23 CAR pt. 84, Appendix F. Long-Term Care Insurance Potential Rate Increase Disclosure Form

APPENDIX F The 2006 NAIC version of this form is required to be used on or after January 1, 2009. Prior to January 1, 2009, the 2000 NAIC version of this form shall continue to be used. Instructions: This form provides information to the applicant regarding premium rate schedules, rate schedule adjustments, potential rate revisions, and policyholder options in the event of a rate increase. Insurers shall provide all of the following information to the applicant: Long-Term Care Insurance Potential Rate Increase Disclosure Form 1. [Premium Rate] [Premium Rate Schedules]: [Premium rate] [Premium rate schedules] that [is][are] applicable to you and that will be in effect until a request is made and approved for an increase [is][are] [on the application][$_____]) 2. The [premium] [premium rate schedule] for this policy [will be shown on the schedule page of] [will be attached to] your policy. 3. Rate Schedule Adjustments: The company will provide a description of when premium rate or rate schedule adjustments will be effective (e.g., next anniversary date, next billing date, etc.) (fill in the blank): __________________. 4. Potential Rate Revisions: This policy is Guaranteed Renewable. This means that the rates for this product may be increased in the future. Your rates can NOT be increased due to your increasing age or declining health, but your rates may go up based on the experience of all policyholders with a policy similar to yours. If you receive a premium rate or premium rate schedule increase in the future, you will be notified of the new premium amount and you will be able to exercise at least one of the following options:  Pay the increased premium and continue your policy in force as is.  Reduce your policy benefits to a level such that your premiums will not increase. (Subject to state law minimum standards.)  Exercise your nonforfeiture option if purchased. (This option is available for purchase for an additional premium.)  Exercise your contingent nonforfeiture rights.* (This option may be available if you do not purchase a separate nonforfeiture option.) * Contingent Nonforfeiture If the premium rate for your policy goes up in the future and you didn’t buy a nonforfeiture option, you may be eligible for contingent nonforfeiture. Here’s how to tell if you are eligible: You will keep some long-term care insurance coverage, if: • Your premium after the increase exceeds your original premium by the percentage shown (or more) in the following table; and • You lapse (not pay more premiums) within 120 days of the increase. The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will equal the total amount of premiums you’ve paid since your policy was first issued. If you have already received benefits under the policy, so that the remaining maximum benefit amount is less than the total amount of premiums you’ve paid, the amount of coverage will be that remaining amount. Except for this reduced lifetime maximum benefit amount, all other policy benefits will remain at the levels attained at the time of the lapse and will not increase thereafter. Should you choose this Contingent Nonforfeiture option, your policy, with this reduced maximum benefit amount, will be considered “paid-up” with no further premiums due. Example: • You bought the policy at age 65 and paid the $1,000 annual premium for 10 years, so you have paid a total of $10,000 in premium. • In the eleventh year, you receive a rate increase of 50%, or $500 for a new annual premium of $1,500, and you decide to lapse the policy (not pay any more premiums). • Your “paid-up” policy benefits are $10,000 (provided you have a least $10,000 of benefits remaining under your policy.) Contingent Nonforfeiture Cumulative Premium Increase over Initial Premium That qualifies for Contingent Nonforfeiture (Percentage increase is cumulative from date of original issue. It does NOT represent a one-time increase.) Issue Age Percent Increase Over Initial Premium 29 and under 200% 30-34 190% 35-39 170% 40-44 150% 45-49 130% 50-54 110% 55-59 90% 60 70% 61 66% 62 62% 63 58% 64 54% 65 50% 66 48% 67 46% 68 44% 69 42% 70 40% 71 38% 72 36% 73 34% 74 32% 75 30% 76 28% 77 26% 78 24% 79 22% 80 20% 81 19% 82 18% 83 17% 84 16% 85 15% 86 14% 87 13% 88 12% 89 11% 90 and over 10% [The following contingent nonforfeiture disclosure need only be included for those limited pay policies to which Sections 28D(4) and 28D(6) of Rule 13 are applicable]. In addition to the contingent nonforfeiture benefits described above, the following reduced “paid-up” contingent nonforfeiture benefit is an option in all policies that have a fixed or limited premium payment period, even if you selected a nonforfeiture benefit when you bought your policy. If both the reduced “paid-up” benefit AND the contingent benefit described above are triggered by the same rate increase, you can chose either of the two benefits. You are eligible for the reduced “paid-up” contingent nonforfeiture benefit when all three conditions shown below are met: 1. The premium you are required to pay after the increase exceeds your original premium by the same percentage or more shown in the chart below; Triggers for a Substantial Premium Increase Percent Increase Issue Age Over Initial Premium Under 65 50% 65-80 30% Over 80 10% 2. You stop paying your premiums within 120 days of when the premium increase took effect; AND 3. The ratio of the number of months you already paid premiums is 40% or more than the number of months you originally agreed to pay. If you exercise this option your coverage will be converted to reduced “paid-up” status. That means there will be no additional premiums required. Your benefits will change in the following ways: a. The total lifetime amount of benefits your reduced paid up policy will provide can be determined by multiplying 90% of the lifetime benefit amount at the time the policy becomes paid up by the ratio of the number of months you already paid premiums to the number of months you agreed to pay them. b. The daily benefit amounts you purchased will also be adjusted by the same ratio. If you purchased lifetime benefits, only the daily benefit amounts you purchased will be adjusted by the applicable ratio. Example: • You bought the policy at age 65 with an annual premium payable for 10 years. • In the sixth year, you receive a rate increase of 35% and you decide to stop paying premiums. • Because you have already paid 50% of your total premium payments and that is more than the 40% ratio, your “paid-up” policy benefits are .45 (.90 times .50) times the total benefit amount that was in effect when you stopped paying your premiums. If you purchased inflation protection, it will not continue to apply to the benefits in the reduced “paid-up” policy.