DOI Pat Quinn Governor Andrew Boron, Director

Review Requirements Checklist

Long Term Care

Contact: Cindy Colonius

Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767-0001
217-782-4572

Effective 8/15/11

Line(s) of Insurance: Long Term Care Policies

Interactive Version of this document to be downloaded and submitted with this filing. Alteration of this document will result in rejection of the filing.

Links:

Each filing must include a completed Review Requirements Checklist that must contain a completed “Location of Standard in Filing” column for each required element of the filing. Please indicate the proper page # and form # for each entry.

FORM FILING REQUIREMENTS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Review Requirements Checklist Go to Review Requirements Checklists on DOI web site. See next column

Each filing must include a completed Review Requirements Checklist that must contain a completed “Location of Standard in Filing” column for each required element of the filing. Please indicate the proper page # and form # for each entry.

 
Cover Letter and Letter of Submission

50 IL Adm. Code 1405.20 (e)
50 IL Adm. Code 2001.30 (a) (3)

50 IL Adm. Code 916.40 (b)

In addition to referencing any previously approved form number(s) as required by 50 IL Adm. Code 1405.20(e), those references must also include the filing number and SERFF tracking number (if applicable and available) for the referenced forms.

Letters of submission must generally describe the intent and use of the form being filed and, if applicable, how it will be used with any previously approved form(s).
 
Outline of Coverage 50 IL Adm. Code 2007.80 b) An Outline of Coverage must be submitted with a uniform transmittal document and contain a unique filing number.  
Rates 215 ILCS 5/355 Rates must be submitted with a uniform transmittal document and contain a unique filing number.  
Initial Filing Requirements 50 IL Adm. Code 2012.64 Insurers must file the disclosure information required by 50 IL Adm. Code 2012.62. These requirements are for policies issued on or after 1/1/03.  
Shopper's Guide (and requirements for delivery) 50 IL Adm. Code 2012.140 The Shopper's Guide may be submitted with the Outline of Coverage under one informational transmittal sheet.  
Personal Worksheet 50 IL Adm. Code 2012.62 d)
50 IL Adm. Code 2012 Exhibit F
The Personal Worksheet may be submitted with the Outline of Coverage under one informational transmittal sheet.  
GENERAL REQUIREMENTS FOR ALL FILINGS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Entire Contract 215 ILCS 5/357.1
215 ILCS 5/357.2
The policy, including the application and any amendments and riders, constitutes the entire contract of insurance and no change is valid unless approved by an executive officer of the company and unless such approval be endorsed hereon or attached hereto.  
Time Limit on Certain Defenses 215 ILCS 5/357.1
215 ILCS 5/357.3
A policy is incontestable two years from the date of issue except for fraudulent misstatements made by the applicant on the application.  
Notice of Claim 215 ILCS 5/357.1
215 ILCS 5/357.6
Written notice of claim should be submitted to the company within 20 days of the occurrence or commencement of any loss.  
Legal Action 215 ILCS 5/357.1
215 ILCS 5/357.12
No such action shall be brought after 3 years from the date of due proof of loss is required to be furnished.  
Claim Forms 215 ILCS 5/357.1
215 ILCS 5/357.7
The company shall furnish those forms needed to submit proofs of loss within 15 days.  
Payment of Claims 215 ILCS 5/357.1
215 ILCS 5/357.10
Benefits may be assigned.  
Timely Payment of Claims 215 ILCS 5/357.1
215 ILCS 5/357.9
Claims must be paid within 30 days following receipt of written due proof of loss.  
Timely Payment of Health Care Services 215 ILCS 5/368a

Periodic payments must be made within 60 days of insured's selection of a provider or effective date of selection, whichever is later. In case of retrospective enrollment only 30 days after notice by employer to insurer. Subsequent payments must be in monthly periodic cycle. Penalty payment of 9% per year.

Payments other than periodic must be made within 30 days after receipt of due proof of loss. Same penalty provisions.

 
Grace Period 215 ILCS 5/357.1
215 ILCS 5/357.4
A grace period of not less than 7 days (weekly premium), 10 days (monthly premium) and 31 days for all other policies is required.  
Continuation/Conversion 50 IL Adm. Code 2012.50 d) 1), 5)

Group traditional long-term care insurance issued on or after February 1, 1994 must provide insureds with a basis for continuation or conversion of coverage.

