Some long-term care insurance policies [certificates] sold in Wisconsin may qualify for the Wisconsin 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 policies [certificates] that qualify as Qualifying Partnership Policies [Certificates] may protect the policyholder’s [certificateholder’s] assets through a feature known as “Asset Disregard” under Wisconsin’s Medicaid program.
Asset Disregard means that amount of the policyholder’s [certificateholder’s] assets equal to the amount of long-term care insurance benefits received under a Qualifying Partnership Policy [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 Qualifying Partnership Policy [Certificate] without affecting the person’s eligibility for Medicaid. The disregarded assets are also exempt from estate recovery. All other Medicaid eligibility criteria will apply and special rules may apply to persons whose home equity exceeds $750,000. Asset Disregard is available under a Qualifying Partnership Policy [Certificate]. Therefore, you should consider if Asset Disregard is important to you, and whether a Qualifying Partnership Policy meets your needs. The purchase of a Qualifying Partnership Policy does not automatically qualify you for Medicaid.
What are the Requirements for a Partnership Policy [Certificate]? In order for a policy [certificate] to qualify as a Qualifying Partnership Policy [Certificate], it shall, among other requirements:
• Have an effective date on or after January 1, 2009;
• Be issued to an individual who was a Wisconsin resident when coverage first becomes effective under the policy;
• Be a tax-qualified policy under s. 7702(B)(b) of the Internal Revenue Code of 1986, as amended;
• Meet certain consumer protection standards; and,
• Meet the following inflation requirements:
• For persons age 60 or younger – provide compound annual inflation protection of at least 3%.
• For persons age 61-75 – provide annual inflation protection of at least 3% not compounded.
• For persons age 76 and older – there are no requirements for purchasing inflation protection.
If you apply and are approved for long-term care insurance coverage, [carrier name] will provide you with written documentation as to whether or not your policy [certificate] is a Qualifying Partnership Policy.
You should also be aware that insurers are required to provide personally identifying information, including your name, to the federal government to be entered into a federal data base to which state Medicaid departments will have access.
What Could Disqualify a Policy [Certificate] from Continuing to be a Qualifying Partnership Policy? Certain types of changes to a Qualifying Partnership Policy [Certificate] could affect whether or not such policy [certificate]continues to be a Qualifying Partnership Policy [Certificate]. If you purchase a Qualifying Partnership Policy [Certificate] and later decide to make a change, you should first consult with [carrier name] to determine the effect of the proposed changes. In addition, if you move to a state that does not maintain a Partnership Program or does not recognize your policy [certificate] as a Qualifying Partnership Policy [Certificate], you would not receive treatment of you policy [certificate] under the Medicaid program of that state. However, the coverage under your policy will not be affected. The information contained in this disclosure is based upon current Wisconsin and Federal laws. These laws may be subject to change. Any change in law could modify, reduce or eliminate the treatment of your policy [certificate] under Wisconsin’s Medicaid program.
Additional Information: If you have questions regarding long-term care insurance policies [certificates] please contact [carrier name]. If you have questions regarding current laws governing Wisconsin Medicaid eligibility, you should contact State of Wisconsin Member Services at 1-800-362-3002.
