Ins 3.46(4)(m)2.a.a. Treatment provided in a government facility, unless otherwise required by law. Ins 3.46(4)(m)2.b.b. Services for which benefits are available under Medicare or other governmental programs, except Medicaid, or under a state or federal worker’s compensation, employer’s liability, occupational disease law, or any motor vehicle no-fault law. Ins 3.46(4)(m)2.c.c. Services provided by a member of the insured’s immediate family or for which no charge is normally made in the absence of insurance. Ins 3.46(4)(m)2.g.g. Suicide, sane or insane, attempted suicide or intentionally self-inflicted injury. Ins 3.46(4)(m)2.h.h. Aviation, however, this exclusion applies only to non-fare-paying passengers. Ins 3.46(4)(m)3.3. Mental or nervous disorders; however, this may not permit exclusion or limitation of benefits on the basis of Alzheimer’s Disease. Ins 3.46(4)(m)5.5. Expenses for services or items available or paid under another long-term care insurance or health insurance policy. Ins 3.46(4)(m)6.6. This paragraph is not intended to prohibit exclusions or limitation by type of provider. In this subdivision, “state of policy issue” means the state in which the individual policy or certificate was originally issued. However, no long-term care insurer may deny a claim because services are provided in a state other than the state of policy issue when either of the following conditions occurs: Ins 3.46(4)(m)6.a.a. When a state other than the state of policy issue does not have the provider licensing, certification, or registration required in the policy, but where the provider satisfies the policy requirements outlined for providers in lieu of licensure, certification or registration. Ins 3.46(4)(m)6.b.b. When a state other than the state of policy issue licenses, certifies or registers the provider under another name. Ins 3.46(4)(m)7.7. This paragraph is not intended to prohibit territorial limitations. Ins 3.46(4)(m)8.8. If payment of benefits is based on standards described as “usual and customary,” “reasonable and customary” or words of similar import shall include a definition of these terms and include an explanation of the terms in its accompanying outline of coverage and comply with s. Ins 3.60 (5). Ins 3.46(4)(m)9.9. 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. Ins 3.46(4)(m)10.10. Subject to the policy provisions, any plan of care required under the policy shall be provided by a licensed health care practitioner and does not require insurer approval. The insurer may provide a predetermination of benefits payable pursuant to the plan of care. This does not prevent the insurer from having discussions with the licensed health care practitioner to amend the plan of care. The insurer may also retain the right to verify that the plan of care is appropriate and consistent with generally accepted standards. Ins 3.46(4)(m)11.11. A long-term care policy containing post-confinement, post-acute care, or recuperative benefits shall include in a separate policy provision entitled “Limitation or Conditions on Eligibility for Benefits,” the limitations or conditions applicable to these benefits, including any required number of days of confinement. Ins 3.46(4)(n)(n) Not exclude or limit any coverage of care provided in a community-based setting, including, but not limited to, coverage of home health care, by any of the following: Ins 3.46(4)(n)2.2. Requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services before community-based care is covered. Ins 3.46(4)(n)3.3. Limiting eligible services to services provided by registered nurses or licensed practical nurses. Ins 3.46(4)(n)4.4. Requiring that the insured have an acute condition before community-based care is covered. Ins 3.46(4)(n)5.5. Limiting benefits to services provided by Medicare certified agencies or providers. Ins 3.46(4)(o)(o) Provide substantial scope of coverage of facilities for any benefits it provides for care in an institutional setting. Ins 3.46(4)(p)(p) Provide substantial scope of coverage of facilities and programs for any benefits it provides for care in a community-based setting. Ins 3.46(4)(q)(q) Contain a description of the benefit appeal procedure and comply with s. 632.84, Stats. Ins 3.46(4)(r)(r) If coverage of care in a community-based setting is included, provide coverage of all types of care provided by state licensed or Medicare certified home health care agencies. A long-term care insurance policy may not, if it provides benefits for home health care or community care services limit or exclude benefits by