certificate is reinstated pursuant to subsection 8 or 9:
(a) A waiting period for the treatment of any preexisting condition must not be required;
(b) The coverage provided must be substantially equivalent to the coverage in effect before the benefits and premiums were suspended, and, if the suspended policy to supplement Medicare provided coverage for outpatient prescription drugs, reinstatement of the policy for Medicare Part D enrollees must be without coverage for outpatient prescription drugs and must otherwise provide substantially equivalent coverage to the coverage in effect before the benefits and premiums were suspended; and
(c) The terms for the classification of premiums must be at least as favorable to the policyholder or certificate holder as the terms in effect before the benefits and premiums were suspended.
11. If an issuer makes a written offer to the Medicare Supplement policyholder or certificate holder of one or more of its plans to exchange, during a specified period, from his or her 1990 standardized benefit plan, as described in NAC 687B.295, to a 2010 standardized benefit plan, as described in NAC 687B.323, the offer and subsequent exchange must comply with the following requirements:
(a) The issuer need not provide justification to the Commissioner if the insured replaces a 1990 standardized benefit plan or certificate with an issue age rated 2010 standardized benefit plan or certificate at the insured’s original issue age and duration;
(b) If an insured’s policy or certificate to be replaced is priced on an issue age rate schedule at the time of such offer, the rate charged to the insured for the new exchanged policy must recognize the policy reserve buildup, due to the prefunding inherent in the use of an issue age rate basis, for the benefit of the insured;
(c) The method proposed to be used by the issuer must be filed with the Commissioner pursuant to NAC 687B.229;
(d) The rating class of the new policy or certificate must be the class closest to the class of the replaced coverage;
(e) The issuer may not apply new limitations on preexisting conditions or a new incontestability period to the new policy for those benefits contained in the exchanged 1990 standardized benefit plan or certificate of the insured, but may apply limitations of not more than 6 months on preexisting conditions to any added benefits contained in the new 2010 standardized benefit plan or certificate not contained in the exchanged policy; and
(f) The new policy or certificate must be offered to all policyholders or certificate holders within a given plan, except where the offer or issue would be in violation of state or federal law.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96; R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.2273 Policy or certificate advertised, solicited, delivered or issued for delivery on or after June 1, 2010: General requirements. (NRS 679B.130, 687B.430)
1. On or after June 1, 2010, no policy or certificate may be advertised, solicited, delivered or issued for delivery in this State as a policy to supplement Medicare or a certificate unless it complies with the standards provided for in NAC 687B.322 and 687B.323.
2. No issuer may offer any 1990 standardized benefit plan to supplement Medicare for sale on or after June 1, 2010.
3. Benefit standards applicable to a policy to supplement Medicare or a certificate issued with an effective date for coverage before June 1, 2010, remain subject to the requirements of NAC 687B.225, 687B.226, 687B.227, 687B.290 and 687B.295.
(Added to NAC by Comm’r of Insurance by R049-09, eff. 10-27-2009)
NAC 687B.229 Filing and approval of rates, rating schedule and supporting documentation required. (NRS 679B.130, 687B.430) An issuer shall not use or change the premium rates for a policy to supplement Medicare or a certificate unless the rates, rating schedule and supporting documentation have been filed with and approved by the Commissioner.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.230 Rates: Calculation of aggregate benefits; standards for ratios of loss; filing requirements; adjustments; hearing on certain requested increases. (NRS 679B.130, 687B.120, 687B.430)
1. A policy to supplement Medicare or a certificate must not be delivered or issued for delivery in this State unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to the policyholder or certificate holder the following amounts in the form of aggregate benefits provided under the policy, not including anticipated refunds or credits:
(a) In the case of a group policy, at least 75 percent of the aggregate amount of premiums earned.
(b) In the case of an individual policy, at least 65 percent of the aggregate amount of premiums earned. For the purposes of this paragraph, a policy issued as a result of any solicitation made by mail or by advertising using the mass media, including any written or broadcasted advertisement, shall be deemed to be an individual policy.
Ê The aggregate benefits must be calculated on the basis of incurred claims experience or incurred expenses for health care if coverage is provided by a health maintenance organization on the basis of payments made to the provider of health care rather than reimbursements made to the insured, and must be calculated in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a health maintenance organization must not include:
(1) Home office and overhead costs;
(2) Advertising costs;
(3) Commissions and other acquisition costs;
(4) Taxes;
(5) Capital costs;
(6) Administrative costs; and
(7) Claims processing costs.
2. All filings of rates and rating schedules must demonstrate that expected claims in relation to premiums comply with the requirements of this section when combined with actual experience as of the date of the filing. Filing of revisions of rates must also demonstrate that the anticipated loss ratio during the period for which the revised rates are computed can be expected to meet the appropriate standards for the loss ratio.
3. On or before May 31 of each year, each issuer providing a policy to supplement Medicare or a certificate in this State shall file with the Division, in a format prescribed by the Commissioner, its rates, rating schedule and supporting documentation, including ratios of incurred losses to earned premiums by policy duration, for approval by the Commissioner. The supporting documentation must:
(a) Demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the appropriate standards for loss ratios can be expected to be met during the entire period for which the rates are computed; and
(b) Exclude active life reserves.
Ê An expected third-year loss ratio that is greater than or equal to the applicable percentage must be demonstrated for policies to supplement Medicare or certificates in force less than 3 years.
4. As soon as practicable before the effective date of any enhancements to Medicare benefits, every issuer shall file with the Division in accordance with NRS 687B.120:
(a) Appropriate adjustments of premiums necessary to produce loss ratios as anticipated for the current premiums for the applicable policies or certificates, together with such supporting documents as are necessary to justify the adjustment; and
(b) Any appropriate riders, endorsements or policy forms needed to accomplish the modifications to the policy to supplement Medicare or the certificate which are necessary to eliminate any duplication of Medicare benefits. Any such riders, endorsements or policy forms must provide a clear description of the benefits to supplement Medicare that are provided by the policy or certificate.
5. An issuer shall make such adjustments to premiums pursuant to paragraph (a) of subsection 4 as are necessary to produce an expected loss ratio that conforms to the minimum standards for loss ratios for policies to supplement Medicare or certificates which are expected to result in a loss ratio that is at least as great as the ratio originally anticipated for the rates used by the issuer to calculate current premiums for the policy to supplement Medicare or the certificate. An adjustment to premiums which modifies the loss ratio, other than an adjustment made pursuant to this section, may not be made at any time other than upon the renewal of the policy or certificate or its anniversary date. If an issuer makes an adjustment to premiums which is not acceptable to the Commissioner, the Commissioner may order an adjustment to premiums, a refund or a credit which he or she deems necessary to achieve the loss ratio required by this section.
6. The Commissioner may conduct a hearing to obtain information concerning a request submitted by an issuer for an increase in the rates for a policy to supplement Medicare or a certificate if the experience incurred during the reporting period does not comply with the applicable standard for loss ratios. The Commissioner will determine whether the experience complies with the applicable standard without considering any refund or credit required for the reporting period.
7. The provisions of this section apply to any policy to supplement Medicare or any certificate delivered or issued for delivery in this State, regardless of the date of its delivery or issuance.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 5-27-92; 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R081-16, 11-2-2016)
NAC 687B.235 Calculation and payment of refunds and credits. (NRS 679B.130, 687B.430)
1. An issuer shall collect and file with the Commissioner by May 31 of each year the data contained in the reporting form prescribed by the Commissioner for each type of policy in a standardized benefit plan to supplement Medicare. The appropriate reporting form may be obtained from the Office of the Commissioner.
2. If, on the basis of the experience reported, the loss ratio since inception, commonly referred to as ratio 1, exceeds the loss ratio adjusted for experience incurred since inception, commonly referred to as ratio 3, a refund or credit must be calculated. The refund must be calculated on a statewide basis for each type of policy in a standardized benefit plan to supplement Medicare. To calculate the refund or credit, experience incurred for:
(a) Policies to supplement Medicare issued within the reporting year must be excluded.
(b) All policy forms and certificate forms of the same type in a standardized benefit plan to supplement Medicare must be combined.
(c) A policy form or certificate form assumed pursuant to an agreement to assume reinsurance must not be combined with the experience incurred for other forms.
3. An issuer shall pay a refund or credit to the policyholder or certificate holder if the loss ratio since inception exceeds the loss ratio adjusted for experience incurred since inception and the amount to be refunded or credited is not de minimis.
4. An issuer shall calculate the refund or credit due on policies or certificates issued before July 16, 1992, on an individual basis, by using the combined loss ratios of all individual policies, including all group policies subject to an individual loss ratio standard when issued and all other group policies combined for experience after May 13, 1996.
5. A refund or credit must include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the Secretary of Health and Human Services, but in no event may the rate be less than the average rate of interest for 13-week United States treasury notes.
6. Any refund or credit made against premiums due must be made by September 30th following the year of experience upon which the refund or credit is based.
7. The provisions of this section apply to any policy to supplement Medicare or certificate delivered or issued for delivery in this State, regardless of the date of its delivery or issuance.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; 5-13-96)
NAC 687B.240 Provision for renewal or continuation; acceptance of riders and endorsements; prohibited standards for payment of benefits; disclosure and dissemination of information. (NRS 679B.130, 687B.430)
1. Each policy to supplement Medicare or certificate must include a renewal or continuation provision. The language or specifications of the provision must be consistent with the type of contract issued. The provision must:
(a) Be captioned appropriately;
(b) Appear on the first page of the policy;
(c) Include any reservation by the issuer to change premiums; and
(d) Include any automatic increases in premiums at the time of renewal which are based on the age of the policyholder.
2. Except for riders or endorsements by which the issuer:
(a) Effectuates a request made in writing by the insured;
(b) Exercises a specifically reserved right under a policy to supplement Medicare; or
(c) Is required to reduce or eliminate benefits to avoid a duplication of benefits provided by Medicare,
Ê any rider or endorsement added to a policy to supplement Medicare after the date of its issue, or upon reinstatement or renewal, which reduces or eliminates benefits or coverage provided by the policy, requires a signed acceptance by the insured. After the date the policy or certificate is issued, any rider or endorsement that increases benefits or coverage with a concomitant increase in premiums during the term of the policy must be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for such policies to supplement Medicare, or if the increased benefits or coverage are required by law. If an additional premium is charged for benefits provided in connection with riders or endorsements, that premium must be set forth in the policy.
3. A policy to supplement Medicare or a certificate must not provide for the payment of benefits based upon standards described as “usual and customary,” “reasonable and customary” or words of similar import.
4. If a policy to supplement Medicare or a certificate contains any limitations with respect to preexisting conditions, those limitations must appear as a separate paragraph of the policy and must be labeled “limitations for preexisting conditions.”
5. Each policy to supplement Medicare or certificate must contain a notice, prominently printed on its first page or attached to that page, stating in substance that the policyholder or certificate holder is entitled to return the policy or certificate within 30 days after its delivery and to have the premium refunded if, after examination of the policy or certificate, the policyholder or certificate holder is not satisfied for any reason.
6. An issuer of an accident or sickness policy or certificate providing hospital or medical expense coverage on an expense incurred or indemnity basis to a person eligible for Medicare shall provide to all applicants a guide which must be entitled Guide to Health Insurance for People with Medicare and which:
(a) Uses the language, format, type size, proportional spacing, bold type and line spacing developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare & Medicaid Services; and
(b) Is in not less than 12-point type.
Ê The Guide to buyers required by this subsection must be delivered whether or not the policy or certificate is advertised, solicited or issued as a policy or certificate to supplement Medicare. Except as otherwise provided in this subsection, delivery of the Guide must be made to the applicant at the time of application. An acknowledgment of receipt of the Guide must be obtained by the issuer. Direct response issuers shall deliver the Guide to the applicant upon request but not later than at the time the policy is delivered.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 5-13-96; R075-02, 9-20-2002)
NAC 687B.243 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Notice required before termination of policy or certificate. (NRS 679B.130, 687B.430)
1. An issuer may not terminate a policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State based on the lack of payment of the premium on or before the date the premium is required to be paid, unless the insured and each person designated by the insured pursuant to NAC 687B.245 has received a notice sent by the issuer stating that the policy has lapsed and may be terminated for nonpayment of the premium.
2. For the purposes of this section, the notice:
(a) Must be sent by first-class mail, postage prepaid, and addressed to the person at his or her last known address.
(b) Shall be deemed to have been received by the insured or the person designated by the insured pursuant to NAC 687B.245 on the fifth day after the date on which the issuer mails the notice.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004)
NAC 687B.245 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Designation of person to receive notice of lapse or waiver of designation. (NRS 679B.130, 687B.430)
1. An issuer shall not issue a policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State until the issuer has received from the applicant a designation of one or more persons to receive notice of lapse or a waiver pursuant to subsection 2.