An application for a converted policy must be made within 31 days after termination of the group policy and must be effective on the day after termination. It must be issued on a guaranteed renewable basis.

 
Discontinuance/Replacement 50 IL Adm. Code 2012.50 e)
50 IL Adm. Code 2012.50 g) 2)
If a group traditional long-term care policy is replaced by another group plan the succeeding insurer must offer coverage to all covered persons under the previous group policy on its date of termination.  
Extension of Benefits 50 IL Adm. Code 2012.50 c) Extension of benefits must be provided up to the duration of the benefit period, if any, or to payment of the maximum benefits.  
Free Look 215 ILCS 5/351A-7 An individual policyholder will have the right to return the policy with full refund of premium within 30 days of its delivery.  
Physical examinations and autopsy 215 ILCS 5/357.11 Insurers, at their own expense, have the right and opportunity to examine the insured when, and as reasonably often as required, during a claim's pending period. It may also conduct an autopsy in the case of death when law does not forbid it.  
Change of Beneficiary 215 ILCS 5/357.1
215 ILCS 5/357.13
The individual designating a beneficiary retains the right to change that designation unless he/she makes that designation irrevocable.  
Reinstatement 215 ILCS 5/357.1
215 ILCS 5/357.5
A policy may be reinstated with or without an application as provided.  
REQUIREMENTS RELATING TO POLICY FORM REVIEW REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Limitations: Cancellation/Non-renewal 215 ILCS 5/351A-4
50 IL Adm. Code 2012.50 g)

A policy may not be non-renewed or terminated due to age or the deterioration of the mental or physical health of the insured.

A policy may not contain a provision establishing a new waiting period in the event existing coverage is converted or replaced by a new or other form unless the insured individual or policyholder voluntarily chooses an increase in benefits.

A policy may not provide coverage for skilled nursing care only, or contain a provision providing significantly more coverage for skilled care in a facility than for coverage at lower levels of care.

 
No Prior Hospitalization 215 ILCS 5/351A-6 No policy may require a prior hospitalization confinement as a condition for eligibility for benefits, nor require a higher level of institutional care as a condition for eligibility for benefits in another institutional care setting. This provision is also applicable to home health care.  
Standards for Benefit Triggers 50 IL Adm. Code 2012.128 A traditional long-term care policy must condition the payment of benefits based on a determination of the insured's ability to perform activities of daily living and on cognitive impairment.  
Standards for Benefit Triggers for Qualified Long-term Care 50 IL Adm. Code 2012.129 A qualified long-term care policy shall only pay for services received by a chronically ill insured provided according to a plan of care prescribed by a licensed health care practitioner. The policy must base payment of benefits on a determination of the insured's inability to perform activities of daily living for an expected period of at least 90 days due to loss of functional capacity or to severe cognitive impairment.  
Requirement to Offer Nonforfeiture Benefit 50 IL Adm. Code 2012.127

An insurer may not issue a policy unless it includes a written offer to include nonforfeiture benefits to the defaulting policyholder or certificate holder.

This section does not apply to life insurance policies or riders containing accelerated traditional long-term care benefits.

 
Tax Qualified Disclosure 215 ILCS 5/351A-3
50 IL Adm. Code 2012.60 h), i)
There must be a disclosure statement in the policy regarding whether the policy is, or is not, intended to be a qualified long-term care insurance contract.  
Policy Summary for Individual Life Insurance with Long Term Care Benefits Rider 215 ILCS 5/351A-9.1
50 IL Adm. Code 2012.60 f)

There must be a disclosure for an accelerated life product policy. It must include an explanation of how the long-term care benefit interacts with other components of the policy, as well as an illustration regarding benefits. Additional details are provided.

The disclosure must appear on the policy summary and outline of coverage.

 
Alzheimer's/Dementia 50 IL Adm. Code 2012.50 b) 1-8 A policy must provide coverage for Alzheimer's disease and senile dementia. Neither condition is a permissible exclusion.  
Minimum Standards for Home Health and Community Care Benefits 50 IL Adm. Code 2012.70 This section provides guidelines for what may not be limited or excluded in traditional long-term care policies that provide home health and community care benefits.  
ADMINISTRATIVE CODE PROVISIONS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Definitions and Policy Definitions 50 IL Adm. Code 2012.30
50 IL Adm. Code 2012.40
Insurers may refer to these sections for appropriate definitions germane to the long-term care regulation.  
Renewability 50 IL Adm. Code 2012.50 a)
50 IL Adm. Code 2012.60 a)

The terms "guaranteed renewable" and "noncancellable" shall not be used in any group and individual direct response or individual traditional long-term care policy or certificate without explanatory language.

