Prohibition Against Post-Claims Underwriting

01. Health Conditions. All applications for long-term care insurance policies or certificates except those that are guaranteed issue contains clear and unambiguous questions designed to ascertain the health condition of the applicant. (3-31-22) 02. Medication. If an application for long-term care insurance contains a question that asks whether the applicant has had medication prescribed by a physician, it will also ask the applicant to list the medication that has been prescribed. If the medications listed in the application were known by the insurer, or should have been known at the time of application, to be directly related to a medical condition for which coverage would be denied, then the policy or certificate cannot be rescinded for that condition. (3-31-22) 03. Non-Guaranteed Issue. Except for policies or certificates which are guaranteed issue: (3-31-22) IDAHO ADMINISTRATIVE CODE IDAPA 18.04.11 – Long-Term Care Department of Insurance Insurance Minimum Standards Section 016 Page 12 a. The following language is set out conspicuously and in close conjunction with the applicant’s signature block on an application for a long-term care insurance policy or certificate: Caution: If your answers on this application are incorrect or untrue, (company) has the right to deny benefits or rescind your policy. (3-31-22) b. The following language, or language substantially similar to the following, is set out conspicuously on the long-term care insurance policy or certificate at the time of delivery: “Caution: The issuance of this long-term care insurance (policy) (certificate) is based upon your responses to the questions on your application. A copy of your (application) (enrollment form) (is enclosed) (was retained by you when you applied). If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your policy. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact the company at this address: (insert address).” (3-31-22) c. Prior to issuance of a long-term care policy or certificate to an applicant aged eighty (80) or older, the insurer obtains one (1) of the following: (7-1-26) i. A report of a physical examination; (3-31-22) ii. An assessment of functional capacity; (3-31-22) iii. An attending physician’s statement; or (3-31-22) iv. Copies of medical records. (3-31-22) 04. Delivery of Application or Enrollment and Form. A copy of the completed application or enrollment form (whichever is applicable) is delivered to the insured no later than at the time of delivery of the policy or certificate unless it was retained by the applicant at the time of application. (3-31-22) 05. Record of Rescissions. Every insurer or other entity selling or issuing long-term care insurance benefits maintains a record of all policy or certificate rescissions, both state and countrywide, except those that the insured voluntarily effectuated and annually furnishes this information to the insurance director in the format prescribed by the National Association of Insurance Commissioners in Appendix A. (3-31-22) 016. MINIMUM STANDARDS FOR HOME HEALTH AND COMMUNITY CARE BENEFITS IN LONG-TERM CARE INSURANCE POLICIES. 01. Limitations or Exclusions. A long-term care insurance policy or certificate cannot, if it provides benefits for home health care or community care services, limit or exclude benefits: (3-31-22) a. By requiring that the insured or claimant would need care in a skilled nursing facility if home health care services were not provided; (3-31-22) b. By 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 are covered; (3-31-22) c. By limiting eligible services to services provided by registered nurses or licensed practical nurses; (3-31-22) d. By 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 their licensure or certification; (3-31-22) e. By excluding coverage for personal care services provided by a home health aide; (3-31-22) f. By requiring that the provision of home health care services be at a level of certification or licensure greater than that prescribed by the eligible service; (3-31-22) IDAHO ADMINISTRATIVE CODE IDAPA 18.04.11 – Long-Term Care Department of Insurance Insurance Minimum Standards Section 017 Page 13 g. By requiring that the insured or claimant have an acute condition before home health care services are covered; (3-31-22) h. By limiting benefits to services provided by Medicare-certified agencies or providers; or (3-31-22) i. By excluding coverage for adult day care services. (3-31-22) 02. Coverage Equivalency. A long-term care insurance policy or certificate, if it provides for home health or community care services, provides total home health or community care coverage that is a dollar amount equivalent to at least one-half (1/2) of one (1) year’s coverage available for nursing home benefits under the policy or certificate, at the time covered home health or community care services are being received. This requirement cannot apply to policies or certificates issued to residents of continuing care retirement communities. (3-31-22) 03. Maximum Coverage. Home health care coverage may be applied to the non-home health care benefits provided in the policy or certificate when determining maximum coverage under the terms of the policy or certificate. (3-31-22)