Ins 3.47Ins 3.47 Cancer insurance solicitation. Ins 3.47(1)(1) Findings. Information on file in the office of the commissioner of insurance shows that significant misunderstanding exists with respect to cancer insurance. Consumers are not aware of the limitations of cancer insurance and do not know how cancer insurance policies fit in with other health insurance coverage. Many of the sales presentations used in the selling of cancer insurance are confusing, misleading and incomplete and consumers are not getting the information they need to make informed choices. The commissioner of insurance finds that such presentations and sales materials are misleading, deceptive and restrain competition unreasonably as considered by s. 628.34 (12), Stats., and that their continued use without additional information would constitute an unfair trade practice under s. 628.34 (11), Stats., and would result in misrepresentation as defined and prohibited in s. 628.34 (1), Stats. Ins 3.47(2)(2) Purpose. This section interprets s. 628.34 (12), Stats., relating to unfair trade practices. It requires insurers and intermediaries who sell cancer insurance to give all prospective buyers of cancer insurance a shopper’s guide prepared by the national association of insurance commissioners. Ins 3.47(3)(3) Scope. This section applies to all individual, group and franchise insurance policies or riders which provide benefits for or are advertised as providing benefits primarily for the treatment of cancer. This section does not apply to solicitations in which the booklet, “Health Insurance Advice for Senior Citizens,” is given to applicants as required by s. Ins 3.39. Ins 3.47(4)(4) Definition. “A Shopper’s Guide to Cancer Insurance” means the document which contains the language set forth in Appendix I to this section. Ins 3.47(5)(a)(a) Each insurer offering a policy or rider described in sub. (3) shall print, and the insurer and its intermediaries shall provide to all prospective purchasers of any policy or rider subject to this section, a copy of “A Shopper’s Guide to Cancer Insurance” at the time the prospect is contacted by the insurer or intermediary with an invitation to apply, as defined in s. Ins 3.27 (5) (g). Ins 3.47(5)(b)(b) “A Shopper’s Guide to Cancer Insurance” shall be printed in an easy-to-read type of not less than 12-pt. size. Ins 3.47 HistoryHistory: Cr. Register, June, 1981, No. 306, eff. 8-1-81; am. (2) to (5), r. (6), r. and recr. Appendix, Register, September, 1990, No. 417, eff. 10-1-90. Ins 3.47 APPENDIX I
A SHOPPER’S GUIDE TO CANCER INSURANCE
Should You Buy Cancer Insurance?
Cancer Insurance is Not a Substitute for Comprehensive Coverage.
Caution: Limitations On Cancer Insurance.
Prepared by the National Association of Insurance Commissioners
CANCER INSURANCE . . .
Cancer insurance provides benefits only if you get cancer. No policy will cover cancer diagnosed before you applied for the policy. Examples of other specified disease policies are heart attack or stroke policies. The information in this booklet applies to cancer insurance, but could very well apply to other specified disease policies.
CANCER INSURANCE IS NOT A SUBSTITUTE FOR COMPREHENSIVE COVERAGE . . .
Cancer treatment accounts for about 10% of U.S. health expenses. In fact, no single disease accounts for more than a small proportion of the American public’s health care bill. This is why it is essential to have insurance coverage for all conditions, not just cancer.
If you and your family are not protected against catastrophic medical costs, you should consider a major medical policy. These policies pay a large percentage of your covered costs after a deductible is paid either by you or your basic insurance. They often have very high maximums, such as $100,000 to $1,000,000. Major medical policies will cover you for any accident or sickness, including cancer. They cost more than cancer policies because they cover more, but they are generally considered a better buy.
SHOULD YOU BUY CANCER INSURANCE? . . . MANY PEOPLE DON’T NEED IT
If you are considering cancer insurance, ask yourself three questions: Is my current coverage adequate for these costs? How much will the treatment cost if I do get cancer? How likely am I to contract the disease?
If you have Medicare and want more insurance, a comprehensive Medicare supplement policy is what you need.
Low income people who are Medicaid recipients don’t need any more insurance. If you think you might qualify, contact your local social service agency.
Duplicate Coverage is Expensive and Unnecessary. Buy basic coverage first such as a major medical policy. Make sure any cancer policy will meet needs not met by your basic insurance. You cannot assume that double coverage will result in double benefits. Many cancer policies advertise that they will pay benefits no matter what your other insurance pays. However, your basic policy may contain a coordination of benefits clause. That means it will not pay duplicate benefits. To find out if you can get benefits from both policies, check your regular insurance as well as the cancer policy.
Some Cancer Expenses May Not Be Covered Even by a Cancer Policy. Medical costs of cancer treatment vary. On the average, hospitalization accounts for 78% of such costs and physician services make up 13%. The remainder goes for other professional services, drugs and nursing home care. Cancer patients often face large nonmedical expenses which are not usually covered by cancer insurance. Examples are home care, transportation and rehabilitation costs.
Don’t be Misled by Emotions. While three in ten Americans will get cancer over a lifetime, seven in ten will not. In any one year, only one American in 250 will get cancer. The odds are against your receiving any benefits from a cancer policy. Be sure you know what conditions must be met before the policy will start to pay your bills.