Individual policies must contain a renewability provision on the first page of the policy and must state that the policy is guaranteed renewable or noncancellable.

 
Pre-Existing Conditions 50 IL Adm. Code 2012.60 d)
215 ILCS 5/351A-5

No policy issued on other than a group basis may use a definition of "pre-existing condition" which is more restrictive than: Preexisting condition means the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment, or a condition for which medical advice or treatment was recommended by, or received from a provider of health care services, within 6 months preceding the effective date of coverage for an insured person.

The provision must appear as a separate paragraph in the policy or certificate and be captioned as "Preexisting Condition Limitations".

 
Pre-Existing Condition Prohibition in Replacement Policies/Certificates 50 IL Adm. Code 2012.126 If an insurer replaces a traditional long-term care policy or certificate with one of its own, it must waive any time periods for similar benefits applicable to pre-existing conditions and probationary periods in the new policy.  
Allowable Exclusions 50 IL Adm. Code 2012.50 b) 1-8 No policy may be delivered or issued for delivery as traditional long-term care coverage in Illinois unless it adheres to the list of limitations and exclusions of this subsection.  
Required Disclosure of Rating Practices to Consumers 50 IL Adm. Code 2012.62
50 IL Adm. Code 2012 Exhibits F, J

These disclosure requirements apply to any traditional long-term insurance policy issued on or after January 1, 2003. For a group traditional long-term policy issued on or after July 1, 2002, which was in force prior to that date, these requirements are applicable on the next policy anniversary following July 1, 2003.

An insurer must provide at least 45 days notice to all policyholders or certificate holders prior to implementing a premium rate increase. The notification must include the information required by 50 IL Adm. Code 2012.62 b).

 
Benefit Reduction or Elimination 50 IL Adm. Code 2012.60 b) Any riders or endorsements added to an individual traditional long-term care policy after the date of issue that reduce or eliminate benefits or coverage require signed acceptance by the insured.  
Use of Terms "Usual and Customary" or "Reasonable and Customary" 50 IL Adm. Code 2012.60 c) Terms such as "usual and customary" or "reasonable and customary" must be defined in the policy.  
Premium Rate Increases 50 IL. Adm. Code 2012.112

An insurer must provide notice of a pending premium rate increase to the Department at least 30 days prior to the notice to the policyholder and must include the information required by 50 IL Adm. Code 2012.62 as well as certification by an actuary as stated.

These requirements apply to any traditional long-term insurance policy issued on or after January 1, 2003. For a group traditional long-term policy issued on or after July 1, 2002, which was in force prior to that date, these requirements are applicable on the next policy anniversary following July 1, 2003.

 
Inflation Protection 50 IL Adm. Code 2012.80 The insurer must offer, at the time of purchase, an inflation protection feature as described. Any rejection of the offer must be received in writing and signed by the policyholder.  
Disclosure for Accelerated Life Insurance 50 IL Adm. Code 2012.60 f) Any individual life insurance policy that contains a rider for traditional long-term care benefits must include a policy summary that details how the traditional long-term care benefit interacts with other components of the policy, including deductions from the death benefit. The disclosure must also list any tax consequences. This requirement does not apply to qualified long-term care contracts.  
Deterioration of Physical or Mental Health 50 IL Adm. Code 2012.50 g) 1) No traditional long-term care policy may be cancelled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder.  
Unintentional Lapse 50 IL Adm. Code 2012.55

No individual long-term care policy shall be issued until the insurer receives from the applicant a written designation of at least one other individual who is to receive notice of termination of the policy for nonpayment of premium. A written waiver of this provision is permissible.

Reinstatement is required if proof of cognitive impairment or loss of functional capacity is provided.

 
Advertising Filing Requirements 50 IL Adm. Code 2012.115
50 IL Adm. Code 2002.180

An insurer shall maintain at its home or principal office a complete file containing every printed, published or prepared advertisement of its individual policies and typical printed, published or prepared advertisements of its blanket, franchise and group policies.

