SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According to [your application] [information you have furnished], you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with the long-term care insurance policy delivered herewith issued by [company name] Insurance Company. Your new policy provides thirty (30) days within which you may decide, without cost, whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy.
You should review this new coverage carefully, comparing it with all accident and sickness or long-term care insurance coverage you now have, and terminate your present policy only if, after due consideration, you find that purchase of this long-term care coverage is a wise decision.
1. Health conditions that you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy. This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.
2. State law provides that your replacement policy or certificate may not contain new preexisting conditions or probationary periods. Your insurer will waive any time periods applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
3. If you are replacing existing long-term care insurance coverage, you may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
4. [To be included only if the application is attached to the policy.] If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to [company name and address] within thirty (30) days if any information is not correct and complete, or if any past medical history has been left out of the application.
[Company Name]
Ins 3.46 APPENDIX 8
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES
FOR THE STATE OF _______________
FOR THE REPORTING YEAR [ ]
Company Name: ________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________
Phone Number: _____________________
Due: March 1 annually
INSTRUCTIONS:
The purpose of this form is to report all rescissions of long-term care insurance policies or certificates. Those rescissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.
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See PDF for table 
Detailed reason for rescission: ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________
Signature
__________________________________
Name and Title (please type)
__________________________________
Date
Ins 3.46 APPENDIX 9
CLAIMS DENIAL REPORTING FORM
LONG-TERM CARE INSURANCE
For the State of ______________________________________
For the Reporting Year of ________________
Company Name: _______________________________________
Due: June 30 annually
Company Address:
_____________________________________________________________
_____________________________________________________________
Company NAIC Number: _____________________________________
Contact Person: _____________________________Phone Number: ______________________
Line of Business: Individual Group
INSTRUCTIONS
The purpose of this form is to report all long-term care claim denials under in force long-term care insurance policies. “Denied" means a claim that is not paid for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition.
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See PDF for table
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.
INS 3.46 Appendix 10
LONG-TERM CARE INSURANCE
REPLACEMENT AND LAPSE REPORTING FORM
For the State of ____________________________________________
For the Reporting Year of ________________
Company Name: ______________________________________________
Due: June 30 annually
Company Address: ______________________________________________
Company NAIC Number: ______________
Contact Person: ______________________________________________
Phone Number: (____) _____________
INSTRUCTIONS:
The purpose of this form is to report on a statewide basis information regarding long-term care insurance policy replacements and lapses. Specifically, every insurer shall maintain records for each agent on that agent's amount of long-term care insurance replacement sales as a percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent's total annual sales. The tables below should be used to report the ten percent (10%) of the insurer's agents with the greatest percentages of replacements and lapses.
Listing of the 10% of Agents with the Greatest Percentage of Replacements
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See PDF for table
Listing of the 10% of Agents with the Greatest Percentage of Lapses
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See PDF for table
Company Totals
Percentage of Replacement Policies Sold to Total Annual Sales ____%
Percentage of Replacement Policies Sold to Policies In Force (as of the end of the preceding calendar year) ____%
Percentage of Lapsed Policies to Total Annual Sales _____%
Percentage of Lapsed Policies to Policies In Force (as of the end of the preceding calendar year) ____%
Ins 3.465
Ins 3.465
Wisconsin long-term care partnership program. Ins 3.465(1)(1)
General applicability. The provisions within s.
Ins 3.46 regarding insurance transactions for long-term care and life insurance policies with long-term care provisions apply to insurance transactions described within this section.
Ins 3.465(2)
(2) Definitions. The definitions contained in ss.
Ins 3.455 and
3.46 also apply in this section. In addition, the following definitions apply in this section:
Ins 3.465(2)(a)
(a) “Automatic exchange" means the issuance of a notice from an insurer informing an existing insured that the policy the insured purchased prior to January 1, 2009, from the insurer has been approved by the commissioner as a policy that meets the requirements of the state's partnership program and, as such, the policy will be treated from the date of the notice as a qualifying partnership policy.
Ins 3.465(2)(b)
(b) “Consumer price index" means the consumer price index for all urban consumers, U.S. city average, all items, as determined by the Bureau of Labor Statistics of the United States Department of Labor.
Ins 3.465(2)(c)
(c) “Qualified long-term care insurance contract" or “federally tax-qualified long-term care insurance contract" means an individual or group insurance long-term care, nursing home or home health care contract that meets the requirements of section
7702B(b) of the Internal Revenue Code of 1986, as amended, or the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of sections
7702B(b) and (c) of the Internal Revenue Code of 1986, as amended.
Ins 3.465(2)(d)
(d) “Qualifying partnership policy exchange" means the exchange of an existing long-term care insurance plan with an identical policy that on or after January 1, 2009 is certified by the insurer to meet the federal requirements established for the state's partnership program or the exchange of an existing long-term care insurance policy with an identical policy except for the addition of a benefit or rider that, on or after January 1, 2009, is certified by the insurer to meet the federal requirements established for the state's partnership program.
Ins 3.465(2)(e)
(e) “Secretary" means the U. S. Secretary of the Department of Health and Human Services.
Ins 3.465(3)(a)(a) This section applies to an insurer offering a long-term care policy that is intended to qualify an insured under the state's partnership program and that is in compliance with the requirements of 42 U.S.C 1396p (b).
Ins 3.465(3)(b)
(b) In order for a long-term care policy to qualify as a qualifying partnership policy, the policy shall comply with the requirements set forth in s.
49.45 (31), Stats., and the all of the following:
Ins 3.465(3)(b)1.
1. Be filed with and approved by the commissioner prior to use and contain the certification referenced in sub.
(5) (a), and comply with s.
631.28, Stats.
Ins 3.465(3)(b)2.
2. Meet the requirements of a tax-qualified long-term care insurance contract as defined in section
7702B(b) of the Internal Revenue Code of 1986, as amended.
Ins 3.465(3)(b)4.
4. Be accompanied by a clear disclosure that the policy is intended to be a qualifying partnership policy. The disclosure shall be in the format contained in Appendix 1.
Ins 3.465(3)(b)6.
6. Not base underwriting criteria upon whether or not the policy is a qualifying partnership policy.
Ins 3.465(4)
(4) Form requirements for qualifying partnership policies. An insurer that offers a long-term care insurance policy that is intended to qualify an insured under the state's partnership program shall comply with all of the following:
Ins 3.465(4)(a)
(a) File the policy, outline of coverage, premium rates, and actuarial memorandum to the commissioner in accordance with s.
631.20, Stats., and s.
Ins 3.455, and include the qualifying partnership policy certification form.
Ins 3.465 Note
Note:
The qualifying partnership policy certification form (OCI No. 26-113) can be obtained from the Office of the Commissioner of Insurance at no cost from the OCI website
http://oci.wi.gov or by writing to the State of Wisconsin Office of the Commissioner of Insurance 125 S. Webster, Madison, WI 53703.