2. Each applicant shall submit to the issuer of the policy to supplement Medicare or the certificate:
(a) A written designation of one or more persons other than the applicant to receive notice from the issuer that the policy to supplement Medicare or the certificate has lapsed and may be terminated for nonpayment of a premium; or
(b) A written waiver which is dated and signed by the applicant and which:
(1) Indicates that the applicant does not wish to designate any person other than the applicant to receive notice that the policy to supplement Medicare or the certificate has lapsed and may be terminated for nonpayment of a premium; and
(2) Includes the statement required pursuant to subsection 4.
3. The form provided by an issuer for making a designation pursuant to paragraph (a) of subsection 2 must provide space clearly designated for listing at least one person to receive notice. A designation made pursuant to paragraph (a) of subsection 2:
(a) Must include the full name and address of the person designated; and
(b) Does not constitute acceptance by the person designated of any liability for services provided to the applicant.
4. A waiver submitted pursuant to paragraph (b) of subsection 2, must contain the following statement:
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 of this policy to supplement Medicare or certificate for nonpayment of a premium. I elect NOT to designate a person to receive this notice.
5. An issuer shall, at least once every 2 years, notify an insured of his or her right to make or change a written designation pursuant to subsection 2.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004)
NAC 687B.247 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Provision for reinstatement of coverage. (NRS 679B.130, 687B.430) A policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State must include a provision which provides that, in the event of a lapse in coverage of the policy or certificate for nonpayment of a premium, coverage will be reinstated if:
1. Reinstatement is requested within 2 months after the date of lapse of coverage; and
2. Proof of cognitive impairment or loss of functional capacity of the insured before the lapse of coverage or the expiration of any grace period contained in the policy to supplement Medicare or the certificate is provided to the issuer.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004)
NAC 687B.250 Outline of coverage; assistance in understanding health insurance. (NRS 679B.130, 687B.430)
1. Each issuer shall provide an outline of coverage to each applicant at the time the application is presented to the applicant and, except in the case of a direct response policy, shall obtain an acknowledgment from the applicant that he or she has received the outline.
2. If an outline of coverage is provided at the time of application and the policy to supplement Medicare or the certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered. The substitute outline must contain the following statement, in not less than 12-point type, immediately above the name of the company:
NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application, and the coverage originally applied for has not been issued.
3. The outline of coverage provided to the applicant must consist of:
(a) A cover page;
(b) Information regarding premiums;
(c) Disclosure pages; and
(d) Charts displaying the features of each benefit plan offered by the issuer as set forth in subsection 7.
4. All plans must be shown on the cover page and the plans offered by the issuer must be prominently identified.
5. Information regarding premiums for benefit plans to supplement Medicare offered by the issuer must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for all plans that are offered to the applicant. All possible premiums must be illustrated.
6. An insured may contact the Commissioner of Insurance or the Nevada State Health Insurance Assistance Program (SHIP) of the Aging and Disability Services Division of the Department of Health and Human Services for help in understanding his or her health insurance.
7. The outline of coverage must be printed in not less than 12-point type, using the following language and format:
Benefit Chart of Medicare Supplement Plans Sold with an Effective Date for Coverage On or After June 1, 2010
This chart shows the benefits included in each of the Standard Medicare Supplement Plans. Every company must make Plan “A” available. Some plans may not be available in your state.
Basic Benefits:
Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses - Part B coinsurance (generally 20 percent of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments.
Blood - First three pints of blood each year.
Hospice - Part A coinsurance.
|
A |
B |
C |
D |
F |
F* |
G |
K |
L |
M |
N |
|
Basic, including 100% Part B coinsurance |
Basic, including 100% Part B coinsurance |
Basic, including 100% Part B coinsurance |
Basic, including 100% Part B coinsurance |
Basic, including 100% Part B coinsurance |
Basic, including 100% Part B coinsurance |
Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% |
Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% |
Basic, including 100% Part B coinsurance |
Basic, including 100% Part B coinsurance, except up to *** copayment for office visit, and up to *** copayment for ER |
|
|
|
|
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
50% Skilled Nursing Facility Coinsurance |
75% Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
|
|
|
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
50% Part A Deductible |
75% Part A Deductible |
50% Part A Deductible |
Part A Deductible |
|
|
|
|
Part B Deductible |
|
Part B Deductible |
|
|
|
|
|
|
|
|
|
|
|
Part B Excess (100%) |
Part B Excess (100%) |
|
|
|
|
|
|
|
|
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
|
|
Foreign Travel Emergency |
Foreign Travel Emergency |
|
|
|
|
|
|
|
|
Out-of-pocket limit**; paid at 100% after limit reached |
Out-of-pocket limit**; paid at 100% after limit reached |
|
|
|
* Plan F also has an option called a High Deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed the deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
** Out-of-pocket limit will increase each year for inflation.
*** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an insurer to an applicant pursuant to NAC 687B.240.
PREMIUM INFORMATION (Boldface type)
We (insert issuer’s name) can only raise your premium if we raise the premium for all policies like yours in this State. (If the premium is based on the increasing age of the insured, include information specifying when premiums will change.)
DISCLOSURES (Boldface type)
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY
(Boldface type)
This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY (Boldface type)
If you find that you are not satisfied with your policy, you may return it to (insert issuer’s address). If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT (Boldface type)
If you are replacing another policy of health insurance, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE (Boldface type)
This policy may not cover all of your medical costs.
(For agents)
Neither (insert company’s name) nor its agents are connected with Medicare.
(For direct response)
(Insert company’s name) is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local social security office or consult Medicare & You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
(Boldface type)
When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. (If the policy or certificate is guaranteed issue, this paragraph need not appear.)
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
(Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, and the same uniform layout and format as shown in the charts set forth in this subsection. No more than four plans may be shown on one chart. An issuer may use additional designations for benefit plans on these charts as authorized by subsection 4 of NAC 687B.295.)
(Include an explanation of any innovative benefits on the cover page and in the chart, in the manner approved by the Commissioner.)
PLAN A
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days
61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but **
All but ** a day
All but ** a day
$0
$0 |
$0
** a day
** a day
100% of Medicare Eligible Expenses $0 |
(Part A Deductible)
$0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 $0 $0 |
$0 Up to ** a day All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
|
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance
|
$0
|
PLAN A
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0
Generally 80% |
$0
Generally 20% |
(Part B Deductible)
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts * Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs $0
20% |
$0 (Part B Deductible)
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN A
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts * Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
$0
20% |
$0
(Part B Deductible)
$0 |
PLAN B
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ** All but ** a day
All but ** a day
$0
$0 |
(Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 $0 $0 |
$0 Up to ** a day All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
PLAN B
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0
Generally 80% |
$0
Generally 20% |
(Part B Deductible)
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts*
Remainder of Medicare-approved amounts |
$0
$0
80% |
All costs
$0
20% |
$0
(Part B Deductible)
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN B
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
$0
20% |
$0
(Part B Deductible)
$0 |
PLAN C
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ** All but ** a day
All but ** a day
$0
$0 |
(Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 Up to ** a day $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
PLAN C
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0
Generally 80% |
(Part B Deductible)
Generally 20% |
$0
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs (Part B Deductible)
20% |
$0 $0
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN C
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
(Part B Deductible)
20% |
$0
$0
$0 |
PLAN C
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN D
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ** All but ** a day
All but ** a day
$0
$0 |
(Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 Up to ** a day $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
PLAN D
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0
Generally 80% |
$0
Generally 20% |
(Part B Deductible)
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts * Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs $0
20% |
$0 (Part B Deductible)
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN D
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts * Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
(Part B Deductible) $0 |
PLAN D
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ** All but ** a day
All but ** a day
$0
$0 |
(Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 Up to ** a day $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0
Generally 80% |
(Part B Deductible)
Generally 20% |
$0
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs (Part B Deductible)
20% |
$0 $0
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN F
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
(Part B Deductible)
20% |
$0
$0
$0 |
PLAN F
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
HIGH DEDUCTIBLE BENEFIT PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
**** The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE, PLAN PAYS**** |
IN ADDITION TO THE DEDUCTIBLE, YOU PAY**** |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ** All but ** a day
All but ** a day
$0
$0 |
(Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 Up to ** a day $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
HIGH DEDUCTIBLE BENEFIT PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.311.
** The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE, PLAN PAYS** |
IN ADDITION TO THE DEDUCTIBLE, YOU PAY** |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0
Generally 80% |
(Part B Deductible)
Generally 20% |
$0
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs (Part B Deductible)
20% |
$0 $0
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
HIGH DEDUCTIBLE BENEFIT PLAN F
MEDICARE (PARTS A & B)
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.311.
** The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE, PLAN PAYS** |
IN ADDITION TO THE DEDUCTIBLE, YOU PAY** |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
(Part B Deductible)
20% |
$0
$0
$0 |
HIGH DEDUCTIBLE BENEFIT PLAN F
OTHER BENEFITS - NOT COVERED BY MEDICARE
* The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE, PLAN PAYS* |
IN ADDITION TO THE DEDUCTIBLE, YOU PAY* |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN G
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ** All but ** a day
All but ** a day
$0
$0 |
(Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 Up to ** a day $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
PLAN G
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0
Generally 80% |
$0
Generally 20% |
(Part B Deductible)
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs $0
20% |
$0 (Part B Deductible)
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN G
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts *
Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
$0
20% |
$0
(Part B Deductible)
$0 |
PLAN G
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN K
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket limit each calendar year.
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
*** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
**** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days
61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ***
All but *** a day
All but *** a day
$0
$0 |
(50% of Part A Deductible) *** a day
*** a day
100% of Medicare Eligible Expenses $0 |
(50% of Part A Deductible)¿ $0
$0
$0****
All costs |
|
SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day
101st day and after |
All approved amounts All but *** a day
$0 |
$0 Up to 50% of *** a day (50% of Part A Coinsurance) $0 |
$0 Up to 50% of *** a day (50% of Part A Coinsurance) ¿ All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
50% $0 |
50%¿ $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
50% of coinsurance or copayments |
50% of Medicare copayment/coinsurance ¿ |
PLAN K
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts per year.** However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
**** Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts****
Preventive Benefits for Medicare-covered services
Remainder of Medicare-approved amounts |
$0
Generally 80% or more of Medicare-approved amounts Generally 80% |
$0
Remainder of Medicare-approved amounts Generally 10% |
(Part B Deductible) ****¿
All costs above Medicare-approved amounts Generally 10%¿ |
|
Part B Excess Charges (Above Medicare-approved amounts)
|
$0
|
$0
|
All costs (and they do not count toward annual out-of-pocket limit) |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts ****
Remainder of Medicare-approved amounts |
$0 $0
Generally 80% |
50% $0
Generally 10% |
50%¿ (Part B Deductible) ****¿
Generally 10%¿ |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN K
PARTS A & B
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts per year.** However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
***** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts *****
Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
$0
10% |
$0
(Part B Deductible)¿
10%¿ |
PLAN L
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit each calendar year.
