Ga. Comp. R. & Regs. R. 120-2-16-.06 - Policy Practices and Provisions
(1) Renewability. The terms "guaranteed
renewable" and "noncancellable" shall not be used in any individual long-term
care insurance policy without further explanatory language in accordance with
the disclosure requirements of Section
120-2-16-.09 of this Regulation:
(a) A policy issued to an individual shall
not contain renewal provisions other than "guaranteed renewable" or
"noncancellable."
(b) The term
"guaranteed renewable" may be used only when the insured has the right to
continue the long-term care insurance in force by the timely payment of
premiums and when the insurer has no unilateral right to make any change in any
provision of the policy or rider while the insurance is in force, and cannot
decline to renew, except that rates may be revised by the insurer on a class
basis.
(c) The term
"noncancellable" may be used only when the insured has the right to continue
the long-term care insurance in force by the timely payment of premiums during
which period the insurer has no right to unilaterally make any change in any
provision of the insurance or in the premium rate.
(d) The term "level premium" may only be used
when the insurer does not have the right to change the premium.
(e) In addition to the other requirements of
this subsection, a qualified long-term care insurance contract shall be
guaranteed renewable, within the meaning of Section 7702B(b)(1)(C) of the
Internal Revenue Code of 1986, as amended.
(2) Limitations and Exclusions. A policy may
not be delivered or issued for delivery in this state as long-term care
insurance if the policy limits or excludes coverage by type of illness,
treatment, medical condition or accident, except as follows:
(a) Preexisting conditions or
diseases;
(b) Mental or nervous
disorders; however, this shall not permit exclusion or limitation of benefits
on the basis of Alzheimer's Disease;
(c) Alcoholism and drug addiction;
(d) Illness, treatment or medical condition
arising out of:
(i) War or act of war (whether
declared or undeclared);
(ii)
Participation in a felony, riot or insurrection;
(iii) Service in the armed forces or units
auxiliary thereto;
(iv) Suicide
(sane or insane), attempted suicide or intentionally self-inflicted injury;
or
(v) Aviation (this exclusion
applies only to non-fare-paying passengers).
(e) Treatment provided in a government
facility (unless otherwise required by law), services for which benefits are
available under Medicare or other governmental program (except Medicaid), any
state or federal workers' compensation, employer's liability or occupational
disease law, or any motor vehicle no-fault law, services provided by a member
of the covered person's immediate family and services for which no charge is
normally made in the absence of insurance;
(f) Expenses for services or items available
or paid under another long-term care insurance or health insurance
policy;
(g) 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 Title XVIII of the Social
Security Act or would be so reimbursable but for the application of a
deductible or coinsurance amount.
(h)
(i) This
subparagraph is not intended to prohibit exclusions and limitations by type of
provider. However, no long-term care issuer may deny a claim because services
are provided in a state other than the state of policy issued under the
following conditions:
(A) When the 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; or
(B) When the state other than the state of
policy issue licenses, certifies or registers the provider under another
name.
(ii) For purposes
of this subparagraph, "state of policy issue" means the state in which the
individual policy or certificate was originally issued.
(i) This subsection is not intended to
prohibit territorial limitations.
(3) Extension of Benefits. Termination of
long-term care insurance shall be without prejudice to any benefits payable for
institutionalization if the institutionalization began while the long-term care
insurance was in force and continues without interruption after termination.
The extension of benefits beyond the period the long-term care insurance was in
force 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 waiting
period, and all other applicable provisions of the policy.
(4) Continuation or Conversion.
(a) Group long-term care insurance issued in
this state on or after the effective date of this section shall provide covered
individuals with a basis for continuation or conversion of coverage.
(b) For the purposes of this subsection, "a
basis for continuation of coverage" means a policy provision that maintains
coverage under the existing group policy when the coverage would otherwise
terminate and which is subject only to the continued timely payment of premium
when due. Group policies that restrict provision of benefits and services to,
or contain incentives to use certain providers or facilities may provide
continuation benefits that are substantially equivalent to the benefits of the
existing group policy. The Commissioner shall make a determination as to the
substantial equivalency of benefits, and in doing so, shall take into
consideration the differences between managed care and non-managed care plans,
including, but not limited to, provider system arrangements, service
availability, benefit levels and administrative complexity.
(c) For the purposes of this subsection, "a
basis for conversion of coverage" means a policy provision that an individual
whose coverage under the group policy would otherwise terminate or has been
terminated for any reason, including discontinuance of the group policy in its
entirety or with respect to an insured class, and who has been continuously
insured under the group policy (and any group policy which it replaced), for at
least six months immediately prior to termination, shall be entitled to the
issuance of a converted policy by the insurer under whose group policy he or
she is covered, without evidence of insurability.