any of the following acts: Ins 3.46(4)(r)1.1. Requiring that the insured or claimant would need care in a skilled nursing facility if home health care services were not provided. Ins 3.46(4)(r)2.2. Requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services, or both, in a home, community or institutional setting before home health care services is covered. Ins 3.46(4)(r)3.3. Requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide or other licensed or certified home care worker acting within the scope of his or her licensure or certification. Ins 3.46(4)(r)4.4. Excluding coverage for personal care services provided by a home health aide. Ins 3.46(4)(r)5.5. Requiring that the provision of home health care services be at a level of certification or licensure greater than that required by the eligible service. Ins 3.46(4)(r)6.6. Requiring that the insured or claimant have an acute condition before home health care services are covered. Ins 3.46(4)(r)7.7. Limiting benefits to services provided by Medicare-certified agencies or providers. Ins 3.46(4)(s)(s) If coverage of care in an institutional setting is provided, not condition eligibility for coverage of custodial or intermediate care on the concurrent or prior receipt of intermediate or skilled care. Ins 3.46(4)(t)(t) Include a provision which allows for reinstatement of coverage, in the event of lapse, if the insurer is provided proof of cognitive impairment or the loss of functional capacity and if the reinstatement of coverage is requested within 5 months after termination and provision is made for the collection of past due premiums, where appropriate. The standard of proof of cognitive impairment or loss of functional capacity to be used in evaluating an application for reinstatement may not be more stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional capacity, if any, contained in the policy and certificate. Ins 3.46(4)(u)(u) Require a signed acceptance by the individual insured for all riders or endorsements added to an individual long-term care insurance policy after the date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy, 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 policy. After the date of issue, any rider or endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, except if 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 charge shall be set forth in the policy, rider, or endorsement. Ins 3.46(5)(5) Form requirements for long-term care, nursing home and home health care policies only. Ins 3.46(5)(b)(b) A form for long-term care policy or certificate shall: Ins 3.46(5)(b)2.2. Include the unrestricted right to return the policy or certificate within 30 days of the date it is received by the policyholder and comply with s. 632.73 (2m), Stats. Ins 3.46(5)(b)3.3. If it is a policy or certificate which covers care in both institutional and community-based settings, contain a caption as follows: THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR LONG-TERM CARE INSURANCE.
THIS POLICY MEETS THOSE STANDARDS. THIS POLICY COVERS CERTAIN TYPES OF NURSING HOME AND HOME HEALTH CARE SERVICES. THERE MAY BE LIMITATIONS ON THE SERVICES COVERED. READ YOUR POLICY CAREFULLY.
FOR MORE INFORMATION ON LONG-TERM CARE SEE THE “GUIDE TO LONG-TERM CARE” GIVEN TO YOU WHEN YOU APPLIED FOR THIS POLICY. THIS POLICY’S BENEFITS ARE NOT RELATED TO MEDICARE.
Ins 3.46(5)(b)4.4. If it is a policy or certificate which covers care only in an institutional setting, contain a caption as follows: THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR NURSING HOME INSURANCE. THIS POLICY MEETS THOSE STANDARDS.
THIS POLICY COVERS CERTAIN TYPES OF NURSING HOME CARE. THIS POLICY DOES NOT COVER HOME HEALTH CARE. THERE MAY BE LIMITATIONS ON THE SERVICES COVERED. READ YOUR POLICY CAREFULLY.
FOR MORE INFORMATION ON LONG-TERM CARE SEE THE “GUIDE TO LONG-TERM CARE” GIVEN TO YOU WHEN YOU APPLIED FOR THIS POLICY. THIS POLICY’S BENEFITS ARE NOT RELATED TO MEDICARE.
Ins 3.46(5)(b)5.5. If it is a policy or certificate which covers care in a community setting only, contain a caption as follows: THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR HOME HEALTH CARE INSURANCE. THIS POLICY MEETS THOSE STANDARDS.
THIS POLICY COVERS CERTAIN TYPES OF HOME HEALTH CARE. THIS POLICY DOES NOT COVER NURSING HOME CARE. THERE MAY BE LIMITATIONS ON THE SERVICES COVERED. READ YOUR POLICY CAREFULLY.
FOR MORE INFORMATION ON LONG-TERM CARE SEE THE “GUIDE TO LONG-TERM CARE” GIVEN TO YOU WHEN YOU APPLIED FOR THIS POLICY. THIS POLICY’S BENEFITS ARE NOT RELATED TO MEDICARE.