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
*** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
**** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days
61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ***
All but *** a day
All but *** a day
$0
$0 |
(75% of Part A Deductible) *** a day
*** a day
100% of Medicare Eligible Expenses $0 |
(25% of Part A Deductible)¿ $0
$0
$0****
All costs |
|
SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day
101st day and after |
All approved amounts All but *** a day
$0 |
$0 Up to 75% of *** a day (75% of Part A Coinsurance) $0 |
$0 Up to 25% of *** a day (25% of Part A Coinsurance) ¿ All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
75% $0 |
25%¿ $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
|
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care |
75% of copayment/ coinsurance |
25% of copayment/ coinsurance ¿ |
PLAN L
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts per year.** However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
**** Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts ****
Preventive Benefits for Medicare-covered services
Remainder of Medicare-approved amounts |
$0
Generally 80% or more of Medicare-approved amounts Generally 80% |
$0
Remainder of Medicare-approved amounts
Generally 15% |
(Part B Deductible) ****¿
All costs above Medicare-approved amounts Generally 5%¿ |
|
Part B Excess Charges (Above Medicare-approved amounts)
|
$0
|
$0
|
All costs (and they do not count toward annual out-of-pocket limit)* |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts ****
Remainder of Medicare-approved amounts |
$0 $0
Generally 80% |
75% $0
Generally 15% |
25%¿ (Part B Deductible)¿
Generally 5%¿ |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN L
PARTS A & B
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts per year.** However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
***** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts ***** Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
$0
15% |
$0
(Part B Deductible)¿
5%¿ |
PLAN M
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days
61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but **
All but ** a day
All but ** a day
$0
$0 |
(50% of Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
(50% of Part A Deductible) $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 Up to ** a day $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
PLAN M
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts (equal to the Part B Deductible) for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0
Generally 80% |
$0
Generally 20% |
(Part B Deductible)
$0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs $0
20% |
$0 (Part B Deductible)
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN M
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts (equal to the Part B Deductible) for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts * Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
$0
20% |
$0
(Part B Deductible)
$0 |
PLAN M
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN N
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
All but ** All but ** a day
All but ** a day
$0
$0 |
(Part A Deductible) ** a day
** a day
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0***
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts All but ** a day $0 |
$0 Up to ** a day $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness |
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care |
Medicare copayment/coinsurance |
$0 |
PLAN N
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed a portion of Medicare-approved amounts (equal to the Part B Deductible) for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved amounts* Remainder of Medicare-approved amounts
|
$0
Generally 80%
|
$0
Balance, other than up to ** per office visit and up to ** per emergency room visit. The copayment of up to ** is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. |
(Part B Deductible)
Up to ** per office visit and up to ** per emergency room visit. The copayment of up to ** is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next portion of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0
80% |
All costs $0
20% |
$0 (Part B Deductible)
$0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN N
PARTS A & B
* Once you have been billed a portion of Medicare-approved amounts (equal to the Part B Deductible) for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First portion of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0
80% |
$0
$0
20% |
$0
(Part B Deductible)
$0 |
PLAN N
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 5-27-92, 7-16-92, eff. 7-30-98; 8-2-94; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R066-07, 1-30-2008; R049-09, 10-27-2009; R087-10, 12-16-2010, eff. 6-2-2011)
NAC 687B.255 Elicitation and dissemination of information regarding existing coverage and its replacement; inclusion of certain statements and questions in application. (NRS 679B.130, 687B.430)
1. An application for a policy to supplement Medicare must include questions designed to elicit information about whether, as of the date of the application, the applicant currently has another policy to supplement Medicare, Medicare Advantage, Medicaid coverage, or another health insurance policy or certificate in force or whether the policy to supplement Medicare or the certificate is intended to replace any other policy or certificate presently in force. A supplementary application or other form containing such questions and statements may be used if it is signed by the applicant and the issuer or its agent.
2. An application must contain the following statements and questions:
(a) You do not need more than one policy to supplement Medicare.
(b) If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.
(c) You may be eligible for benefits under Medicaid and may not need a policy to supplement Medicare.
(d) If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your policy to supplement Medicare may, if requested, be suspended during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days after becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended policy to supplement Medicare or, if that is no longer available, a substantially equivalent policy will be reinstituted if requested within 90 days after loss of eligibility. If the policy to supplement Medicare provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
(e) If you are eligible for, and have enrolled in a policy to supplement Medicare by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your policy to supplement Medicare can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your policy to supplement Medicare under these circumstances, and later lose your employer or union-based group health plan, your suspended policy to supplement Medicare or, if that is no longer available, a substantially equivalent policy will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the policy to supplement Medicare provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
(f) Counseling services may be available in your state to provide advice concerning your purchase of a policy to supplement Medicare and concerning medical assistance available through the state Medicaid program, including benefits available to qualified Medicare beneficiaries, as that term is defined in 42 U.S.C. § 1396d(p)(1), and to specified low-income Medicare beneficiaries, as described in 42 U.S.C. § 1396a(a)(10)(E)(iii).
(g) If you lost or are losing your health insurance coverage and received a notice from your prior insurer saying that you were eligible for guaranteed issue of a policy to supplement Medicare, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our policies to supplement Medicare. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.
(h) [Please mark Yes or No below with an “X”]
To the best of your knowledge,
(1) (a) Did you turn age 65 in the last 6 months?
Yes _____ No _____
(b) Did you enroll in Medicare Part B in the last 6 months?
Yes _____ No _____
(c) If yes, what is the effective date? ______________________________________
(2) Are you covered for medical assistance through the state Medicaid program?
[NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer NO to this question.]
Yes _____ No _____
If yes,
(a) Will Medicaid pay your premiums for this policy to supplement Medicare?
Yes _____ No _____
(b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
Yes _____ No _____
(3) (a) If you had coverage from any Medicare plan other than the original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave “End” blank.
Start ___/___/___ End ___/___/___
(b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new policy to supplement Medicare?
Yes _____ No _____
(c) Was this your first time in this type of Medicare plan?
Yes _____ No _____
(d) Did you drop a policy to supplement Medicare to enroll in the Medicare plan?
Yes _____ No _____
(4) (a) Do you have another policy to supplement Medicare in force?
Yes _____ No _____
(b) If so, with what company, and what plan do you have [optional for Direct Mailers]?
(c) If so, do you intend to replace your current policy to supplement Medicare with this policy?
Yes _____ No _____
(5) Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union or individual plan)
Yes _____ No _____
(a) If so, with what company and what kind of policy?
(b) What are your dates of coverage under the policy?
Start ___/___/___ End ___/___/___
(If you are still covered under the other policy, leave “End” blank.)
3. An issuer shall provide to the applicant a list of any other policies of health insurance he or she has sold to the applicant. The list must include policies sold to the applicant which are in force at the time of the application and policies sold to the applicant in the previous 5 years which are no longer in force.
4. If the issuer is a direct response issuer, a copy of the application or supplemental form, signed by the applicant and acknowledged by the issuer, must be returned to the applicant by the issuer upon delivery of the policy to supplement Medicare.
5. Upon determining that the sale will involve the replacement of coverage to supplement Medicare, the issuer or its agent shall, before issuing or delivering the policy to supplement Medicare or the certificate, furnish the applicant with a notice regarding the replacement of coverage to supplement Medicare. One copy of the notice, signed by the applicant and the agent, must be provided to the applicant and another copy, signed by the applicant, must be retained by the issuer.
6. A direct response issuer shall deliver the notice required by subsection 5 to the applicant at the time of the issuance of the policy to supplement Medicare.
7. The notice required by subsection 5:
(a) Must be in a form prescribed by the Division;
(b) Must be in not less than 12-point type; and
(c) Except as otherwise provided in subsection 8, must be in substantially the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF INSURANCE TO SUPPLEMENT MEDICARE
OR MEDICARE ADVANTAGE
(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 terminate existing insurance to supplement Medicare or Medicare Advantage and replace it with a policy to be issued by (company name) Insurance Company. Your new policy will provide 30 days within which you may decide, without cost, whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all coverage for accidents and sickness you now have. If, after due consideration, you find that the purchase of this coverage to supplement Medicare is a wise decision, you should terminate your present policy to supplement Medicare or Medicare Advantage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICATION BY ISSUER, AGENT (BROKER OR OTHER REPRESENTATIVE):
I have reviewed the coverage provided by your current policies of medical or health insurance. This policy to supplement Medicare will not duplicate your existing policy to supplement Medicare or, if applicable, Medicare Advantage because you intend to terminate your existing policy to supplement Medicare or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):
Additional benefits.
No change in benefits, but lower premiums.
Fewer benefits and lower premiums.
My plan has outpatient prescription drug coverage, and I am enrolling in Medicare Part D.
Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment. [optional only for Direct Mailers]
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Other (please specify).
Note: If the issuer of the policy to supplement Medicare being applied for does not, or is otherwise prohibited from, imposing preexisting condition limitations, please skip to the next statement below. Any health condition which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in the denial of a claim for benefits or a delay in the payment of a claim under the new policy, whereas a similar claim might be payable under your present policy.
State law provides that your replacement policy or certificate may not contain any new preexisting condition, waiting period, elimination period or probationary period. The issuer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
If you still wish to terminate your present policy and replace it with new coverage, be certain to answer truthfully and completely all questions on the application concerning your medical and 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, review it carefully to be certain that all information has been properly recorded. (If the policy or certificate is guaranteed issue, this paragraph need not appear.)
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
...................................................................
(Signature of Agent, Broker or Other Representative)*
...................................................................
[Typed Name and Address of Issuer, Agent or Broker]
...................................................................
(Applicant’s Signature)
...................................................................
(Date)
*Signature not required for direct response sales.
8. The provisions of the replacement notice applicable to preexisting conditions may be deleted by an issuer if the replacement does not involve the application of a new limitation on a preexisting condition.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 5-27-92; 7-16-92, eff. 7-30-92; 8-2-94; 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.258 Replacement of existing coverage: Limitations on time periods for preexisting conditions, waiting periods, elimination periods and probationary periods. (NRS 679B.130, 687B.430)
1. If a policy to supplement Medicare or a certificate replaces another policy to supplement Medicare or certificate, the replacing issuer shall waive any time periods for preexisting conditions, waiting periods, elimination periods and probationary periods in the new policy or certificate for similar benefits to the extent that such time was spent under the original policy.
2. If a policy to supplement Medicare or a certificate replaces another policy to supplement Medicare or certificate which has been in effect for at least 6 months, the replacing policy or certificate must not provide any time period for preexisting conditions, waiting periods, elimination periods or probationary periods for benefits similar to those contained in the original policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92)
NAC 687B.260 Policy to supplement Medicare or certificate issued before January 1, 1992: Replacement with standardized benefit plan. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in subsection 2, an issuer shall, at the request of an insured, replace a policy to supplement Medicare which was issued before January 1, 1992, or a certificate which was issued before January 1, 1992, with any standardized benefit plan offered by the issuer. An insured may submit a request to replace a policy to supplement Medicare or certificate pursuant to this subsection not more than once.
2. An issuer may refuse a request made pursuant to subsection 1 for the issuance of a standardized benefit plan to replace a policy to supplement Medicare or certificate which was issued before January 1, 1992, if:
(a) The standardized benefit plan includes coverage for prescription drugs; or
(b) The insured does not otherwise qualify for the standardized benefit plan.
3. If an insured requests a standardized benefit plan to replace a policy to supplement Medicare or certificate pursuant to subsection 1 from an issuer that establishes the rates of a standardized benefit plan on the basis of the age of an applicant, the issuer must use the attained age of the insured on the date his or her request is submitted to establish the rate for the standardized benefit plan.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.263 Termination and replacement of coverage under group policy. (NRS 679B.130, 687B.430)
1. If a group policy to supplement Medicare or a certificate is terminated by the group policyholder or certificate holder and is not replaced as provided in subsection 3, the issuer shall offer each certificate holder an individual policy to supplement Medicare or a certificate. The issuer shall offer the certificate holder an individual policy that provides for the continuation of the benefits contained in the group policy.
2. If a certificate holder is provided coverage under a group policy to supplement Medicare or a certificate and the certificate holder terminates his or her membership in the group, the issuer shall:
(a) Offer the certificate holder an individual policy to supplement Medicare pursuant to subsection 1; or
(b) At the request of the group policyholder, continue coverage for the certificate holder under the group policy to supplement Medicare.
3. If a group policy to supplement Medicare or a certificate is replaced by another group policy to supplement Medicare or certificate which is purchased by the same person, the issuer of the replacement policy or certificate shall offer coverage to all persons who are covered under the policy or certificate that is being replaced on the date it is terminated. The replacement policy or certificate may not provide for the exclusion of coverage for preexisting conditions that were covered under the policy or certificate that is being replaced.
4. If a group policy to supplement Medicare eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this section.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92; 8-2-94; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.265 Notice of modifications to policy or certificate; compliance with certain notice requirements. (NRS 679B.130, 687B.430)
1. As soon as practicable, but not later than 30 days before the annual effective date of any changes in Medicare benefits, an issuer shall notify each policyholder and certificate holder of any modifications it has made to the policy to supplement Medicare or the certificate. The notice must:
(a) Include a description of any revisions to the Medicare program and a description of each modification made to the coverage provided under the policy or certificate.
(b) Inform each policyholder or certificate holder of the date on which any adjustment of premiums is to be made because of changes in Medicare.
(c) Be in outline form and in clear and simple terms so as to facilitate comprehension.
(d) Be in a format which is acceptable to the Commissioner.
2. The notice must not contain or be accompanied by any solicitation.
3. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.269 Notice required that certain policies of insurance are not supplementary to Medicare; disclosure of extent to which policy or certificate duplicates coverage of Medicare. (NRS 679B.130, 687B.430)
1. An insurer that delivers or issues for delivery in this State:
(a) An insurance policy that provides coverage for accidents or sickness, including a policy to provide income in case of a disability, other than a policy to supplement Medicare;
(b) A policy of insurance issued pursuant to a contract under section 1876 of the Social Security Act, 42 U.S.C. §§ 1395 et seq.; or
(c) A policy of insurance identified in subsection 2 of NAC 687B.205,
Ê to a person who is eligible for Medicare shall give notice to the insureds under the policy that the policy is not a policy to supplement Medicare.
2. Such notice must be:
(a) Printed on or attached to the first page of the outline of coverage delivered to the insureds under the policy or, if an outline of coverage is not delivered to the insureds, to the first page of the policy or certificate delivered to the insureds.
