Cal. Code Regs. Tit. 22, § 58060 - Required Provisions for Partnership Policies and Certificates

Partnership Long Term Care Policies or Certificates shall contain the following provisions:

(a) a provision that benefits may not be paid in excess of actual charges.

(b) a provision that the long-term care services covered by the Partnership Policy or Certificate may not be delivered by a member of the individual's family, unless:

(1) the family member is a regular employee of an organization which is providing the services; and

(2) the organization receives the payment for the services; and

(3) the family member receives no compensation other than the normal compensation for employees in his or her job category.

(c) a provision to protect against unintentional lapse that provides the following:

(1) No individual long-term care Policy or Certificate shall be issued until the Issuer has received from the applicant either of the following:

(A) A written designation of at least one Authorized Designee, in addition to the applicant, who is to receive notice of lapse or termination of the Policy or Certificate for nonpayment of premium.

(B) A written waiver dated and signed by the applicant electing not to designate additional persons to receive notice.

(2) The applicant has the right to designate at least one Authorized Designee who is to receive the notice of termination, in addition to the insured. Designation shall not constitute acceptance of any liability on the third party for services provided to the insured. The form used for the written designation must provide space clearly designated for listing at least one Authorized Designee. The designation shall include each Authorized Designee's full name and home address. The Issuer shall notify the insured of the right to change this written designation, no less often than once every two years. In the case of an applicant who elects not to designate an additional person, the waiver shall state:

"Protection Against Unintended Lapse.

I understand that I have the right to designate at least one Authorized Designee other than myself to receive notice of lapse or termination of this long-term care insurance policy for nonpayment of premium. I understand that notice will not be given until 30 days after a premium is due and unpaid. I elect not to designate any person to receive this notice."

(3) When the Policy or Certificate holder pays the premium for a Partnership Long-Term Care Insurance Policy or Certificate through a payroll or pension deduction plan, the requirements contained in paragraph

(1) need not be met until 60 days after the Policy or Certificate holder is no longer on that deduction payment plan. The application or enrollment form for a Partnership Long-Term Care Insurance Policy or Certificate shall clearly indicate the deduction payment plan selected by the applicant.

(4) No individual long-term care Policy or Certificate shall lapse or be terminated for nonpayment of premium unless the Issuer, at least 30 days prior to the effective date of the lapse or termination, gives notice to the insured and to those Authorized Designees named pursuant to paragraph (1), at the address provided by the insured for purposes of receiving notice of lapse or termination. Notice shall be given by first-class United States mail, postage prepaid, no less than 30 days after a premium is due and unpaid. Notice shall be deemed to have been given as of five days after the date of mailing.

(5) In addition to the requirement in Subsection (c)(1), a Partnership Long-Term Care Insurance Policy or Certificate shall include a provision which, in the event of lapse, provides for reinstatement of coverage, if the Issuer is provided with proof of the insured's Cognitive Impairment or loss of functional capacity. This option shall be available to the insured if requested within five months after termination and shall allow for the collection of past due premium, where appropriate. The standard of proof of Severe Cognitive Impairment or loss of functional capacity shall not be more stringent than the benefit eligibility criteria on Severe Cognitive Impairment or the loss of functional capacity contained in the Policy or Certificate.

(d) a provision that benefits shall only be paid after the payment of all other benefits to which the Policy or Certificate holder is otherwise entitled, excluding Medi-Cal. The Issuer shall make reasonable efforts to determine whether benefits are available from other policies or certificates or from Medicare. Benefits are not payable for Medicare co-payments and deductibles.

(e) a statement on the outline of coverage, the Policy or Certificate application, and the Policy or Certificate in bold type and in a separate box as follows:

"THE BENEFITS PAYABLE BY THIS POLICY [CERTIFICATE] QUALIFY FOR MEDI-CAL ASSET PROTECTION UNDER THE CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE.