Ins 3.46(5)(b)6.6. Contain the caption required under subd. 3., 4. or 5. imprinted on the face of the policy or certificate in type not smaller than 18-point and either in contrasting color from the text or with a distinctly contrasting background which is at least as prominent as contrasting color. Ins 3.46(5)(b)7.7. Include an extension of benefits provision which provides that if the policy is terminated for any reason, including, but not limited to, failure to pay premium, any benefits provided for care in an institutional setting will continue to be payable for institutionalization if the institutionalization begins when the policy is in force and continues without interruption after termination. This extension of benefits 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 policy elimination period and all other applicable provisions of the policy. Ins 3.46(5)(b)8.8. If it is an individual policy, be plainly printed in black or blue ink in a uniform type of a style in general use with not less than 10-point with a lower case unspaced alphabet length not less than 120-point. If it is a group policy, certificates issued under the policy shall be plainly printed in black or blue ink in a uniform type of a style in general use, not less than 10-point with a lower case unspaced alphabet length not less than 120-point. Ins 3.46(5)(b)9.9. If it is an individual policy, include a provision which provides that the policy is guaranteed renewable for life or noncancellable, then such provision shall be appropriately captioned and shall appear on the first page of the policy and shall include any reservation by the insurer of the right to change premiums and any automatic renewal premium increase based on the policyholder’s age. Ins 3.46(6)(6) Nursing home and home health care coverage forms may not use the term “long-term care”. Only a form for a long-term care policy, life insurance-long-term care coverage or certificate which provides substantial coverage of care in both an institutional setting and in a community-based setting may use the term “long-term care” or a substantially similar term. Ins 3.46(7)(a)(a) No insurer or intermediary may use the term “long-term care” or similar terminology in an advertisement or offer of a policy, coverage or certificate unless the policy, coverage or certificate advertised or offered: Ins 3.46(7)(a)1.1. Covers care in both institutional and community-based settings; Ins 3.46(7)(a)3.3. Is approved as a long-term care policy or certificate covering care in both institutional and community settings and as appropriately using the term “long-term care” by the office. Ins 3.46(7)(b)(b) No insurer may file a form under s. 631.20, Stats., for a long-term care policy, life insurance-long-term care coverage or certificate, unless the form complies with this section. Ins 3.46(8)(a)(a) An outline of coverage for a long-term care policy, life insurance-long-term care coverage or certificate shall: Ins 3.46(8)(a)1.1. Have captions printed in 18-point bold letters and conspicuously placed; Ins 3.46(8)(a)2.2. Be printed in an easy to read type and written in easily understood language; and Ins 3.46(8)(b)(b) No insurer or intermediary may use an outline of coverage to comply with sub. (9) or advertise, market or offer a long-term care policy, life insurance-long-term care coverage or certificate, unless prior to the use, advertising, marketing or offer the outline of coverage is approved in writing by the office. Ins 3.46(8)(c)(c) Display prominently by type, stamp or other appropriate means, on the first page of the outline of coverage and policy all of the following: Ins 3.46(8)(c)1.1. “Notice to Buyer: This policy 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 policy limitations.” Ins 3.46(8)(c)2.2. A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation by the insurer of the right to change premium. Continuation or conversion provisions of group coverage shall be specifically described. Ins 3.46(8)(d)(d) This par. does not apply to a group that is offered coverage as a result of collective bargaining and has guaranteed issue. Ins 3.46(9)(a)(a) An insurer or intermediary at the time the insurer or intermediary contacts a person to solicit the sale of a long-term care policy, life insurance-long-term care coverage or certificate shall deliver to the person: Ins 3.46(9)(a)1.1. A copy of the current edition of the guide to long-term care; and Ins 3.46(9)(b)(b) Other than a policy for which no applicable premium rate or rate schedule increases can be made, an insurer shall provide all of the following information to the applicant at the time of application or enrollment: Ins 3.46(9)(b)1.1. A statement that the policy may be subject to rate increases in the future. Ins 3.46(9)(b)2.2. An explanation of potential future premium rate revisions and the policyholder’s or certificateholder’s option in the event of a premium rate revision. Ins 3.46(9)(b)3.3. The premium rate or rate schedules applicable to the applicant that will be in effect until a request is made for an increase. Ins 3.46(9)(b)4.4. A general explanation for applying premium rate or rate schedule adjustments that shall include a description of when premium rate or rate schedule adjustments will be effective, such as next anniversary date or next billing date, and the right to a revised premium rate or rate schedule as provided in subd. 2. if the premium rate or rate schedule is changed. Ins 3.46(9)(b)5.5. Information regarding each premium rate increase on this policy form or similar policy forms over the past 10 years for this state or any other state that, at a minimum, identifies the policy forms for which premium rates have been increased; the calendar years when the form was available for purchase; and the amount or percentage of each increase. The percentage may be expressed as a percentage of the premium rate prior to the increase and may also be expressed as minimum and maximum percentages if the rate increase is variable by rating characteristics. Ins 3.46(9)(c)(c) The insurer may as part of the disclosure under par. (b) in a fair manner, provide additional explanatory information related to the rate increases.