(b) In not less than 12-point type and contain the following language:
THIS (POLICY OR CERTIFICATE) IS NOT A (POLICY OR CONTRACT) TO SUPPLEMENT MEDICARE. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare which is available from the insurance company.
3. Applications for the health insurance policies or certificates described in subsection 1 provided to persons eligible for Medicare must disclose on the appropriate statement developed by the National Association of Insurance Commissioners and approved by the Commissioner the extent to which the health insurance policy or certificate duplicates the coverage of Medicare. The disclosure must be provided as part of or together with the application for the policy or certificate.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96)
NAC 687B.273 Standards of practice for marketing. (NRS 679B.130, 687B.430)
1. An issuer, directly or through its producers, shall:
(a) Establish marketing procedures to ensure that any comparison of policies to supplement Medicare by its agents or other producers is fair and accurate.
(b) Establish marketing procedures to ensure that excessive insurance is not sold or issued.
(c) Establish marketing procedures which set forth a mechanism or formula for determining whether a replacement policy or certificate contains benefits clearly and substantially greater than the benefits under the replaced policy.
(d) Display prominently by type, stamp or other appropriate means, on the first page of the policy to supplement Medicare the following notice:
“Notice to buyer: This policy may not cover all of your medical expenses.”
(e) Inquire and otherwise make every reasonable effort to determine whether a prospective applicant or person enrolled for a policy to supplement Medicare has accident and sickness insurance and identify the types and amounts of any such insurance.
(f) Establish procedures that may be audited for verifying compliance with this section.
2. In addition to the practices prohibited in chapters 686A of NRS and NAC, the following practices are prohibited:
(a) Knowingly making any misleading representation or incomplete or fraudulent comparison of any policies of insurance or issuers to induce or tend to induce any person to allow to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any policy of insurance or to take out a policy of insurance with another issuer, commonly referred to as “twisting.”
(b) High-pressure tactics, including:
(1) Any method of marketing that has the effect of or tends to induce the purchase of insurance through force, fright or threat, whether explicit or implied; and
(2) Undue pressure to purchase or recommend the purchase of insurance.
(c) Directly or indirectly making use of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is the solicitation of insurance and that contact will be made by an agent or insurance company, commonly referred to as “cold lead advertising.”
(d) Using the terms “Medicare Supplement,” “Medigap,” “Medicare Wrap-Around” or words of similar import in a policy to supplement Medicare or a certificate if the policy or certificate does not comply with the provisions of NAC 687B.200 to 687B.330, inclusive.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92)
NAC 687B.275 Compensation of agents and other representatives and producers. (NRS 679B.130, 687B.430)
1. An issuer or other entity may provide a commission or other compensation to an agent or other representative for the sale of a policy to supplement Medicare or a certificate only if the commission or other compensation for the first year is no more than 200 percent of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period.
2. The commission or other compensation provided in a subsequent renewal year must be:
(a) The same as that provided in the second year or period; and
(b) Provided for not less than 5 renewal years.
3. An issuer or other entity shall not provide to its agents or other producers, and an agent or producer shall not accept, compensation that is greater than the compensation for renewal that would have been paid by the replacing issuer on a renewal policy to supplement Medicare or a certificate if the existing policy or certificate is replaced.
4. As used in this section, “compensation” includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy to supplement Medicare or the certificate, including, but not limited to, any bonus, gift, prize, award or finders fee.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92)
NAC 687B.280 Review of proposed advertising. (NRS 679B.130, 687B.430) Each issuer shall furnish the Division, for its review, with a copy of any advertisement for a policy to supplement Medicare which is intended for use in this State, including any written, radio, television or newspaper advertisement.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 5-27-92; 7-16-92, eff. 7-30-92)
NAC 687B.282 Recommendations for purchase or replacement; sale of multiple policies or certificates; issuance of policy or certificate to person enrolled in Medicare Part C. (NRS 679B.130, 687B.430)
1. If an agent recommends the purchase or replacement of any policy to supplement Medicare or certificate, the agent shall make reasonable efforts to determine the appropriateness of the recommended purchase or replacement.
2. Any sale of a policy to supplement Medicare or a certificate that provides a person with more than one policy to supplement Medicare or certificate is prohibited.
3. An issuer shall not issue a policy to supplement Medicare or certificate to a person enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the person’s Part C coverage.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.283 Annual reporting of multiple policies or certificates. (NRS 679B.130, 687B.430)
1. On or before May 31 of each year, an issuer shall report the number of the policy, the certificate number and the date of issuance for each resident of this State for whom the issuer has in force more than one policy to supplement Medicare or certificate. The report must include all this information for each individual policyholder in a format prescribed by the Commissioner.
2. The provisions of this section apply to an issuer of a policy to supplement Medicare delivered or issued for delivery in this State, regardless of the date the policy was delivered or issued for delivery.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92; R081-16, 11-2-2016)
NAC 687B.286 Compliance with certain provisions of Social Security Act regarding notice and payment of claims. (NRS 679B.130, 687B.430)
1. An issuer shall comply with the provisions of section 1882(c)(3) of the Social Security Act, 42 U.S.C. §§ 1395 et seq., as enacted by section 4081(b)(2)(c) of the Omnibus Budget Reconciliation Act of 1987, Public Law No. 100-203, by:
(a) Accepting a notice from a Medicare carrier on an assigned claim submitted by a participating physician or supplier as a claim for benefits in lieu of any other claim form otherwise required;
(b) Making a determination for payment on the basis of the information contained in that notice;
(c) Notifying the participating physician or supplier and the beneficiary of the determination for payment;
(d) Paying the participating physician or supplier directly;
(e) Furnishing each enrollee, at the time of enrollment, with a card listing the name and number of the policy and a central mailing address to which notices from a Medicare carrier may be sent;
(f) Paying the user fees for claim notices that are transmitted electronically or otherwise; and
(g) Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.
2. Compliance with the requirements set forth in subsection 1 must be certified on the form for reporting experience incurred for policies to supplement Medicare and certificates which is prescribed by the Commissioner.
3. The provisions of this section apply to an issuer of a policy to supplement Medicare or a certificate which is delivered or issued for delivery in this State, regardless of the date the policy or certificate was delivered or issued for delivery.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
Standardized Benefit Plans
NAC 687B.290 Availability; minimum benefits. (NRS 679B.130, 687B.430)
1. An issuer who delivers or issues for delivery in this State a policy to supplement Medicare or a certificate on or after July 30, 1992, and with an effective date for coverage before June 1, 2010, shall make available to each prospective insured a policy or certificate that provides only the following benefits:
(a) Coverage of Medicare Part A eligible expenses for hospitalization to the extent they are not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
(b) Coverage of Medicare Part A eligible expenses incurred for hospitalization to the extent they are not covered by Medicare for each Medicare lifetime inpatient reserve day used.
(c) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days.
(d) Plans A to J, inclusive, provide coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations. Plans K and L provide for 50 percent and 75 percent, respectively, of the reasonable cost for the first 3 pints of blood.
(e) Coverage for the coinsurance amount of Medicare eligible expenses under Part B regardless of confinement in a hospital, subject to the Medicare Part B deductible.
2. In addition to the benefits required by subsection 1, an issuer may make available to prospective insureds any other 1990 standardized benefit plans to supplement Medicare as set forth in NAC 687B.295 to 687B.323, inclusive.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.295 General requirements. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in NAC 687B.330, a standardized benefit plan to supplement Medicare may not be delivered or issued for delivery in this State on or after July 30, 1992, and with an effective date for coverage before June 1, 2010, unless it complies with the provisions of NAC 687B.300 to 687B.323, inclusive.
2. Except as otherwise provided in subsection 4, a 1990 standardized benefit plan must:
(a) Have the same style, arrangement, overall content and designation as the 1990 standardized benefit plans set forth in NAC 687B.300 to 687B.323, inclusive.
(b) Conform to the definitions set forth in NAC 687B.2002 to 687B.2045, inclusive.
3. Each benefit for a 1990 standardized benefit plan must be structured in accordance with the format and listed in the order indicated in NAC 687B.300 to 687B.323, inclusive.
4. In addition to the designations for 1990 standardized benefit plans set forth in NAC 687B.300 to 687B.323, inclusive, an issuer may use other designations if he or she obtains the prior approval of the Commissioner.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R110-98, 2-23-99; R049-09, 10-27-2009)
NAC 687B.300 Standardized Benefit Plan A. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan A must be limited to the benefits required by NAC 687B.290.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R049-09, 10-27-2009)
NAC 687B.302 Standardized Benefit Plan B. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan B must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R049-09, 10-27-2009)
NAC 687B.304 Standardized Benefit Plan C. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan C must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage for all of the Medicare Part B deductible amount per calendar year, regardless of whether the insured has been confined in a hospital.
5. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R049-09, 10-27-2009)
NAC 687B.306 Standardized Benefit Plan D. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan D must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
5. Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his or her home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R049-09, 10-27-2009)
NAC 687B.308 Standardized Benefit Plan E. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan E must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
5. Coverage for the following preventative health services for the actual amount charged for each service not to exceed 100 percent of the amount approved by Medicare for that service, as identified in the American Medical Association’s Current Procedural Terminology (AMA CPT) codes, not to exceed $120 per year, and to the extent not covered by Medicare:
(a) An annual clinical medical history and physical examination that may include the tests and services set forth in paragraph (b) and educational services that address measures to be taken for preventative health care.
(b) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96; R110-98, 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.311 Standardized Benefit Plan F or High Deductible Benefit Plan F. (NRS 679B.130, 687B.430)
1. A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan F or High Deductible Benefit Plan F must provide the following benefits:
(a) The benefits required by NAC 687B.290.
(b) Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
(c) For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
(d) Coverage for all of the Medicare Part B deductible amount per calendar year, regardless of whether the insured has been confined in a hospital.
(e) Coverage for 100 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
(f) Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this paragraph, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
2. In addition to the requirements of subsection 1, a 1990 standardized benefit plan to supplement Medicare which is designated as High Deductible Benefit Plan F must require the insured to pay an annual deductible. The annual deductible for High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to NAC 687B.250 must specify the current amount of the deductible. The annual deductible for High Deductible Benefit Plan F may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. The deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; R049-09, 10-27-2009)
NAC 687B.313 Standardized Benefit Plan G. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan G must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage for 80 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
5. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
6. Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his or her home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R049-09, 10-27-2009)
NAC 687B.315 Standardized Benefit Plan H. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan H must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. For plans sold or issued before January 1, 2006, as a basic benefit, coverage is provided for 50 percent of the charges for prescription drugs received as an outpatient, after payment of a deductible of $250 per calendar year, not to exceed $1,250 in benefits received by the insured per calendar year, and to the extent not covered by Medicare. This subsection only applies to those persons currently covered by Plan H and who do not apply for Medicare Part D.
5. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.317 Standardized Benefit Plan I. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan I must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage for 100 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
5. For plans sold or issued before January 1, 2006, as a basic benefit, coverage is provided for 50 percent of the charges for prescription drugs received as an outpatient, after payment of a deductible of $250 per calendar year, not to exceed $1,250 in benefits received by the insured per calendar year, to the extent not covered by Medicare. This subsection only applies to those persons currently covered by Plan I and who do not apply for Medicare Part D.
6. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
7. Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his or her home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.319 Standardized Benefit Plan J or High Deductible Benefit Plan J. (NRS 679B.130, 687B.430)
1. A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan J or High Deductible Benefit Plan J must provide the following benefits:
(a) The benefits required by NAC 687B.290.
(b) Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
(c) For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
(d) Coverage for all of the Medicare Part B deductible amount per calendar year, regardless of whether the insured has been confined in a hospital.
(e) Coverage for 100 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
(f) For plans sold or issued before January 1, 2006, as an extended benefit, coverage is provided for 50 percent of the charges for prescription drugs received as an outpatient, after payment of a deductible of $250 per calendar year, not to exceed $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare. This paragraph only applies to those persons currently covered by Plan J and who do not apply for Medicare Part D.
(g) Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this paragraph, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
(h) Coverage for the following preventative health services for the actual amount charged for each service not to exceed 100 percent of the amount approved by Medicare for that service, as identified in the American Medical Association’s Current Procedural Terminology (AMA CPT) codes, not to exceed $120 per year, to the extent not covered by Medicare:
(1) An annual clinical medical history and physical examination that may include the tests and services set forth in subparagraph (2) and educational services that address measures to be taken for preventative health care.
(2) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.
(i) Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his or her home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
2. In addition to the requirements of subsection 1, a 1990 standardized benefit plan to supplement Medicare which is designated as High Deductible Benefit Plan J must require the insured to pay an annual deductible. The annual deductible for High Deductible Benefit Plan J is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to NAC 687B.250 must specify the current amount of the deductible. The annual deductible for High Deductible Benefit Plans F and J may be adjusted annually by the Secretary of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. The deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.320 Standardized Benefit Plan K. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan K must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subsection 8.