ELIGIBILITY FOR MEDI-CAL IS NOT AUTOMATIC. IF AND WHEN YOU NEED MEDI-CAL, YOU MUST APPLY AND MEET THE ASSET STANDARDS IN EFFECT AT THAT TIME. UPON BECOMING A MEDI-CAL BENEFICIARY, YOU WILL BE ELIGIBLE FOR ALL MEDICALLY NECESSARY BENEFITS MEDI-CAL PROVIDES AT THAT TIME, BUT YOU MAY NEED TO APPLY A PORTION OF YOUR INCOME TOWARD THE COST OF YOUR CARE. MEDI-CAL SERVICES MAY BE DIFFERENT THAN THE SERVICES RECEIVED UNDER THE PRIVATE INSURANCE.

(f) a provision that, in the event a non-Medicaid national or State long-term care program is created through public funding that substantially duplicates benefits covered by Partnership Policies or Certificates, the Policy or Certificate holder will be entitled to be compensated as follows:

(1) for Policies or Certificates issued before January 1, 1997, or for Policies or Certificates issued after January 1, 1997 that are not federally tax-qualified, the Policy or Certificate holder will be entitled to select either a partial refund of premiums paid or a reduction in future premiums. An actuarial method for determining the premium refunds and premium reductions will be mutually agreed upon by the Department of Insurance and the Issuers. The amount of the premium refunds and reductions to be made by each Issuer will be based on the extent of the duplication of covered benefits, the amount of past premium payments, and claims experience. Each participating Issuer's premium refund and reduction plans shall be filed and approved by the Department of Insurance.

(2) for Policies or Certificates issued after January 1, 1997, that are federally tax-qualified, the Policy or Certificate holder will be entitled to select either a reduction in future premiums or an increase in future benefits. An actuarial method for determining the premium reductions and increases in future benefits will be mutually agreed upon by the Department of Insurance and the Issuers. The amount of the premium reductions and benefit increases to be made by each Issuer will be based on the extent of the duplication of covered benefits, the amount of past premium payments and claims experience. Each participating Issuer's premium reduction and benefit increase plans shall be filed and approved by the Department of Justice.

(g) a provision for a waiver of premium as specified in Section 58065(d).

Notes

Cal. Code Regs. Tit. 22, § 58060

1. New section filed 8-30-93 as an emergency; operative 8-30-93 (Register 93, No. 36). Submitted for printing only pursuant to section 22009, Welfare and Institutions Code.
2. Certificate of Compliance as to 8-30-93 order, including repealer of subsection (a) and subsection relettering, and amendment of newly designated subsections (c)(5) and (e) transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No. 4).
3. Amendment filed 1-23-97 as an emergency; operative 1-23-97 (Register 97, No. 10). A Certificate of Compliance must be transmitted to OAL by 5-23-97 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction of HISTORY 3 (Register 97, No. 27).
5. Certificate of Compliance as to 1-23-97 order transmitted to OAL 5-21-97 and filed 7-1-97 (Register 97, No. 27).
6. Amendment of section heading, first paragraph and subsections (b), (c)(3), (c)(5) and (d)-(f) filed 10-1-98 as an emergency; operative 10-1-98. Submitted to OAL for printing only pursuant to Welfare and Institutions Code section 22009(d) (Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-29-99 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 10-1-98 order transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No. 12).

Note: Authority cited: Section 22009(a), Welfare and Institutions Code. Reference: Section 22005, Welfare and Institutions Code.

1. New section filed 8-30-93 as an emergency; operative 8-30-93 (Register 93, No. 36). Submitted for printing only pursuant to section 22009, Welfare and Institutions Code.
2. Certificate of Compliance as to 8-30-93 order, including repealer of subsection (a) and subsection relettering, and amendment of newly designated subsections (c)(5) and (e) transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No. 4).
3. Amendment filed 1-23-97 as an emergency; operative 1-23-97 (Register 97, No. 10). A Certificate of Compliance must be transmitted to OAL by 5-23-97 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction of History 3 (Register 97, No. 27).
5. Certificate of Compliance as to 1-23-97 order transmitted to OAL 5-21-97 and filed 7-1-97 (Register 97, No. 27).
6. Amendment of section heading, first paragraph and subsections (b), (c)(3), (c)(5) and (d)-(f) filed 10-1-98 as an emergency; operative 10-1-98. Submitted to OAL for printing only pursuant to Welfare and Institutions Code section 22009(d) (Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-29-99 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 10-1-98 order transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No. 12).