The Department does not require advertisements be filed for information or approval.

 
Standards for Marketing 50 IL Adm. Code 2012.122 Each outline of coverage for a traditional long-term care policy must contain by type or stamp on the first page: "NOTICE TO BUYER: THIS POLICY MAY NOT COVER ALL THE COSTS ASSOCIATED WITH LONG-TERM CARE INCURRED BY THE BUYER DURING THE PERIOD OF COVERAGE. THE BUYER IS ADVISED TO REVIEW CAREFULLY ALL POLICY LIMITATIONS." Insurers are encouraged to carefully review all the requirements of this section.  
Suitability 50 IL Adm. Code 2012.123
50 IL Adm. Code 2012. Exhibit H

This section requires insurers of traditional long-term care policies to develop and use suitable standards for determining whether the purchase or replacement of coverage is appropriate. It does not apply to life insurance policies that accelerate benefits for traditional long-term care.

This section also provides additional details regarding the personal worksheet.

 
GENERAL INFORMATION REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Applicability of Mandated Benefits 215 ILCS 5/356z.16 This provision lists sections of the Insurance Code that are inapplicable to certain policies.  
Discretionary Authority 215 ILCS 5/143(1)
50 IL Adm. Code 2001.3
Insurers are not permitted to place discretionary authority language in contracts of accident and health.  
HIV/AIDS Questions on Application 215 ILCS 5/143(1) Questions designed to elicit information regarding AIDS, ARC and HIV must be specifically related to the testing, diagnosis or treatment done by a physician or an appropriately licensed clinical professional acting within the scope of his/her license.  
Requirements for Application Forms and Replacement Coverage 50 IL Adm. Code 2012.90 This section provides insurers with required questions to ask on the application regarding replacement of existing coverage.  
Post Claims Underwriting 50 IL Adm. Code 2012.65 a) 1), 2) If the application contains a question asking whether a physician has prescribed medication(s) it must also ask the applicant to list the medications. If the medications were known to the insurer or were included in the insurer's underwriting standards at the time of the application, and are directly related to a condition for which coverage would otherwise have been denied, the policy may not be rescinded for that condition.  
Delivery of Policy 215 ILCS 5/351A-9.2 The policy or certificate must be delivered no later than 30 days after the date of approval.  
Outline of Coverage (and format) 215 ILCS 5/351A-8
50 IL Adm. Code 2012.130
50 IL Adm. 2012 Exhibit C
An outline of coverage must be delivered to a prospective applicant at the time of the initial solicitation. It must be a "free-standing document", using no smaller than ten point type.  
Claim Denial/Explanation 215 ILCS 5/351A-9.3 If a claim is denied and the insured provides a written inquiry, the insurer is required to respond within 60 days and provide the reasons for the denial as well as make available all information directly related to it.  
Use of SSN on ID Cards 815 ILCS 505 2QQ
215 ILCS 138/15

The focus of HB 4712 is on any card required for an individual to access products or services, while SB 2545 is more limited in that it just focuses on insurance cards.

HB 4712 prevents a person from:

· Publicly posting or displaying an individual's SSN;

· Printing an individual's SSN on any card required for the individual to access products or services, however, an entity providing an insurance card must print on the card a unique identification number as required by 215 ILCS 138/15.

· Being required to transmit an SSN over the Internet to access a web site unless the connection is secure or the SSN is encrypted;

· Requiring the individual to use his/her SSN to access a web site unless a PIN number or other authentication device is also used; and,

· Printing an individual's SSN on any materials mailed to an individual unless required by state or federal law.

Insurers are required to comply with both provisions.

 
DEPARTMENT POSITIONS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Care Coordination Services 215 ILCS 5/143(1) Care Coordination Services are optional and must be so stated in bold within the policy form.  
Plan of Care 50 IL Adm. Code 2012.129 a) The "plan of care" requirement may only appear in tax-qualified policies. Traditional long-term care contracts may not condition benefits on this provision.  
Alternative Benefits 215 ILCS 5/143(1) Long-term care policies may offer alternative benefits such as building ramps for wheelchairs or modifying kitchens or bathrooms. However, these benefits must be stated within the policy.