3. Coverage for 50 percent of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subsection 8.
4. Coverage for 50 percent of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation is met as described in subsection 8.
5. Coverage for 50 percent, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations, until the out-of-pocket limitation is met as described in subsection 8.
6. Except for coverage provided in subsection 8, coverage for 50 percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subsection 8.
7. Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible.
8. Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the person has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of Health and Human Services.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.321 Standardized Benefit Plan L. (NRS 679B.130, 687B.430) A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan L must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for 75 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subsection 8.
3. Coverage for 75 percent of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subsection 8.
4. Coverage for 75 percent of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation is met as described in subsection 8.
5. Coverage for 75 percent, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations, until the out-of-pocket limitation is met as described in subsection 8.
6. Except for coverage provided in subsection 8, coverage for 75 percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subsection 8.
7. Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible.
8. Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the person has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $2,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of Health and Human Services.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)
NAC 687B.322 Standards for policies to supplement Medicare or certificates effective on or after June 1, 2010. (NRS 679B.130, 687B.430)
1. In addition to the standards set forth in NAC 687B.323, the standards provided for in this section are:
(a) Applicable to all policies to supplement Medicare or certificates delivered or issued for delivery in this State with an effective date for coverage on or after June 1, 2010; and
(b) Not applicable to policies to supplement Medicare or certificates delivered or issued for delivery in this State with an effective date for coverage before June 1, 2010.
2. On or after June 1, 2010, the following standards apply to policies to supplement Medicare and certificates and are in addition to all other requirements:
(a) A policy to supplement Medicare or a certificate must not:
(1) Exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because of a preexisting condition.
(2) Define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
(3) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.
(b) A policy to supplement Medicare or a certificate must provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment or coinsurance amounts. Premiums may be modified to correspond with such changes.
(c) No policy to supplement Medicare or certificate may provide for the termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premiums.
(d) A policy to supplement Medicare must be guaranteed renewable and:
(1) The issuer shall not cancel or fail to renew the policy solely because of the health status of the person.
(2) The issuer shall not cancel or fail to renew the policy for any other reason than the nonpayment of premiums or for a material misrepresentation.
(e) If a policy to supplement Medicare is terminated by the group policyholder and is not replaced as provided under paragraph (g), the issuer shall offer to each certificate holder an individual policy to supplement Medicare which, at the option of the certificate holder:
(1) Provides for the continuation of the benefits contained in the group policy; or
(2) Provides benefits that otherwise meet the requirements of this subsection.
(f) If a person is a certificate holder in a group policy to supplement Medicare and the person terminates membership in the group, the issuer shall:
(1) Offer the certificate holder the conversion opportunity described in paragraph (e); or
(2) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.
(g) If a group policy to supplement Medicare is replaced by another group policy to supplement Medicare which is purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage under the new policy must not result in the exclusion of coverage for preexisting conditions that would have been covered under the group policy being replaced.
(h) Termination of a policy to supplement Medicare or a certificate must be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be conditioned upon the continuous total disability of the insured, and limited to the duration of the policy benefit period, if any, or to the payment of the maximum benefits. The receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
(i) A policy to supplement Medicare or a certificate must provide that benefits and premiums under the policy or certificate must be suspended at the request of the policyholder or certificate holder for the period, not to exceed 24 months, during which the policyholder or certificate holder has applied for and is determined to be eligible for medical assistance under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the person becomes eligible for such assistance. If benefits or premiums are suspended and the policyholder or certificate holder loses eligibility for such medical assistance, the policy or certificate must be automatically reinstated effective as of the date eligibility is terminated if the policyholder or certificate holder provides notice of loss of eligibility to the insurer within 90 days after the date of loss and pays the premium attributable to the period of eligibility.
(j) A policy to supplement Medicare or a certificate must provide that benefits and premiums under the policy must be suspended at the request of the policyholder for any period that may be provided by federal regulation if the policyholder is entitled to benefits under section 226(b) of the Social Security Act, 42 U.S.C. § 426(b), and is covered under a group health plan as defined in section 1862(b)(1)(A)(v) of the Social Security Act, 42 U.S.C. § 1395y(b)(1)(A)(v). If benefits and premiums are suspended and the policyholder or certificate holder loses coverage under the group health plan, the policy must be automatically reinstated, effective as of the date of loss of coverage if the policyholder provides notice of loss of coverage within 90 days after the date of the loss and pays the premium attributable to the period.
(k) Reinstatement of coverage as described in paragraphs (i) and (j):
(1) Must not provide for any waiting period with respect to treatment of preexisting conditions;
(2) Must provide for resumption of coverage that is substantially equivalent to the coverage in effect before the premiums and benefits were suspended; and
(3) Must provide for the classification of premiums on terms at least as favorable to the policyholder or certificate holder as the terms in effect before the benefits and premiums were suspended.
3. On or after June 1, 2010, every issuer shall make available a policy or certificate which includes a basic core package of benefits to each prospective insured, but an issuer may make available to prospective insureds any of the other benefit plans to supplement Medicare in addition to, but not in lieu of, the basic core package. The basic core package of benefits must consist of:
(a) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
(b) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used.
(c) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days, and the provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance.
(d) Coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations.
(e) Coverage for the coinsurance amount, or, in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.
(f) Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.
4. On or after June 1, 2010, the following additional benefits must be included in Standardized Benefit Plans B, C, D, F, F with High Deductible, G, M and N to supplement Medicare as provided by NAC 687B.323:
(a) Coverage for 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;
(b) Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;
(c) Coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A;
(d) Coverage for 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;
(e) Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Part B charge approved by Medicare; and
(f) Coverage to the extent not covered by Medicare for 80 percent of the billed charges for Medicare eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this paragraph, “emergency care” means care needed immediately because of an injury or an illness of sudden and unexpected onset.
(Added to NAC by Comm’r of Insurance by R049-09, eff. 10-27-2009)
NAC 687B.323 Requirements regarding policies to supplement Medicare or certificates effective on or after June 1, 2010. (NRS 679B.130, 687B.430)
1. In addition to the standards set forth in NAC 687B.322, the standards provided for in this section are:
(a) Applicable to all policies to supplement Medicare or certificates delivered or issued for delivery in this State with an effective date for coverage on or after June 1, 2010; and
(b) Not applicable to policies to supplement Medicare or certificates delivered or issued for delivery in this State with an effective date for coverage before June 1, 2010.
2. On or after June 1, 2010, an issuer shall make available to each prospective policyholder or certificate holder a policy form or certificate form containing only the basic core benefits, as set forth in subsection 3 of NAC 687B.322.
3. On or after June 1, 2010, if an issuer makes available any of the additional benefits set forth in subsection 4 of NAC 687B.322, or offers Standardized Benefit Plan K or L as described in paragraphs (h) and (i) of subsection 7, the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic core benefits as described in subsection 2, a policy form or certificate form containing either Standardized Benefit Plan C as described in paragraph (c) of subsection 7 or Standardized Benefit Plan F as described in paragraph (e) of subsection 7.
4. On or after June 1, 2010, no group, package or combinations of benefits to supplement Medicare other than those listed in this section may be offered for sale in this State, except as may be permitted in subsection 8 and in NAC 687B.340 to 687B.376, inclusive.
5. On or after June 1, 2010, a benefit plan must be uniform in structure, language, designation and format to the standardized benefit plans listed in this section and must conform to the definition in NAC 687B.2003. Each benefit must be structured in accordance with the format provided in subsections 3 and 4 of NAC 687B.322 or, in the case of Standardized Benefit Plan K or L, in paragraphs (h) and (i) of subsection 7, and list the benefits in the order shown in the applicable requirements.
6. On or after June 1, 2010, and in addition to the benefit plans required in subsection 5, an issuer may use other designations to the extent permitted by law.
7. On or after June 1, 2010, the contents of standardized benefit plans must be as follows:
(a) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan A must include only the basic core benefits as defined in subsection 3 of NAC 687B.322.
(b) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan B must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible as defined in paragraph (a) of subsection 4 of NAC 687B.322.
(c) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan C must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c), (d) and (f) of subsection 4 of NAC 687B.322, respectively.
(d) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan D must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c) and (f) of subsection 4 of NAC 687B.322, respectively.
(e) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan F must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, the skilled nursing facility care, 100 percent of the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c), (d), (e) and (f) of subsection 4 of NAC 687B.322, respectively.
(f) A 2010 standardized benefit plan to supplement Medicare which is designated as High Deductible Benefit Plan F:
(1) Must include only 100 percent of covered expenses following the payment of the annual deductible set forth in subparagraph (2) and the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c), (d), (e) and (f) of subsection 4 of NAC 687B.322, respectively; and
(2) Has an annual deductible that:
(I) Must consist of out-of-pocket expenses, other than premiums, for services covered by Standardized Benefit Plan F.
(II) Must be in addition to any other specific benefit deductibles; and
(III) Has a base which must be $1,500 and must be adjusted annually from 1999 by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.
(g) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan G must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c), (e) and (f) of subsection 4 of NAC 687B.322, respectively.
(h) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan K is mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, and must include:
(1) Coverage of 100 percent of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
(2) Coverage of 100 percent of the Medicare Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
(3) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days, and the provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance;
(4) Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph (10);
(5) Coverage for 50 percent of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subparagraph (10);
(6) Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph (10);
(7) Coverage for 50 percent, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations, until the out-of-pocket limitation is met as described in subparagraph (10);
(8) Except for coverage provided in subparagraph (9), coverage for 50 percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subparagraph (10);
(9) Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
(10) Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the person has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the United States Department of Health and Human Services.
(i) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan L is mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, and must include only the following:
(1) The benefits described in subparagraphs (1), (2), (3) and (9) of paragraph (h);
(2) The benefits described in subparagraphs (4) to (8), inclusive, of paragraph (h), but substituting 75 percent for 50 percent; and
(3) The benefit described in subparagraph (10) of paragraph (h), but substituting $2,000 for $4,000.
(j) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan M must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 50 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs (b), (c) and (f) of subsection 4 of NAC 687B.322, respectively.
(k) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan N must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c) and (f) of subsection 4 of NAC 687B.322, respectively, with coinsurance or copayments in the following amounts:
(1) The lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit, including visits to medical specialists; and
(2) The lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit. This coinsurance or copayment must be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
8. On or after June 1, 2010, an issuer may, with the prior approval of the Commissioner, offer a policy to supplement Medicare or a certificate with new or innovative benefits in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards, and:
(a) The new or innovative benefits must include only benefits that are appropriate to insurance to supplement Medicare, are new or innovative, are not otherwise available and are cost-effective;
(b) Approval of new or innovative benefits must not adversely impact the goal of simplifying policies to supplement Medicare;
(c) New or innovative benefits must not include an outpatient prescription drug benefit; and
(d) New or innovative benefits must not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized benefit plan.
9. As used in this section, “structure, language, designation and format” means style, arrangement and overall content of a benefit.
(Added to NAC by Comm’r of Insurance by R049-09, eff. 10-27-2009)
NAC 687B.325 Coverage for short-term services provided to person recovering at home. (NRS 679B.130, 687B.430)
1. For a 1990 standardized benefit plan, coverage for short-term services provided to a person recovering from an illness, injury or surgery in his or her home must comply with the following requirements:
(a) The insured’s attending physician must certify that the specific type and frequency of recovery services provided at home are necessary because of a condition for which a plan of treatment provided at home was approved by Medicare.
(b) Coverage must be limited to:
(1) No more than the number and type of recovery visits certified as necessary by the insured’s attending physician. The total number of recovery visits may not exceed the number of visits approved by Medicare pursuant to a plan of treatment provided at home that has been approved by Medicare.
(2) The actual charges for each recovery visit not to exceed a maximum reimbursement of $40 per visit.
(3) A maximum reimbursement of $1,600 per calendar year.
(4) Seven visits in any 1 week.
(5) Care furnished on a visiting basis in the insured’s home.
(6) Services provided by a provider of health care.
(7) Recovery visits received:
(I) While the insured is covered under the policy to supplement Medicare or the certificate and not otherwise excluded.
(II) During the period the insured is receiving services at home which are approved by Medicare or no later than 8 weeks after the date of the last recovery visit approved by Medicare.
(c) Coverage must be excluded for:
(1) Recovery visits paid for by Medicare or another governmental program.
(2) Care provided by members of the insured’s family, unpaid volunteers or other persons who are not providers of health care.
2. As used in this section:
(a) “Home” means any location used by the insured as a place of residence if that location would qualify as a residence for health care services provided at home which are covered by Medicare. The term does not include a hospital or skilled nursing facility.
(b) “Provider of health care” means a qualified or licensed aide or homemaker who provides health care in the home, an aide who provides personal care or a nurse provided through a licensed agency for home health care or referred by a licensed referral agency or licensed registry for nurses.
(c) “Recovery visit” means a visit required to provide care to the insured at home, without a limit on the duration of the visit, except each consecutive 4 hours of services in a 24-hour period is one visit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R049-09, 10-27-2009)
NAC 687B.330 Provision of new or innovative benefits. (NRS 679B.130, 687B.430)
1. An issuer may, with the prior approval of the Commissioner, offer a policy to supplement Medicare or a certificate with new or innovative benefits in addition to the benefits required by NAC 687B.290 to 687B.321, inclusive. The new or innovative benefits may include benefits that are:
(a) Appropriate to supplement Medicare;
(b) Not otherwise available;
(c) Cost-effective; and
(d) Offered in a manner that is consistent with the goal of simplifying policies to supplement Medicare.
2. After December 31, 2005, an innovative benefit must not include an outpatient prescription drug benefit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
Medicare Select Policies and Certificates
NAC 687B.340 Definitions. (NRS 679B.130, 687B.430) As used in NAC 687B.340 to 687B.376, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.342 to 687B.354, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.342 “Complaint” defined. (NRS 679B.130, 687B.430) “Complaint” means any dissatisfaction with a Medicare select issuer or a network provider expressed by a holder of a Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.344 “Grievance” defined. (NRS 679B.130, 687B.430) “Grievance” means any dissatisfaction with the administration, claims practices or provision of services of a Medicare select issuer or a network provider that is expressed in writing by a holder of a Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.346 “Medicare select issuer” defined. (NRS 679B.130, 687B.430) “Medicare select issuer” means an issuer who is offering or seeking to offer a Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.348 “Medicare select policy” and “Medicare select certificate” defined. (NRS 679B.130, 687B.430) “Medicare select policy” or “Medicare select certificate” means a policy or certificate to supplement Medicare that contains a provision for a restricted network.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.350 “Network provider” defined. (NRS 679B.130, 687B.430) “Network provider” means a provider of health care or a group of providers of health care that has entered into a written agreement with a Medicare select issuer to provide benefits insured under a Medicare select policy.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.352 “Provision for a restricted network” defined. (NRS 679B.130, 687B.430) “Provision for a restricted network” means a provision of a policy or certificate to supplement Medicare that conditions the payment of benefits, in whole or in part, on the use of network providers.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.354 “Service area” defined. (NRS 679B.130, 687B.430) “Service area” means the geographic area approved by the Commissioner within which a Medicare select issuer is authorized to offer a Medicare select policy.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.356 Compliance with regulations required before advertising. (NRS 679B.130, 687B.430) No policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requirements of NAC 687B.200 to 687B.376.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.358 Authorization to offer and approval to issue. (NRS 679B.130, 687B.430)
1. The Commissioner may authorize an issuer to offer a Medicare select policy or certificate, pursuant to NAC 687B.340 to 687B.376, inclusive, and section 4358 of the Omnibus Budget Reconciliation Act of 1990, 42 U.S.C. § 1395ss(t), if the Commissioner:
(a) Determines that the issuer has satisfied all of the requirements of NAC 687B.200 to 687B.376; and
(b) Approves the issuer’s plan of operation.
2. An issuer may not issue a Medicare select policy or certificate in this State until the Commissioner has approved its plan of operation.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.360 Filing and contents of proposed plan of operation. (NRS 679B.130, 687B.430) A Medicare select issuer shall file a proposed plan of operation with the Commissioner which must include:
1. Evidence that all services covered under the policy that are subject to a provision for a restricted network are available and accessible through network providers, including evidence that:
(a) Such services are available from network providers with reasonable promptness with respect to geographic location, hours of operation during regular business hours and hours of operation after regular business hours. The reasonableness of hours of operation and availability must be based on the usual practice in the local area. The reasonableness of the geographic location must be based on average travel times within the community.
(b) The number of network providers in the service area is sufficient in relation to the number of current and expected policyholders and certificate holders to:
(1) Deliver adequately services that are subject to a provision for a restricted network; or
(2) Make appropriate referrals.
(c) The Medicare select issuer has executed written agreements with network providers that describe the specific responsibilities of those providers.
(d) Emergency care is available 24 hours a day and 7 days a week.
(e) For such services that are provided on a prepaid basis, the Medicare select issuer has executed written agreements with network providers that prohibit such providers from billing or otherwise seeking additional reimbursement or recourse against any policyholder or certificate holder, other than seeking collection of supplemental charges or coinsurance payments that are required under the Medicare select policy or certificate.
2. A statement or map providing a clear description of the service area.
3. A description of the procedure that will be utilized for addressing grievances.
4. A description of the program that will be utilized for quality assurance, including details regarding:
(a) The formal organizational structure of the program;
(b) The written criteria for selecting, retaining and removing network providers;
(c) The procedure for evaluating the quality of care provided by network providers; and
(d) The process used for initiating corrective action when warranted.
5. A list and description of the network providers, categorized by their specialties.
6. Copies of the written information, including the contracts and written agreements executed between the Medicare select issuer and the network providers, proposed to be used by the Medicare select issuer to ensure that all services covered under the policy that are subject to a provision for a restricted network are available and accessible through a network provider.
7. Any other information requested by the Commissioner.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.362 Proposed changes to plan of operation; update of list of network providers. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall file any proposed changes to the plan of operation, other than changes to the list of network providers, with the Commissioner before implementing the changes. If the Commissioner does not approve or disapprove the proposed changes within 30 days after their receipt, the changes shall be deemed approved.
2. A Medicare select issuer shall file an updated list of network providers with the Commissioner every 3 months.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.364 Payment for covered services provided by persons other than network providers. (NRS 679B.130, 687B.430) A Medicare select policy or certificate must not restrict payment for services covered under the policy that are provided by persons other than network providers if:
1. The services were for symptoms requiring emergency care or for symptoms of an unforeseen illness or condition requiring immediate attention; or
2. It was not reasonable to obtain the services through a network provider.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.366 Full payment required for covered services not available through network provider. (NRS 679B.130, 687B.430) A Medicare select policy or certificate must provide full payment for services covered under the policy that are not available through a network provider.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.368 Written disclosure of provisions, restrictions and limitations. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall disclose in writing the provisions, restrictions and limitations of the Medicare select policy or certificate to each applicant. The disclosure must include:
(a) An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate with:
(1) Other policies or certificates to supplement Medicare offered by the Medicare select issuer; and
(2) Other Medicare select policies.
(b) A description of the primary care physicians, specialty physicians, hospitals and other network providers, including their addresses, phone numbers and hours of operation.
(c) A description of the provisions for a restricted network, including those provisions addressing payments for coinsurance and deductibles when providers other than network providers are utilized. Except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in Plans K and L.
(d) A description of coverage for emergency and urgently needed care and coverage for care provided outside the service area.
(e) A description of any limitations on referrals by network providers to persons other than network providers.
(f) A description of the policyholder’s or certificate holder’s rights to purchase other policies or certificates to supplement Medicare that the Medicare select issuer offers.
(g) A description of the program for quality assurance and the procedure for addressing grievances that the Medicare select issuer utilizes.
2. Before the sale of a Medicare select policy or certificate, a Medicare select issuer must obtain from the applicant a signed and dated form stating that the applicant has received the written disclosure required by subsection 1 and that the applicant understands the restrictions of the Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.370 Procedures for hearing complaints and resolving grievances; annual report regarding grievance procedure. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall have written procedures for hearing complaints and resolving written grievances made by policyholders and certificate holders under a Medicare select policy or certificate. The procedures may include the utilization of arbitration if the Medicare select issuer and the policyholder or certificate holder or the policyholder’s or certificate holder’s spouse mutually agree to use it.
2. The procedure for addressing grievances must be described in all policies and certificates and in the outline of coverage provided to applicants for coverage pursuant to NAC 687B.368.
3. The Medicare select issuer shall provide detailed information to the policyholder or certificate holder at the time the policy or certificate is issued that describes how to file a grievance with the Medicare select issuer.
4. The Medicare select issuer shall begin evaluating a grievance filed with it within 10 working days after the filing date by transmitting the grievance to the person who has authority to investigate the issue fully and take corrective action to address it.
5. If a grievance is found to be valid, corrective action must commence within 48 hours after the determination or within 72 hours after the determination if a holiday occurs within the 48-hour period.
6. All concerned parties must be notified of the determination made with regard to the grievance.
7. The Medicare select issuer shall report to the Commissioner on or before May 31 of each year regarding its grievance procedure. The report must be submitted in a format prescribed by the Commissioner and must contain the number of grievances filed in the past year and a summary of the nature and resolution of those grievances.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by R081-16, 11-2-2016)
NAC 687B.372 Availability of certain policies and certificates offered by Medicare select issuer. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall offer to each applicant for a Medicare select policy or certificate, at the time of initial purchase, the opportunity to purchase any policies or certificates to supplement Medicare that the Medicare select issuer offers.
2. Upon request by a policyholder or certificate holder, a Medicare select issuer shall make available the opportunity to purchase a different policy or certificate to supplement Medicare offered by the Medicare select issuer which has comparable or lesser benefits and which does not contain a provision for a restricted network. The Medicare select issuer shall make such policies or certificates available without requiring evidence of insurability if the person has been a policyholder or certificate holder for 6 months or more.
3. For the purposes of this section, a policy or certificate to supplement Medicare will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare select policy or certificate being replaced. For the purposes of this subsection, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Medicare Part B excess charges.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.374 Provision for continuation of coverage; availability of policies to supplement Medicare as continuation of coverage. (NRS 679B.130, 687B.430)
1. Medicare select policies and certificates must provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare select policies and certificates issued pursuant to NAC 687B.340 to 687B.376, inclusive, must be discontinued because the Medicare select program has not been reauthorized by Congress or because the statutory authority for the program has been substantially amended.
2. If the Secretary of Health and Human Services makes such a determination, each Medicare select issuer shall make available to each policyholder and certificate holder the opportunity to purchase any policy to supplement Medicare offered by the Medicare select issuer which has comparable or lesser benefits and which does not contain a provision for a restricted network. The Medicare select issuer shall make such policies and certificates available without requiring evidence of insurability.
3. For the purposes of this section, a policy to supplement Medicare will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare select policy or certificate being replaced. For the purpose of this subsection, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.376 Compliance with requests for data for evaluation of Medicare select program. (NRS 679B.130, 687B.430) A Medicare select issuer shall comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare select program.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
REQUIREMENTS FOR DELIVERY
NAC 687B.405 Delivery of certificates to policyholder of group insurance. (NRS 679B.130, 688B.110, 689B.090) All companies and all resident or nonresident agents or brokers doing group life insurance or group accident and health insurance business in Nevada must provide for delivery to the policyholder of the individual certificates required by NRS 688B.110, 689B.090 and 690A.070. Each company, agent and broker shall use his or her best efforts to see that policyholders distribute those certificates of insurance to all debtors, members or employees afforded coverage under the policy.
[Comm’r of Insurance, part M-5, eff. 5-13-72] — (Substituted in revision for NAC 687B.110)
NAC 687B.415 Delivery of other policies, memoranda or certificates of insurance. (NRS 679B.130)
1. Except for policies of group life or group accident and health insurance, all companies and all resident or nonresident agents and brokers shall deliver a copy of the policy or a memorandum or certificate of insurance to each insured person.
2. The memorandum or certificate of insurance must indicate the:
(a) Kind and amount of coverage;
(b) Term of the coverage;
(c) Amount of premium for each coverage provided; and
(d) Name and address of the company issuing the coverage.
3. For risks relating to a business, each insurer shall deliver the policy or memorandum or certificate of insurance to the insured within 90 days after the effective date of the policy.
[Comm’r of Insurance, part M-5, eff. 5-13-72] — (NAC A 10-30-85) — (Substituted in revision for NAC 687B.120)
CANCELLATION OF POLICIES
NAC 687B.520 Refunds to third parties. (NRS 679B.130)
1. All forms used by an agent broker, solicitor, company or any other person, partnership or corporation, for the purpose of obtaining authorization from an insured to cancel an existing insurance policy or policies, which authorize the payment of the unearned premium to anyone other than the insured, shall state in the heading or title of the form, in 14-point type or larger:
Authorization for Insurance Cancellation and Payment of Return Premium to a Third Party.
2. No form may be used for that purpose unless the title calls the attention of the insured to the fact that the insured is signing away his or her interest in the unearned premium to a third person.