(d) For the purposes of this subsection,
"converted policy" means an individual policy of long-term care insurance
providing benefits identical to or benefits determined by the Commissioner to
be substantially equivalent to or in excess of those provided under the group
policy from which conversion is made. Where the group policy from which
conversion is made restricts provision of benefits and services to, or contains
incentives to use certain providers or facilities, the Commissioner, in making
a determination as to the substantial equivalency of benefits, shall take into
consideration the differences between managed care and non-managed care plans,
including, but not limited to, provider system arrangements, service
availability, benefit levels and administrative complexity.
(e) Written application for the converted
policy shall be made and the first premium due, if any, shall be paid as
directed by the insurer not later than 31 days after termination of coverage
under the group policy. The converted policy shall be issued effective on the
day following the termination of coverage under the group policy, and shall be
renewable annually.
(f) Unless the
group policy from which conversion is made replaced previous group coverage,
the premium for the converted policy shall be calculated on the basis of the
insured's age at inception of coverage under the group policy from which
conversion is made. Where the group policy from which conversion is made
replaced previous group coverage, the premium for the converted policy shall be
calculated on the basis of the insured's age at inception of coverage under the
group policy replaced.
(g)
Continuation of coverage or issuance of a converted policy shall be mandatory,
except where:
(i) Termination of group
coverage resulted from an individual's failure to make any required payment of
premium or contribution when due; or
(ii) The terminating coverage is replaced not
later than thirty-one (31) days after termination, by group coverage effective
on the day following the termination of coverage:
(A) Providing benefits identical to or
benefits determined by the Commissioner to be substantially equivalent to or in
excess of those provided by the terminating coverage; and
(B) The premium for which is calculated in a
manner consistent with the requirements of subparagraph (f) of this
paragraph.
(h) Notwithstanding any other provision of
this Section, a converted policy issued to an individual who at the time of
conversion is covered by another long-term care insurance policy that provides
benefits on the basis of incurred expenses, may contain a provision that
results in a reduction of benefits payable if the benefits provided under the
additional coverage, together with the full benefits provided by the converted
policy, would result in payment of more than 100 percent of incurred expenses.
The provision shall only be included in the converted policy if the converted
policy also provides for a premium decrease or refund which reflects the
reduction in benefits payable.
(i)
The converted policy may provide that the benefits payable under the converted
policy, together with the benefits payable under the group policy from which
conversion is made, shall not exceed those that would have been payable had the
individual's coverage under the group policy remained in force and
effect.
(j) Notwithstanding any
other provision of this Section, an insured individual whose eligibility for
group long-term care coverage is based upon his or her relationship to another
person shall be entitled to continuation of coverage under the group policy
upon termination of the qualifying relationship by death or dissolution of
marriage.
(k) For the purposes of
this Section a "managed-care plan" is a health care or assisted living
arrangement designed to coordinate patient care or control costs through
utilization review, case management or use of specific provider
networks.
(5)
Discontinuance and Replacement.
If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage provided or offered to individuals by the insurer and premiums charged to persons under the new group policy:
(a) Shall not result in an exclusion for
preexisting conditions that would have been covered under the group policy
being replaced; and
(b) Shall not
vary or otherwise depend on the individual's health or disability status, claim
experience or use of long-term care services.
(6)
(a) The
premium charged to an insured shall not increase due to either:
(i) The increasing age of the insured at ages
beyond 65; or
(ii) The duration the
insured has been covered under the policy.
(b) The purchase of additional coverage shall
not be considered a premium rate increase, but for purposes of the calculation
required under Section
120-2-16-.26, the portion of the
premium attributable to the additional coverage shall be added to and
considered part of the initial annual premium.
(c) A reduction in benefits shall not be
considered a premium change, but for purpose of the calculation required under
Section 120-2-16-26, the initial annual premium shall be based on the reduced
benefits.
(7) Electronic
Enrollment for Group Policies.
(a) In the
case of a group defined in O.C.G.A. Section
33-42-4, any requirement that a
signature of an insured be obtained by an agent or insurer shall be deemed
satisfied if:
(i) The consent is obtained by
telephonic or electronic enrollment by the group policyholder or insurer. A
verification of enrollment information shall be provided to the
enrollee;
(ii) The telephonic or
electronic enrollment provides necessary and reasonable safeguards to assure
the accuracy, retention and prompt retrieval of records; and
(iii) The telephonic or electronic enrollment
provides necessary and reasonable safeguards to assure that the confidentiality
of individually identifiable information and "privileged information" as
defined by O.C.G.A. Chapter 33-39, is maintained.
(b) The insurer shall make available, upon
request of the Commissioner, records that will demonstrate the insurer's
ability to confirm enrollment and coverage amounts.
Notes
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