CAUTION: LIMITATIONS OF CANCER INSURANCE
Cancer policies sold today vary widely in cost and coverage. If you decide to purchase a cancer policy, contact different companies and agents, and compare the policies before you buy. Here are some common limitations:
Some policies pay only for hospital care. Today cancer care treatment, including radiation, chemotherapy and some surgery, is often given on an outpatient basis. Because the average stay in the hospital for a cancer patient is only 13 days, a policy which pays only when you are hospitalized has limited value.
Many policies promise to increase benefits after a patient has been in the hospital for 90 consecutive days. However, since the average stay in a hospital for a cancer patient is 13 days, large dollar amounts for extended benefits have very little value for most patients.
Many cancer insurance policies have fixed dollar limits. For example, a policy might pay only up to $1,500 for surgery costs or $1,000 for radiation therapy, or it may have fixed payments such as $50 or $100 for each day in the hospital. Others limit total benefits to a fixed amount such as $5,000 or $10,000.
No policy will cover cancer diagnosed before you applied for the policy. Some policies will deny coverage if you are later found to have had cancer at the time of purchase, even if you did not know it.
Most cancer insurance does not cover cancer-related illnesses. Cancer or its treatment may lead to other physical problems, such as infection, diabetes or pneumonia.
Many policies contain time limits. Some policies require waiting periods of 30 days or even several months before you are covered. Others stop paying benefits after a fixed period of two or three years.:
FOR ADDITIONAL HELP . . .
If you are considering a cancer policy, the company or agent should answer your questions. You do not need to make a decision to purchase the policy the same day you talk to the agent. Be sure to ask how long you have to make your decision. If you do not get the information you want, call or write
Office of the Commissioner of Insurance
121 East Wilson Street
P.O. Box 7873
Madison, WI 53707-7873
(608) 266-0103
If you have a complaint against an insurance company or agent, write the Office of the Commissioner of Insurance at the address above, or call the Complaints Hotline, 800-236-8517.
Ins 3.49Ins 3.49 Wisconsin automobile insurance plan. Ins 3.49(1)(1) Purpose. This section interprets s. 619.01 (6), Stats., to continue a plan to make automobile insurance available to those who are unable to obtain it in the voluntary market by providing for the equitable distribution of applicants among insurers and outlines access and grievance procedures for such a plan. Ins 3.49(2)(a)(a) “Committee” means the governing committee of the Wisconsin Automobile Insurance Plan which is the group of companies administering the Plan. Ins 3.49(2)(b)(b) “Plan” means the Wisconsin Automobile Insurance Plan, an unincorporated facility established by s. 204.51, 1967 Stats., and continued under s. 619.01 (6), Stats. Ins 3.49(3)(3) Filing and access. The committee shall submit revisions to its rules, rates and forms for the Plan to the commissioner. Prior approval by the commissioner of the documents is required before they may become effective. The documents shall provide: Ins 3.49(3)(a)(a) Reasonable rules governing the equitable distribution of risks by direct insurance, reinsurance or otherwise and their assignment to insurers; Ins 3.49(3)(b)(b) Rates and rate modifications applicable to such risks which shall not be excessive, inadequate or unfairly discriminatory; Ins 3.49(3)(c)(c) The limits of liability which the insurer shall be required to assume; Ins 3.49(3)(d)1.1. A method by which an applicant to the Plan denied insurance or an insured under the Plan whose insurance is terminated may request the committee to review the denial or termination and by which an insurer subscribing to the Plan may request the committee to review actions or decisions of the Plan which adversely affect the insurer. The method shall specify that requests for review must be made in writing to the Plan and that the decision of the committee in regard to the review may be appealed by the applicant, insured or insurer to the commissioner of insurance as provided for in ch. Ins 5. A request for review does stay the termination of coverage. Ins 3.49(3)(d)2.2. The committee’s decision under subd. 1. shall be in writing and shall include notice of the right to a hearing under ch. Ins 5 if the person files a petition for a hearing with the commissioner of insurance not later than 30 days after the notice is mailed. The notice shall describe the requirements of s. Ins 5.11 (1). Ins 3.49 NoteNote: A petition under subd. 2. shall be filed as provided in s. Ins 5.17. Ins 3.49(3)(d)3.3. The office of the commissioner of insurance shall hold a hearing within 30 days after receipt of a complete petition