[Comm’r of Insurance, PC-15, eff. 9-23-72]
NAC 687B.530 Notice to agent. (NRS 679B.130) Each insurer shall also provide a copy of the notice of cancellation of a policy to the agent who wrote the policy.
(Added to NAC by Comm’r of Insurance, eff. 10-30-85)
NOTICE OF TERMINATION TO EMPLOYEE LEASING COMPANIES
NAC 687B.550 Definitions. (NRS 679B.130) As used in NAC 687B.550 to 687B.564, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.552 to 687B.560, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.552 “Client company” defined. (NRS 679B.130) “Client company” has the meaning ascribed to it in NRS 616B.670.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.554 “Employee leasing company” defined. (NRS 679B.130) “Employee leasing company” has the meaning ascribed to it in NRS 616B.670.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.556 “Health maintenance organization” defined. (NRS 679B.130) “Health maintenance organization” has the meaning ascribed to it in NRS 695C.030.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.558 “Insurer” defined. (NRS 679B.130) “Insurer” has the meaning ascribed to it in NRS 679A.100.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.560 “Producer of insurance” defined. (NRS 679B.130) “Producer of insurance” has the meaning ascribed to it in NRS 679A.117.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.562 Disclosure of names and addresses of client companies; confidentiality. (NRS 679B.130, 687B.420)
1. Employee leasing companies applying for insurance coverage under chapter 688B, 689A, 689B, 689C, 695A, 695B, 695C, 695D or 695F of NRS shall submit the names and addresses of client companies to:
(a) Insurers or health maintenance organizations with their applications; and
(b) Producers of insurance.
2. Employee leasing companies shall update the names and addresses of client companies submitted pursuant to subsection 1 on the first business day of each month.
3. The information provided by employee leasing companies pursuant to subsections 1 and 2 is confidential.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.564 Notice of cancellation or failure to renew policy or contract. (NRS 679B.130, 687B.420)
1. An insurer or health maintenance organization shall not cancel or fail to renew a policy or contract issued to an employee leasing company pursuant to chapter 688B, 689A, 689B, 689C, 695A, 695B, 695C, 695D or 695F of NRS unless notice in writing of the termination is given to:
(a) The employee leasing company; and
(b) The client companies included on the current client company list.
2. As used in this section, “current client company list” means the most recent list of client companies provided by the employee leasing company pursuant to NAC 687B.562.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
MISCELLANEOUS POLICIES
NAC 687B.630 Health policy, contract or plan that includes grace period for payment of premiums. (NRS 679B.130, 695B.280, 695D.100, 695F.300)
1. If an insurer issues a health insurance policy or contract, health care plan, health benefit plan or plan for dental care, whether individual, group or blanket, that includes a grace period:
(a) The insurer shall not require the payment of an additional premium for the grace period. If a premium is not paid by the end of the grace period, the contract of insurance terminates retroactively to the end of the day next preceding the grace period.
(b) Except as otherwise provided in this paragraph, the insurer is not required to pay claims incurred during the grace period while a required premium remains unpaid and may seek reimbursement for any such claim erroneously paid during the grace period. The insurer is liable for any claims incurred during the grace period if the required premium payment is received during the grace period in accordance with the contract of insurance.
2. The Commissioner will, pursuant to NRS 687B.130, disapprove or withdraw the approval of any form used by an insurer which provides that, in lieu of requiring during the grace period the payment of a premium due, the insurer may deduct the premium due from the payment of a claim.
3. As used in this section:
(a) “Grace period” means the time after the date that a premium is due during which the premium can be paid without penalty to keep the policy in force.
(b) “Insurer” means any insurer that issues any health insurance policy or contract, health care plan, health benefit plan or plan for dental care, whether individual, group or blanket, and includes any:
(1) Insurance company;
(2) Carrier;
(3) Nonprofit corporation for hospital, medical or dental service;
(4) Health maintenance organization;
(5) Organization for dental care; or
(6) Prepaid limited health service organization.
(Added to NAC by Comm’r of Insurance by R009-02, eff. 5-23-2002; A by R009-02, 7-11-2002)
NAC 687B.640 Medical examination required by insurer; standard set of criteria to be applied consistently to each insured. (NRS 679B.130, 687B.450)
1. Any medical examination required by an insurer pursuant to NRS 687B.450 must follow a standard set of criteria established by the insurer for the medical examination. The standard set of criteria for the medical examination must be consistently applied to each insured.
2. As used in this section, “medical examination”:
(a) Means an examination completed by a licensed physician or by a provider of health care who is acting within the scope of his or her license and under the direct supervision of a licensed physician; and
(b) Includes, without limitation, a physical, laboratory tests, radiology or imaging tests, completion of a medical history, the taking of physical measurements, including, without limitation, height, weight or blood pressure, or an examination of the heart or other bodily systems or organs.
(Added to NAC by Comm’r of Insurance by R110-07, eff. 1-30-2008)
POLICIES THAT DUPLICATE BENEFITS PROVIDED UNDER MEDICARE
NAC 687B.700 Notice of duplication for policy which provides reimbursement upon both expense-incurred and fixed-indemnity basis. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement upon both an expense-incurred and a fixed-indemnity basis and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
· any expenses or services covered by the policy are also covered by Medicare; or
· it pays the fixed dollar amount stated in the policy and Medicare covers the same event
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice care
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, which is available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.706 Notice of duplication for certain policies which provide reimbursement in fixed dollar amounts per day. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State an indemnity policy or other policy which provides reimbursement in a fixed dollar amount per day, excluding long-term care policies, and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
· any expenses or services covered by the policy are also covered by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· outpatient prescription drugs if you are enrolled in Medicare Part D
· hospice
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.711 Notice of duplication for policy which provides reimbursement in fixed dollar amounts for specified diseases or other specified impairments. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement in fixed dollar amounts for specified diseases or other specified impairments and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.716 Notice of duplication for policy which provides reimbursement for expenses incurred for accidental injury only. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement for expenses incurred for an accidental injury only and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
· hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.720 Notice of duplication for policy which provides reimbursement for expenses incurred for specified diseases and other specified impairments. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement for expenses incurred for specified diseases and other specified impairments and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
· hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
Before You Buy This Insurance
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.725 Notice of duplication for policy which provides reimbursement for expenses incurred for specified limited services. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement for expenses incurred for specified limited services and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
· any of the services covered by the policy are also covered by Medicare
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.730 Notice of duplication for policy not described in NAC 687B.700 to 687B.725, inclusive. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance, other than a policy of insurance described in NAC 687B.700 to 687B.725, inclusive, and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance.
This insurance duplicates Medicare benefits when it pays:
· the benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.735 Payment of benefits that are covered under other policies. (NRS 679B.130) A policy of health insurance described in NAC 687B.700, 687B.720, 687B.725 or 687B.730 which provides benefits that are provided under Medicare may not be delivered or issued for delivery in this State unless the policy includes a provision that specifically states that the benefits under the policy will be provided without regard to any other policy or coverage of health insurance, including Medicare.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by R110-98, 2-23-99)
ADEQUACY OF NETWORK PLANS
NAC 687B.750 Definitions. (NRS 679B.130, 687B.490) As used in NAC 687B.750 to 687B.784, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.752 to 687B.762, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.752 “Carrier” defined. (NRS 679B.130, 687B.490) “Carrier” means an insurer that makes a network plan available for sale in this State pursuant to NRS 687B.490.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.754 “Council” defined. (NRS 679B.130, 687B.490) “Council” means the Network Adequacy Advisory Council established by NAC 687B.770.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.756 “Covered person” defined. (NRS 679B.130, 687B.490) “Covered person” means a policyholder, subscriber, enrollee or other person participating in a network plan.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.758 “Network plan” defined. (NRS 679B.130, 687B.490) “Network plan” has the meaning ascribed to it in NRS 689B.570.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.760 “Provider of health care” defined. (NRS 679B.130, 687B.490) “Provider of health care” has the meaning ascribed to it in NRS 695G.070.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.762 “Qualified health plan” defined. (NRS 679B.130, 687B.490) “Qualified health plan” has the meaning ascribed to it in NRS 695I.080.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.764 Applicability: Network plans issued by certain smaller carriers. (NRS 679B.130, 687B.490) The provisions of NAC 687B.776 to 687B.784, inclusive, do not apply during any calendar year to a network plan that:
1. Is issued by a carrier that has been authorized to transact insurance in this State pursuant to chapter 680A of NRS;
2. Had a statewide enrollment of not more than 1,000 persons during the immediately preceding calendar year;
3. Has an anticipated statewide enrollment of not more than 1,250 persons during the next succeeding calendar year; and
4. Is not a qualified health plan.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.766 Applicability: Generally. (NRS 679B.130, 687B.490) The provisions of NAC 687B.750 to 687B.784, inclusive, do not apply to:
1. A network plan issued pursuant to NRS 422.273 for the purpose of providing services through a Medicaid managed care program on behalf of the Department of Health and Human Services;
2. A network plan issued for a health benefit plan that is regulated pursuant to chapter 689B of NRS and is not available for sale to small employers, as defined in NRS 689C.095;
3. A grandfathered plan, as defined in NRS 679A.094; or
4. A plan issued pursuant to Medicare, as defined in NAC 687B.2028, or a Medicare Advantage plan, as defined in NAC 687B.2034.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.768 Requirements and standards for determining adequacy. [Effective through December 31, 2018.] (NRS 679B.130, 687B.490)
1. In order for the Commissioner to determine that a network plan made available for sale in this State is adequate, the network plan must contain, at a minimum:
(a) The standards contained in the most recent Letter to Issuers in the Federally-facilitated Marketplaces issued by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. A copy of the letter may be obtained free of charge at the Internet address https://www.cms.gov/CCIIO/resources/regulations-and-guidance/.
(b) Evidence that the network plan provides reasonable access to at least one provider in the specialty area listed in the following table for at least 90 percent of enrollees by complying with the area designations for the maximum time and distance standards in the following table:
|
Specialty Area |
Maximum Time and Distance Standards (Minutes/Miles) |
|||
|
Metro |
Micro |
Rural |
Counties with Extreme Access Considerations (CEAC) |
|
|
Pediatrics |
25/15 |
30/20 |
40/30 |
105/90 |
2. If the area designations for the maximum time and distance standards required pursuant to paragraph (b) of subsection 1 are changed by the most recent Letter to Issuers in the Federally-facilitated Marketplaces, the Commissioner will post on the Internet website maintained by the Division notice of such changes.
3. Upon the issuance of a new Letter to Issuers in the Federally-facilitated Marketplaces, the Commissioner will determine whether the requirements of NAC 687B.750 to 687B.784, inclusive, including, without limitation, the standards required pursuant to subsection 1, conform with any similar standards prescribed in the new Letter to Issuers in the Federally-facilitated Marketplaces. If the Commissioner determines that the requirements of NAC 687B.750 to 687B.784, inclusive, do not conform with any similar standards prescribed in the new Letter to Issuers in the Federally-facilitated Marketplaces, the Commissioner will hold a public hearing concerning possible amendments to NAC 687B.750 to 687B.784, inclusive, and give notice of that hearing in accordance with NRS 233B.060.
4. As used in this section, “maximum time and distance standards” has the meaning ascribed to it in the most recent Letter to Issuers in the Federally-facilitated Marketplaces.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017)
NAC 687B.768 Requirements and standards for determining adequacy. [Effective January 1, 2019.] (NRS 679B.130, 687B.490)
1. In order for the Commissioner to determine that a network plan made available for sale in this State is adequate, the network plan must contain, at a minimum:
(a) The standards contained in the most recent Letter to Issuers in the Federally-facilitated Marketplaces issued by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. A copy of the letter may be obtained free of charge at the Internet address https://www.cms.gov/CCIIO/resources/regulations-and-guidance/.
(b) Evidence that the network plan provides reasonable access to at least one provider in the specialty area listed in the following table for at least 90 percent of enrollees by complying with the area designations for the maximum time or distance standards in the following table:
|
Specialty Area |
Maximum Time or Distance Standards (Minutes/Miles) |
|||
|
Metro |
Micro |
Rural |
Counties with Extreme Access Considerations (CEAC) |
|
|
Primary Care |
15/10 |
30/20 |
40/30 |
70/60 |
|
Endocrinology |
60/40 |
100/75 |
110/90 |
145/130 |
|
Infectious Diseases |
60/40 |
100/75 |
110/90 |
145/130 |
|
Oncology - Medical/Surgery |
45/30 |
60/45 |
75/60 |
110/100 |
|
Oncology - Radiation/Radiology |
60/40 |
100/75 |
110/90 |
145/130 |
|
Mental Health (Including Substance Use Disorder Treatment) |
45/30 |
60/45 |
75/60 |
110/100 |
|
Pediatrics |
25/15 |
30/20 |
40/30 |
105/90 |
|
Rheumatology |
60/40 |
100/75 |
110/90 |
145/130 |
|
Hospitals |
45/30 |
80/60 |
75/60 |
110/100 |
|
Outpatient Dialysis |
45/30 |
80/60 |
90/75 |
125/110 |
(c) Evidence that the network plan:
(1) Contracts with at least 30 percent of the essential community providers in the service area of the network plan that are available to participate in the provider network of the network plan, as calculated using the methodology contained in the most recent Letter to Issuers in the Federally-facilitated Marketplaces.
(2) Offers contracts in good faith to all available Indian health care providers in the service area of the network plan, including, without limitation, the Indian Health Service, Indian Tribes, tribal organizations and urban Indian organizations, as defined in 25 U.S.C. § 1603, which apply the special terms and conditions necessitated by federal statutes and regulations as referenced in the Model Qualified Health Plan Addendum for Indian Health Care Providers. A copy of the Model Qualified Health Plan Addendum for Indian Health Care Providers may be obtained free of charge at the Internet address https://www.qhpcertification.cms.gov/s/ECP%20and%20Network%20Adequacy.
(3) Offers contracts in good faith to at least one essential community provider in each category of essential community provider, as contained in the most recent Letter to Issuers in the Federally-facilitated Marketplaces, in each county in the service area of the network plan, where an essential community provider in that category is available and provides medical or dental services that are covered by the network plan.
2. If the area designations for the maximum time or distance standards required pursuant to paragraph (b) of subsection 1 are changed by the most recent Letter to Issuers in the Federally-facilitated Marketplaces, the Commissioner will post on the Internet website maintained by the Division notice of such changes.
3. To offer a contract in good faith pursuant to paragraph (c) of subsection 1, a network plan must offer contract terms comparable to the terms that a carrier or other person or entity which issues a network plan would offer to a similarly situated provider which is not an essential community provider, except for terms that would not be applicable to an essential community provider, including, without limitation, because of the type of services that an essential community provider provides. A network plan must be able to provide verification of such offers if the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services requests to verify compliance with this policy.
4. Upon the issuance of a new Letter to Issuers in the Federally-facilitated Marketplaces, the Commissioner will determine whether the requirements of NAC 687B.750 to 687B.784, inclusive, including, without limitation, the standards required pursuant to subsection 1, conform with any similar standards prescribed in the new Letter to Issuers in the Federally-facilitated Marketplaces. If the Commissioner determines that the requirements of NAC 687B.750 to 687B.784, inclusive, do not conform with any similar standards prescribed in the new Letter to Issuers in the Federally-facilitated Marketplaces, the Commissioner will hold a public hearing concerning possible amendments to NAC 687B.750 to 687B.784, inclusive, and give notice of that hearing in accordance with NRS 233B.060.
5. As used in this section:
(a) “Essential community provider” has the meaning ascribed to it in the most recent Letter to Issuers in the Federally-facilitated Marketplaces.
(b) “Maximum time or distance standards” has the meaning ascribed to “maximum time and distance standards” in the most recent Letter to Issuers in the Federally-facilitated Marketplaces.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017; R002-18, 5-16-18, eff. 1-1-2019)
NAC 687B.770 Network Adequacy Advisory Council: Establishment; membership; vacancy; meetings. (NRS 679B.130, 679B.160, 687B.490)
1. The Network Adequacy Advisory Council is hereby established.
2. The Council consists of nine members appointed by the Commissioner. The members of the Council will be chosen to ensure fair representation of the interests of carriers, providers of health care and consumers of health care. The members of the Council serve at the pleasure of the Commissioner and without compensation.
3. If a vacancy occurs in the membership of the Council, the Commissioner will appoint a qualified person to fill the vacancy. The person appointed to fill the vacancy must represent interests similar to those represented by the member who is being replaced.
4. The Council shall meet at least three times each year. The first meeting of the Council must take place not later than June 15 of each year. Written notice of each meeting of the Council must be given as provided in NRS 241.020, except that the notice must be given at least 5 working days before the meeting.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016)
NAC 687B.772 Network Adequacy Advisory Council: Recommendations for additional or alternative standards for determining adequacy; determination by Commissioner; effective date of new requirements. (NRS 679B.130, 679B.160, 687B.490)
1. The Council shall consider the standards required pursuant to NAC 687B.768 and any other requirements of NAC 687B.750 to 687B.784, inclusive, and may recommend additional or alternative standards for determining whether a network plan is adequate.
2. The recommendations proposed by the Council to the Commissioner:
(a) Must include quantifiable metrics commonly used in the health care industry to measure the adequacy of a network plan;
(b) Must include, without limitation, recommendations for standards to determine the adequacy of a network plan with regard to the number of providers of health care that:
(1) Practice in a specialty or are facilities that appear on the Essential Community Providers/Network Adequacy Template issued by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services and available at the Internet address https://www.cms.gov/CCIIO/programs-and-initiatives/health-insurance-marketplaces/qhp.html free of charge, which is hereby adopted by reference; and
(2) Are necessary to provide the coverage required by law, including, without limitation, the provisions of NRS 689A.0435, 689C.1655, 695C.1717 and 695G.1645;
(c) May propose standards to determine the adequacy of a network plan with regard to types of providers of health care other than those described in paragraph (b); and
(d) May, if a sufficient number of essential community providers, as defined in 45 C.F.R. § 156.235(c), are available and willing to enter into an agreement with a carrier to participate in network plans, propose requiring a network plan to include a greater number of such providers than the number of providers of health care of that type that a network plan is required to include pursuant to the standards required pursuant to NAC 687B.768 and any other requirements of NAC 687B.750 to 687B.784, inclusive.
3. The Council must submit its recommendations to the Commissioner on or before September 15 of each year. On or before October 15 of each year, the Commissioner will determine whether to accept any of the recommendations of the Council and take any action necessary to issue any new requirements for determining the adequacy of a network plan. Any such new requirements will become effective on the second January 1 next ensuing after the adoption of the requirements.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017)
NAC 687B.776 Application for approval to issue network plan: Additional data and documentation required. (NRS 679B.130, 687B.490)
1. Each carrier or other person or entity that applies to the Commissioner for approval to issue a network plan pursuant to NRS 687B.490 shall submit to the Commissioner with its annual rate filing sufficient data and documentation to establish that the proposed network plan meets the standards required pursuant to NAC 687B.768 and any other requirements of NAC 687B.750 to 687B.784, inclusive.
2. The data and documentation submitted to the Commissioner pursuant to subsection 1 must be in a format prescribed by the Commissioner.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017)
NAC 687B.778 Update of directory of providers of health care; public availability of directory. (NRS 679B.130, 687B.490)
1. Each carrier shall update its directory of providers of health care at least once each month. Except as otherwise provided in this subsection, each update to the directory must include each provider of health care who, as of the previous month, is no longer in the network plan or has stopped accepting new patients. A carrier shall not be deemed to have violated the provisions of this subsection if a provider of health care fails to provide information to the carrier which the provider of health care is contractually obligated to provide to the carrier.
2. If a change occurs to the network plan of a carrier that results in the network plan failing to meet the standards required pursuant to NAC 687B.768 or any other requirement of NAC 687B.750 to 687B.784, inclusive, the carrier must update its directory of providers of health care not later than 5 business days after the effective date of the change and include in the directory a clear description of the change.
3. The directory of providers of health care and each update to the directory must be:
(a) Posted to a publicly available Internet website maintained by the carrier not later than 5 business days after the update is completed;
(b) Posted in a manner that allows a person who is not enrolled in any plan offered by the carrier to view the directory; and
(c) Made available in a printed format to any person upon request.
4. As used in this section:
(a) “Directory of providers of health care” means a list of physicians, hospitals and other professionals and organizations that provide health care services, including, without limitation, through telehealth, as part of a network plan.
(b) “Telehealth” has the meaning ascribed to it in NRS 629.515.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017)
NAC 687B.780 Change to network plan resulting in failure to meet standards or requirements: Carrier required to notify Commissioner; description of cause and impact of change; summary of measures to bring plan in compliance. (NRS 679B.130, 687B.490) A carrier shall:
1. Within 3 business days after the effective date of a change to a network plan that results in the network plan failing to meet the standards required pursuant to NAC 687B.768 or any other requirement of NAC 687B.750 to 687B.784, inclusive, notify the Commissioner in writing of the change; and
2. Within 10 business days after the effective date of a change to a network plan that results in the network plan failing to meet the standards required pursuant to NAC 687B.768 or any other requirement of NAC 687B.750 to 687B.784, inclusive, provide to the Commissioner a written description of the cause of the change, the impact of the change on the network plan and a summary of the measures that the carrier will take to bring the network plan into compliance with those standards and requirements.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017)
NAC 687B.782 Change to network plan resulting in failure to meet standards or requirements: Submission of corrective action plan by carrier; requirement to ensure covered persons receive covered services; exception. (NRS 679B.130, 687B.490)
1. A carrier shall, within 60 days after the effective date of a change to a network plan that results in the network plan failing to meet the standards required pursuant to NAC 687B.768 or any other requirement of NAC 687B.750 to 687B.784, inclusive, submit to the Commissioner for approval a written corrective action plan to bring the network plan into compliance with those standards and requirements.
2. Except as otherwise provided in subsection 3, during the period in which the network plan does not meet the standards required pursuant to NAC 687B.768 or any other requirement of NAC 687B.750 to 687B.784, inclusive, the carrier shall, at no greater cost to the covered person:
(a) Ensure that each covered person affected by the change may obtain any covered service from a qualified provider of health care who is:
(1) Within the network plan; or
(2) Not within the network plan by entering into an agreement with the nonparticipating provider of health care pursuant to NRS 695G.164; or
(b) Make other arrangements approved by the Commissioner to ensure that each covered person affected by the change is able to obtain the covered service.
3. The provisions of subsection 2 do not apply to services received from a nonparticipating provider of health care without the prior authorization of the carrier unless the services received are medically necessary emergency services, as defined in subsection 3 of NRS 695G.170.
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017)
NAC 687B.784 Change to network plan resulting in failure to meet standards or requirements: Authority of Commissioner to determine inadequacy of plan; submission of statement of network capacity for certain plans. (NRS 679B.130, 687B.490) If a network plan does not meet the standards required pursuant to NAC 687B.768 or any other requirement of NAC 687B.750 to 687B.784, inclusive, and the Commissioner does not approve the corrective action plan submitted pursuant to NAC 687B.782, the Commissioner may:
1. For a qualified health plan, determine that the network plan is inadequate pursuant to subsection 5 of NRS 687B.490; or
2. For any network plan other than a qualified health plan, determine that the network plan is inadequate pursuant to subsection 5 of NRS 687B.490 and require the carrier to submit a statement of network capacity to the Commissioner demonstrating that the carrier meets the conditions described in 42 U.S.C. § 300gg-1(c)(1)(B).
(Added to NAC by Comm’r of Insurance by R049-14, eff. 4-4-2016; A by R025-17, 12-19-2017)
POLICIES OF LIABILITY INSURANCE
NAC 687B.800 Policy sold by short-term lessor of motor vehicle: Deemed primary coverage; filing requirements. (NRS 679B.130) A policy of liability insurance that is sold by a short-term lessor of a motor vehicle to a short-term lessee of a motor vehicle:
1. Shall be deemed to provide primary coverage, and any other policy of liability insurance shall be deemed to provide excess coverage; and
2. Must be filed with the Commissioner as a policy of insurance for personal risk in the manner set forth in chapter 686B of NRS.
(Added to NAC by Comm’r of Insurance by R151-99, eff. 1-28-2000)
POLICIES OF MOTOR VEHICLE INSURANCE
NAC 687B.850 Chargeable accidents: Restrictions on authority of insurer; filing and use of definition. (NRS 679B.130, 687B.385)
1. An insurer shall not cancel, refuse to renew or increase the premium charge for the liability coverage under a policy of motor vehicle insurance upon renewal of the policy of motor vehicle insurance because of an accident that is not a chargeable accident.
2. Each insurer shall file with the Division its definition of a “chargeable accident” and shall use the filed definition. The insurer’s definition of a “chargeable accident” may include only those accidents for which the insured is 50 percent or more at fault.
3. Each filing of a rate for a policy of motor vehicle insurance submitted to the Division must define a “chargeable accident” in terms of a monetary amount of damage.
4. An insurer may not define a claim made under the comprehensive portion of a policy of motor vehicle insurance as a chargeable accident in order to increase the premium for the policy or to cancel the policy, but the insurer may use a series of such claims to discontinue comprehensive coverage or to offer a higher deductible for comprehensive coverage upon the renewal of the policy.
(Added to NAC by Comm’r of Insurance by R100-06, eff. 12-7-2006)
