N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3602, app III

Current through Register No. 50, December 12, 2024

Appendix III - Long-Term Care Partnership Program Insurer Certification Form

Section 1917(b)(5)(B)(iii) of the Social Security Act, 42 U.S.C. § 1396p(b)(5)(B)(iii), authorizes the New Hampshire insurance commissioner upon implementing a qualified state long-term care partnership program ("qualified partnership") to certify that long-term care insurance policies (including certificates issued under a group insurance contract) covered under the qualified partnership meet certain consumer protection requirements, and policies so certified are deemed to satisfy such requirements. These consumer protection requirements are set forth in §1917(b)(5)(A) of the Social Security Act, 42 U.S.C. § 1396p(b)(5)(A) and principally include certain specific provisions of the long-term care insurance model regulation and long-term care insurance model act promulgated by the National Association of Insurance Commissioners, referred to herein as the "Model Regulation 641" and "Model Act 640" respectively, and available as referenced in Appendix II.

In order to provide the Insurance Commissioner with information necessary to provide a certification for policies, this issuer certification form requests information and a certification from issuers of long-term care insurance policies with respect to policy forms that may be covered under the qualified partnership program of the state.

An insurance company may request certification of policies from time to time and, accordingly, may supplement this issuer certification form, e.g., as it introduces new long-term insurance policy forms for issuance.

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II. QUESTIONS REGARDING APPLICABLE PROVISIONS OF THE MODEL REGULATION 641 AND MODEL ACT 640

Please answer each of the questions below with respect to the policy forms identified in section I.C. above. For purposes of answering the questions below, any provision of the Model Regulation 641 or Model Act 640 listed below shall be treated as including any other provision of the Model Regulation 641 or Model Act 640 necessary to implement the provision.

Are the following requirements of the Model Regulation 641 met with respect to all policies (including certificates issued under a group insurance contract) intended to be covered under the qualified partnership program that are issued on each of the policy forms identified in Section I.C. above?

Yes___	No___	N/A___	A.	Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5) thereof, and the requirements of section 6B of the Model Act 640 relating to such section 6A.
Yes___	No___	N/A___	B.	Section 6B (relating to prohibitions on limitations and exclusions) other than paragraph (7) thereof.
Yes___	No___	N/A___	C.	Section 6C (relating to extension of benefits).
Yes___	No___	N/A___	D.	Section 6D (relating to continuation or conversion of coverage).
Yes___	No___	N/A___	E.	Section 6E (relating to discontinuance and replacement of policies).
Yes___	No___	N/A___	F.	Section 7 (relating to unintentional lapse).
Yes___	No___	N/A___	G.	Section 8 (relating to disclosure), other than sections 8F, 8G, 8H, and 81 thereof.
Yes___	No___	N/A___	H.	Section 9 (relating to required disclosure of rating practices to consumer).
Yes___	No___	N/A___	I.	Section 11 (relating to prohibitions against post-claims underwriting).
Yes___	No___	N/A___	J.	Section 12 (relating to minimum standards).
Yes___	No___	N/A___	K.	Section 14 (relating to application forms and replacement coverage).
Yes___	No___	N/A___	L.	Section 15 (relating to reporting requirements).
Yes___	No___	N/A___	M.	Section 22 (relating to filing requirements for advertising).
Yes___	No___	N/A___	N.	Section 23 (relating to standards for marketing).
Yes___	No___	N/A___	O.	Section 24 (relating to suitability).
Yes___	No___	N/A___	P.	Section 25 (relating to prohibition against preexisting conditions and probationary periods in replacement policies or certificates).
Yes___	No___	N/A___	Q	Section 28 (the provisions relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in section 7702B(g)(4) of the Internal Revenue Code of 1986, 26 U.S.C. 7702BJ(g)(4).
Yes___	No___	N/A___	R.	Section 33 (relating to standard format outline of coverage).
Yes___	No___	N/A___	S.	Section 34 (relating to requirement to deliver shopper's guide).

Are the following requirements of the Model Act 640 met with respect to all policies (including certificates issued under a group insurance contract) intended to be covered under the qualified partnership program that are issued on each of the policy forms identified in section I.C. above?

Yes___	No___	N/A___	A.	Section 6C (relating to preexisting conditions).
Yes___	No___	N/A___	B.	Section 6D (relating to prior hospitalization).
Yes___	No___	N/A___	C.	Section 8 (provisions relating to contingent nonforfeiture benefits).
Yes___	No___	N/A___	D.	Section 6F (relating to right to return).
Yes___	No___	N/A___	E.	Section 6G (relating to outline of coverage).
Yes___	No___	N/A___	F.	Section 6H (relating to requirements for certificates under group plans).
Yes___	No___	N/A___	G.	Section 6J (relating to policy summary).
Yes___	No___	N/A___	H.	Section 6K (relating to monthly reports on accelerated death benefits).
Yes___	No___	N/A___	I.	Section 7 (relating to incontestability period).

In order for a policy to be covered under the qualified partnership program of the state, the answers to all questions above should be "yes" (or "N/A" where all requirements with respect to a provision are not applicable). If answers differ between policy forms (e.g., a requirement would be answered "Yes" for one form and "N/A" for another), you should use separate issuer certification forms for such policies.

III. CERTIFICATION

I hereby certify that the policy forms and endorsements identified in section C. above meet all of the requirements of the National Association of Insurance Commissioners' Long-Term Care Model Act 640 and Model Regulation 641 that are specified in 42 U.S.C. § 1396p(b)(l)(C)(iii) and further certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct, and complete.

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

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

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

^[4] Examples - a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.

N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3602, app III