under subd. 2., unless the petitioner waives the right to a hearing within 30 days. At the hearing, the petitioner has the burden of proving by a preponderance of the evidence that the committee’s decision is erroneous under the policy terms or the plan’s rules. Ins 3.49(3)(d)4.4. Filing a petition under subd. 2. does not stay the action of the plan with respect to termination of coverage. The plan shall comply with the final decision and order in the contested case proceeding. Ins 3.49(3)(e)(e) The commissioner shall maintain files of the Plan’s approved rules, rates, and forms and such documents must be made available for public inspection at the office of the commissioner of insurance. Ins 3.49 HistoryHistory: Cr. Register, November, 1984, No. 347, eff. 12-1-84; renum. (3) (d) to be (3) (d) 1. and am., cr. (3) (d) 2. to 4., Register, March, 1996, No. 483, eff. 4-1-96. Ins 3.51Ins 3.51 Reports by individual practice associations. Ins 3.51(1)(1) Definitions. For the purpose of this section only: Ins 3.51(1)(a)(a) “Accountant” means an independent certified public accountant who is duly registered to practice and in good standing under the laws of this state or a state with similar licensing requirements. Ins 3.51(1)(b)(b) “Individual practice association” means an individual practice association as defined under s. 600.03 (23g), Stats., which contracts with a health maintenance organization insurer or a limited service health organization to provide health care services which are principally physician services. Ins 3.51(1)(c)(c) “Work papers” are the records kept by the accountant of the procedures followed, the tests performed, the information obtained, and conclusions reached pertinent to the examination of the financial statements of the independent practice association. Work papers include, but are not limited to, work programs, analysis, memorandum, letters of confirmation and representation, management letters, abstracts of company documents and schedules or commentaries prepared or obtained by the accountant in the course of the examination of the financial statements of the independent practice association and which support the accountant’s opinion. Ins 3.51(2)(2) Filing of annual audited financial reports. Unless otherwise ordered by the commissioner, an individual practice association shall file an annual audited financial report with the commissioner within 180 days after the end of each individual practice association’s fiscal year. This section applies to individual practice associations for fiscal years terminating on or after March 31, 1991. The annual audited financial report shall report the assets, liabilities and net worth; the results of operations; and the changes in net worth for the fiscal year then ended on the accrual basis in conformity with generally accepted accounting practices. The annual audited financial report shall not be presented on the cash basis or the income tax basis or any other basis that does not fully account for all the independent practice association’s liabilities incurred as of the end of the fiscal year. The annual audited financial report shall include all of the following: Ins 3.51(2)(f)(f) Notes to the financial statements. These notes shall include those needed for fair presentation and disclosure. Ins 3.51(2)(g)(g) Supplemental data and information which the commissioner may from time to time require to be disclosed. Ins 3.51(3)(3) Scope of audit and report of independent certified public accountant. Financial statements filed under sub. (2) shall be audited by an independent certified public accountant. The audit shall be conducted in accordance with generally accepted auditing standards. The commissioner may from time to time require that additional auditing procedures be observed by the accountant in the audit of the financial statements of the independent practice association under this rule. Ins 3.51(4)(4) Availability and maintenance of cpa work papers. Ins 3.51(4)(a)(a) An independent practice association required to file an audited financial report under this rule shall, if requested by the office, require the accountant to make available to the office all the work papers prepared in the conduct of the audit. The independent practice association shall require that the accountant retain the audit work papers for a period of not less than 5 years after the period reported. Ins 3.51(4)(b)(b) The office may photocopy pertinent audit work papers. These copies are part of the office’s work papers. Audit work papers are confidential unless the commissioner determines disclosure is necessary to carry out the functions of the office. Ins 3.51(5)(5) Contracts. A health maintenance organization insurer contracting with an independent practice association shall include provisions in the contract which are necessary to enable the individual practice association to comply with this section including, but not limited to:
