The State of California has no regulatory oversight of care management organizations, other than those that provide services to California Partnership policyholders, so it is prudent for agents to ask their insurers what type of care management/advisory/coordination services they offer and how it is provided to the insured.
All TQ policyholders have the benefit of having a qualified licensed health care professional evaluate their need for care, and, with the policy holder’s input, develop a customized plan of care, necessary to help them maintain as much independence in the most efficient way possible.
Before payment of care will be paid under the policy, a face-to-face assessment (comprehensive evaluation) of each individual’s needs, health, social, environmental, financial and support systems should be performed by a care management agency, after which, a plan of care is designed for the individual to fit their needs in regard to level of services and costs.
The plan is monitored to be sure that it is working and to determine if and when changes to the plan are required.
“Licensed health care practitioner” means a physician, registered nurse, licensed social worker, or other individual whom the Secretary of the United States Department of the Treasury may prescribe by regulation.
A licensed health care practitioner, independent of the insurer, shall certify that the insured meets the definition of “chronically ill individual” as defined under Public Law 104-191. If a health care practitioner makes a determination, pursuant to this section, that an insured does not meet the definition of “chronically ill individual,” the insurer shall notify the insured that the insured shall be entitled to a second assessment by a licensed health care practitioner, upon request, who shall personally examine the insured. The requirement for a second assessment shall not apply if a practitioner who otherwise meets the requirements of this section and who personally examined the insured performed the initial assessment. The assessments conducted pursuant to this section shall be performed promptly with the certification completed as quickly as possible to ensure that an insured’s benefits are not delayed.
The written certification shall be renewed every 12 months. A licensed health care practitioner shall develop a written plan of care after personally examining the insured. The costs to have a licensed health care practitioner certify that an inured meets, or continues to meet, the definition of “chronically ill individual,” or to prepare written plans of care shall not count against the lifetime maximum of the policy or certificate. In order to be considered “independent of the insurer,” a licensed health care practitioner shall not be an employee of the insurer and shall not be compensated in any manner that is linked to the outcome of the certification. It is the intent of this subdivision that the practitioner’s assessments be unhindered by financial considerations.
This subdivision shall apply only to a policy or certificate intended to be a federally qualified long-term care insurance contract. 238
Case management agencies usually consist of a multidisciplinary team (such as nurses; health care and social workers whose profession and training include experience and/or expertise in managing and arranging for long-term care services) under medical direction that will do the following:
“Plan of Care” means a written individualized plan of services approved by a health care practitioner which specifies the type, frequency, and providers of all formal and informal Long-Term Care services required for the individual, and the cost, if any, of any formal long-term care services prescribed.239 The Plan of Care identifies the type, frequency, and providers of all formal and informal care providers including the costs. This plan incorporates the services covered by the LTC policy, Medicare, other insurance coverage, community sponsored services and programs, and care available from family and friends, in a way to make the most of the insureds benefit dollars. The assessment is conducted, and plan of care revised, at least every 6 months.
Changes in the Plan of Care must be documented to show that such alterations are required by changes in the clients’ medical situation, functional and/or cognitive abilities, behavior abilities or the availability of support services.
The insurer should pay for all initial assessments, reassessments and Plans of Care. The cost of these assessments and plans of care should not reduce the policyholder’s “pool of dollars” as it is a separate benefit under the policy.
The criteria to determine eligibility for benefits are based on either the inability to perform activities of daily living and/or cognitive limitation. The definitions of ADLs used in the policy must be those listed in the California Insurance Code for TQ or NTQ policies.
The insured qualifies for a benefit when they meet the policy requirements, i.e. when they meet the policy “triggers.” The determination of how and when the benefits will be paid is, obviously, extremely important. Exactly what will trigger benefits is doubly important when the decision has to be made whether to purchase a tax-qualified (TQ) or non-tax-qualified (NTQ plan. In order to make this very important decision, the agent must be able to fully explain the difference in policy triggers so that the purchaser understands completely what is required before benefits will be paid.
In the past LTCI policies paid benefits when a doctor determined that it was medically necessary for the insured to be in a nursing home or receive long-term care. The laws are standard in most respects on the person being diagnosed with a cognitive impairment as a legitimate benefit trigger for long-term care policies. Certain federal requirements mandate that certain tests be used in determining cognitive impairments. Differences between federal and state laws are in respect to the inability to perform ADLs.
Previously, California State law previously required the inability to perform any of 7 ADLs, Federal law requires tax-qualified LTCI policies to have only six ADLs. Further, the federal requirements may make it harder to receive benefits that under the state (non-tax-qualified) policies. This disparity is particularly noticeable when qualifying for short episodes of long-term care.
In every long-term care policy or certificate that covers care in a nursing facility, the threshold establishing eligibility for nursing facility care shall be no more restrictive than a provision that the insured will qualify if either one of two criteria are met:
This means that no insurer can require impairment in more than two ADLs for any covered benefit, whether the policy is tax-qualified or non-tax-qualified, home care, assisted living or nursing facility. "If federal law or regulations allow other types of disability to be used, the commissioner shall promulgate emergency regulations to add those other criteria as a third threshold to establish eligibility for benefits."250
"Each insurer that offers long-term care coverage pursuant to Section 10232.2 may make available at the time of a solicitation the following notice in a separate document, in 12-point type, to be signed and dated by the applicant and agent or insurer, with a copy provided to the applicant and the original maintained in accordance with paragraph (8) of subdivision (c) of Section 10508:IMPORTANT NOTICE (b) The notice required by subdivision (a) shall be made available by employers to employees and dependents who are offered by employers a choice of the two types of policies described and apply for coverage. (c) The Commissioner, after consulting with the Health Insurance Counseling and Advocacy Program, and after issuing a public notice and receiving public comments, may approve modifications to the language in the notice set forth in subdivision (a), if the modifications (1) are warranted based on federal or state laws, federal regulations, or other relevant federal decisions, and (2) are strictly limited to those necessary to ensure that the summary notice required by this section does not provide false or misleading information.105
HIPAA (Health Insurance Portability & Accountability Act of 1996—See Attachment 1 in Appendix) legislation is specific for receiving benefits under a tax-qualified policy. The Act is quite specific, defining tax-qualified long-term care services and further defines the conditions to be met to receive benefits.
All tax-qualified policies use the prescribed language, or language to accomplish the same ends.
NOTE: When “Qualified” is used as a defining adjective, it is referring to “Tax Qualified” issues.
Qualified long -term care services are:
For a long-term care policy or certificate that is intended to be a federally qualified Long-term-care insurance contract and that provides home care benefits, the California Code that establishes the eligibility for home care benefits must be that the person has been determined to be “chronically ill, which is determined by the person either being so impaired that they cannot perform two out of six activities of daily living, or suffers severe cognitive impairment.106
The definitions to be used in policies and certificates for impairment in activities of daily living, “impairment in cognitive ability,” and any third eligibility criterion adopted by regulation shall be the same (verbatim) definitions of these benefit eligibility triggers that are allowed by federal regulations. The Insurance Commissioner can approve, and in most cases, will approve, additional descriptive language to be added to the definitions provided the additional language is (1) warranted based on federal or state laws, federal or state regulations, or other relevant federal decision, and (2) strictly limited to that language which is necessary to ensure that the definitions of the regulations are not misleading to the insured. 107
If federal law or regulations allow other types of disability to be used, the Commissioner shall provide emergency regulations that will add to the criteria, creating a third threshold to establish eligibility for benefits. When these emergency regulation occur, the insurers shall submit policies for approval within 60 days of the effective date of the regulations, or if the policies have been previously approved, the Insurance Department will review only the changes made to the policies. All new policies that are approved and certificates are issued after the effective date of the regulation shall include the third criterion and no policy may be sold does that does not include this third criterion for a period of 1 year after the effective date of the regulations. An insured meeting this third criterion shall be eligible for benefits regardless of whether the individual meets the impairment requirements in paragraph (1) or (2) regarding activities of daily living and cognitive ability.107A
An individual is chronically ill if they have been certified by a licensed health care practitioner within the previous 12 months as one of the following:
1) They are unable for at least 90 days, to perform at least two activities of daily living without substantial assistance from another individual due to loss of functional capacity. Activities of daily living are eating, toileting, transferring, bathing, dressing and continence,
(2) (or) They require substantial supervision to be protected from threats to health and safety due to severe cognitive impairment.
Non-qualified policies use similar benefit triggers but usually add a third trigger: “If deemed medically necessary.” These policies also leave out the restrictive language “for at least 90 days.” On the other hand this is offset by the fact that the insurance company often determines eligibility with non-qualified; whereas, a third party, impartial, licensed health care practitioner certifies eligibility under qualified policies. Cognitive impairment covers Alzheimer’s, stroke, dementia and other organic nervous disorders under both policy forms.
Tax-qualified policies include a definition required by the IRS, that lessens the perceived advantage of the non-qualified contracts. TQ contracts define “substantial assistances” as “stand-by” assistance, meaning that this is not “hands-on” care and just verbal encouragement can be considered as substantial assistance. This definition could easily make it simpler to qualify for benefits with a qualified contract than with a non-qualified contract.
Agents should understand and be able to explain the definitions used in the contract under discussion. The difference in transferring or “transferring including ambulating activities” when used as definition for ADLs in a LTCI policy may make a difference in qualifying for benefits and the kind of benefits received.
Definitions may change but for the present, IRS notice 97-31 provides definitions that are appropriate. The following definitions are those addressed in IRS 97-31;
The definitions of “activities of daily living” to be used in policies and certificates that are intended to be federally qualified long-term care insurance, shall consist of the following until such time that these definitions may be superseded by federal law or regulations:
(a) Transferring, which shall mean the ability to move into or out of bed, a chair or wheelchair, or
(b) Transferring, which shall mean the ability to move into and out of a bed, a chair, or- wheelchair, or ability to walk or move around inside or outside the home, regardless of the use of a cane, crutches, or braces.
A tax qualified LTCI policy is not required to recognize any ADL in order to determine whether an individual is chronically ill under the cognitive impairment requirement. It is quite possible for a person who is cognitively impaired—indeed, severely cognitively impaired—to perform activities of daily living without assistance, but still they would require considerable supervision.
“Impairment of cognitive ability” means that the insured needs “substantial supervision” due to “severe cognitive impairment.”
“Severe cognitive impairment” means a loss or deterioration in intellectual capacity that is comparable to (and includes) Alzheimer’s disease and similar forms of irreversible dementia; and measured by clinical evidence and standardized tests that reliably measure impairment in the individual’s short-term or long-term memory, orientation as to people, places, or time, and deductive or abstract reasoning.
“Substantial supervision” means continual supervision (which may include cueing by verbal prompting, gestures, or other demonstrations) by another person that is necessary to protect the severely cognitively impaired individual from threats to his or her health or safety (such as may result from wandering around).
In every long-term care policy or certificate that is not intended to be a federally qualified long-term care insurance contract and provides home care benefits, the threshold establishing eligibility for home care benefits shall be at least as permissive as a provision that the insured will qualify if either one of two criteria are met:
The policy or certificate may provide for lesser but not greater eligibility criteria. The Commissioner, at his or her discretion, may approve other criteria or combinations of criteria to be substituted, if the insurer demonstrates that the interest of the insured is better served.109
“Impairment in activities of daily living” means that the insured needs “human assistance,” or “continual substantial supervision.”
“Activities of daily living” in every policy or certificate that is not intended to be a federally qualified long-term care insurance contract and provides home care benefits shall include eating, bathing, dressing, ambulating, transferring, toileting, and continence;
The definitions of “activities of daily living” to be used verbatim in policies and certificates that are not intended to qualify for favorable tax treatment under Public Law 104-191 shall be the following:111
There are differences between the tax-qualified and the non-tax-qualified ADL requirements and the agent should be able to explain the differences. For instance, eating under the TQ ADL— if the person could “eat” by using a feeding tube, or by using his fingers, they would not be considered as impaired, but under an NTQ plan, if they could not use a fork or spoon, they would be considered as impaired.
“Impairment of cognitive ability” means deterioration or loss of intellectual capacity due to organic mental disease, including Alzheimer’s disease or related illnesses, that requires “continual supervision” to protect the insured or others.
California requires seven activities of daily living, compared to six required by federal law for tax-qualified policies. Since Federal law is more restrictive, it may be more difficult to meet the six federal requirements than the California seven. However, the federal requirements have some flexibility that partially compensates for the differences.
The most apparent difference is that TQ policies do not use the 7th ADL, Ambulating. On the other hand, at the option of the insurer, a TQ policy can use the inability to walk as part of their definition for Transferring. Since the inability to walk is usually accompanied by inability to bathe, use the toilet or dress—ADLs under both TQ and NTQ policies.
As mentioned above, the ADL of eating is quite different between the policies, but in actual practice this does not really mean much as most people would have qualified for coverage under other ADL requirements before they need assistance with eating.
Bathing is ordinarily the first ADL that is impaired, covered under both forms. Since policies require that the insured need assistance with two ADLs before he is eligible for coverage, the second coverage trigger is usually bathing, which usually means that assistance with dressing is also needed—both covered under both forms.
While federal law also requires that the insured be certified as needing assistance with activities of daily living for a period of 90 days or longer before benefits may be paid, California law requires only that the insurer obtain a written declaration from a doctor or other independent source that services are needed. This certification must contain an estimate from the physician or other medical professional that the condition will last at least for 90 days
This requirement was designed to try to make sure that benefits are payable only to those whose impairment requires long-term care. If the condition does not last a full 90 days, the insured is not required to return the benefits received. If it ends up lasting less, the insured does not have to pay back the benefits received. The end result, it is hoped, will keep the coverage available for those situations where it is really needed and also help to stabilize the premiums.
Now comes trade-off time. While qualified policies may allow certain tax advantages, qualifying for benefits may be more difficult for short stays. California requirements may not allow some tax advantages but it may be easier to qualify for benefits.
Under federal regulations, tax-qualified LTCI may not have a lesser requirement than severe cognitive impairment of inability to perform at least two of the six ADLs. However, a non-tax qualified policy only has to meet the state requirements. The trade off is, of course, whether the tax consequences offset the more liberal benefit qualifications, or vice versa.
It must be kept in mind that the benefit triggers are the keys to receive long-term care benefits and regardless if the policy is tax-qualified or not, the eligibility of the insured to receive benefits depends upon the ADLs that are necessary to be impaired in order to obtain benefits. It is critical that the insured understand the ADL requirements to receive benefits and the way that the impairment is defined determines who will receive benefits.
The most frequent impairments with California seniors are bathing, dressing, and continence.
All TQ policies use the words “stand-by” in their definitions of the level of assistance with ADLs required to trigger coverage. Please note the importance of the “stand-by” definition of need for care:
• A policy with a “hands-on” definition will not pay benefits nearly as soon as one with a “stand-by” definition.
• All tax-qualified policies use a “stand-by” definition by federal law, however many non-tax-qualified policies use a “hands-on” type of definition, which may actually make it easier to qualify for benefits.
Significantly larger numbers of individuals are deemed impaired if disability is defined as stand-by assistance than if designed as requiring hands-on assistance to perform the activities of daily living. All tax-qualified policies define ADLs in terms of “stand-by” level of disability.
Some LTCI policies, non-tax qualified, define care or service as the physical touching of the insured, most use the definitive term “hands-on” and other NTQ policies define impairment as when the insured cannot perform an ADL without assistance of another person. NTQ policies in California require 2 out of 6 ADLs as qualification for benefits and approximately 25% of those policyholders are age 65 or older Some non-tax-qualified policies use “hands-on,” or similar language in their definitions . A common definition of impairment in an NTQ policy is “cannot perform the ADL without the assistance of another person.” Using 2 out of 6 ADLs, approximately twenty-five percent additional Californians 65 and over would qualify for insurance benefits if eligibility were defined as requiring stand-by assistance instead of requiring the physical assistance of another person. In many cases—if not most cases—the “stand-by assistance would be needed sooner than “hands-on” assistance, therefore they would receive benefits earlier.
The “stand-by” coverage would come into play if the insured was able to eat with someone cutting up the food, for instance, or if they could bathe themselves, but could not maneuver getting into or out of the tub. Perhaps they could dress themselves except for needing help with zippers and buttons, or they could move from place to place in the house but have a balance problem, so they would need someone to “lean on” in moving on stairs or moving around the kitchen. If the individual needs assistance at the "stand-by" level, the policy benefits could be available under a TQ policy.
Conversely, using the “Hands-on” definition would usually mean that he insured must not be able to perform the ADLs without the assistance of another person. Therefore, if the person in the example just discussed could bathe, eat, move, etc., with another person providing help only when needed, then they probably would not qualify under the policy.113
While both the TQ and NTQ policies define cognitive impairment as a person having a mental impairment that requires continual supervision, for their own protection and for the protection of others in both type of policies, the TQ policy is specific as to how the insured will be diagnosed as having a cognitive impairment, —the NTQ policies had no such instructions.
The California Code states that prior to the payment of benefits for any care covered by the terms of a LTCI policy, whether TQ or NTQ, the insurer may verify that the insured requires care covered under the policy by a written declaration by a physician, independent needs assessment agency, or other source of independent judgment suitable to the insurer—getting a second opinion (see below).
Under the California Code, prior to June 30th each years, every LTCI insurer must report the total number of claims denied by each class of business in the state and the number of these claims denied for failure to meet the waiting period or because of a pre-existing condition as of the end of the preceding calendar year.
"The insurer shall also provide every policyholder or certificate holder whose claim is denied a written notice within 40 days of the date of denial of the reasons for the denial and all information directly related to the denial. Insurers shall annually report to the Department the number of denied claims. The Department shall make available to the public, upon request, the denial rate of claims by insurer."114
"Every policy or certificate shall include a provision giving the policyholder or certificate holder the right to appeal decisions regarding benefit eligibility, care plans, services and providers, and reimbursement payments."115
"If a health care practitioner makes a determination, … that an insured does not meet the definition of 'chronically ill individual,' the insurer shall notify the insured that the insured shall be entitled to a second assessment by a licensed health care practitioner, upon request, who shall personally examine the insured. The requirement for a second assessment shall not apply if a practitioner, … and who personally examined the insured, performed the initial assessment. The assessments conducted pursuant to this section shall be performed promptly with the certification completed as quickly as possible to ensure that an insured’s benefits are not delayed. The written certification shall be renewed every 12 months. A licensed health care practitioner shall develop a written plan of care after personally examining the insured."116
Underwriting and related claims practices have been focal points of Long-term Care Insurance consumer protection issues. Many of the original underwriting problems arose because insurers offering this new product had no broad base of experience from which to establish probabilities of loss ‑ a factor that is imperative to the “spread of risk” concept underlying all insurance.
Added to the lack of statistical data were the inherent risks in the targeted insureds: older people who generally experience more medical problems than the population as a whole.
Even with the earliest policies, insurers generally were willing to cover insureds with certain medical conditions that might eliminate people as prospects for other types of insurance. Insurer’s recognized that, considering the age of the targeted population, there simply would be no prospect pool for this type of coverage if medical underwriting guidelines were too restrictive.
However, attempting to offset or balance their own risk, insurers also built into their policies stringent limitations and exclusions, some of which effectively denied coverage for many insureds when they finally needed to use the insurance benefits.
The resulting complaints led to many of the newer policy features discussed in this course and to consumer protection enhancements. Some of these have been implemented, others proposed, including NAIC model policy regulations.
Underwriting techniques and procedures of Long-Term Care Insurance policies somewhat resemble that of Major Medical Insurance underwriting. When LTC Insurance policies were first introduced to an insurance company, invariably a Major Medical Underwriter would become a LTC Insurance underwriter. At the present time, through the process of underwriter-training- underwriter, the companies writing LTC Insurance will have trained underwriters with LTC Insurance underwriting experience.
While Major Medical underwriting covers the physical condition of the applicant, a LTC Insurance underwriter is also concerned with the mental status of the applicant, and is very sensitive to senility, dementia, Alzheimer’s disease and chronic disabilities. The principal underwriting tool to determine the mental status of an applicant, is a “Cognitive Interview,” either by telephone, or face-to-face.
“Cognitive impairment” usually is defined as the lack of adequate awareness and perception, as well as the ability to understand and reason that will allow an individual to function independently. This is a legal description and is often used as a trigger for LTCI benefits. An insured may be able to bath, dress, eat and otherwise take care of themselves physically, but if they have a cognitive impairment as defined by the law (HIPAA) and attested to by a licensed health care practitioner, they are entitled to benefits under the tax-qualified plan (and under most all LTCI plans).
This test is almost always required for applicants age 75 or older, or younger if there is some underwriting reason to suspect a cognitive impairment. While underwriters tend to discount any situation where a person who is otherwise able to take care of themselves, become flustered at the interview and fail the test, it has happened.
For insurance underwriting purposes, cognitive impairment is often defined as a deficiency in a person’s short or long-term memory; orientation as to person, place and time; deductive or abstract reasoning; or judgment as it related to safety awareness.117 It must be understood that a cognitive impairment does not always mean that the person is suffering from Alzheimer’s disease, although the test is designed to alert the underwriters that a person may have this disease. Alzheimer’s symptoms include forgetfulness, confusion about where one is, and other signs, such as forgetting one’s own name. Further, these patients may experience mood swings, poor judgment and other changes in behavior. Often, these indications of Alzheimer have become apparent.
While insurance companies produce statistics about the frequency of Alzheimer’s, it actually is less common that one would be led to believe. But if an underwriter thinks that the applicant has any early signs of Alzheimer’s, the applicant will be refused coverage. Of course, once a person is insured, if they then develop Alzheimer’s, they are covered.
One insurer’s statistics claims that 10 percent of those over age 65 will have Alzheimer’s, and the incidence increases with age. However, authorities on Alzheimer’s maintain that the vast number of people that are age 79 will not have the disease and that it totally true also for those in their early 80s. Therefore, Alzheimer’s is not inevitable. And short-term memory loss does not necessarily mean Alzheimer’s.
One of the major writers of LTCI rejects any applicant that has any form of aphasia, confusion or mental and nervous conditions that have caused hospitalization within the past 24 months. A benign brain tumor unoperated will cause a decline. Several companies specifically prohibit those with manic depression and many will impose a waiting period of up to 6 months for those who have had a mild depression.
In actuality, the screening for cognitive impairment may begin with the first visit of an agent with a prospective insured. An agent is required to ask certain questions that could disqualify an applicant, including treatment for neurological syndromes such as Parkinson’s – as well as physical history such as juvenile diabetes, etc. The applicant must fill out an application and their physician will also be provided with a form to be completed. Agents notify the applicant that they may be subject to the telephone conversation with the insurer.
If the individual fumbles the telephone interview, then they will usually be required to have a face-to-face interview, particularly is they are over age 75. Interestingly, most of the face-to-face interviews are with women applicants, usually widowed or divorced, and often are driven by the desires of their children. These interviews are rather expensive for the insurer so they are usually ordered only when the age requires it or medical records reflect a short-term memory concern. The additional hazard to an applicant other than being refused coverage due to a cognitive impairment is that during the interview an answer to another question might cause a rejection of the application by the home office underwriter.
While this is, indeed, a test, the insurance companies usually ask their agent to help prepare their clients for the fact-to-face interview. The agent, at the very least, should explain the type of questions to expect and what documents and lists to have convenient. They should be prepared for a meeting to last at least 30 minutes, unless the applicant has a long list of medical problems that need to be discussed, in which case it could last as long as 45 minutes.
Nearly all insurers previously would not allow another person present during the interview, for several reasons, including the fact that they felt that without a witness, the examiner’s word could not be questioned. There were no “lifelines” allowed. Nor is there any written or recorded transcription of the interview. Surprisingly to some, very rarely does the applicant ask for a copy of the test. If they are asked, they generally just tell the applicant that they will hear from the agent.
The interviewers will leave their card with the applicant and if there are telephone calls from the applicant after the exam, it almost always is to report or clarify additional medical information – usually because the applicant is afraid that they would be considered as cheating the company without a fully detailed medical history.
Companies have relaxed their prohibition against having another person in the room during the interview when the insurer feels that it will benefit them (the insurer). For instance in some cases, if there is a caregiver present, it will reduce the strain on the applicant and the caregiver can help if the applicant becomes disturbed at all of the questions being asked, particularly the recalling of the test “words.” Caregivers know their employers well enough in most cases so that they can keep a lid on situations that might get out of hand. Of course, if the caregiver speaks during the interview, that must be noted on the interview report.
Sometimes, having a caregiver can be beneficial just by the fact of having one, as many companies much prefer applicants who have someone nearby in case of emergency and they also provide a means for the applicant to become more socially involved. However, while it may be easier for the caregiver – particularly if they are a relative – to describe medication and pronounce the names and explain its use better than the applicant, the insurance company still wants to hear it from the applicant, not someone else.
Companies usually offer a discount if they write two LTCI policies on a husband and wife – usually the policies must be the same as to amount, etc. In those cases, the insurers do allow both spouses to be present during the interview. However, when this occurs, the interviewer will use different words for the delayed word recall list. In any event, they cannot “help” each other remember the words.
F Not all insurers use the same recall tests, some have their own versions. Others may accept other company’s format, but they are essentially the same in most respects, and variations are usually not significant.
The steps taken by the examiner may vary by company, but basically the following steps are included in all such interviews.
The interviewer collects and verifies name, address, telephone number, social security numbers, and other such information.
During the interview, the interviewer is making observations of their own as to the living conditions, the grooming and demeanor of the client, etc. Of course they also look for such items as wheelchairs, walkers, canes or crutches, or any other indication that the applicant needs assistance in their daily living.
Other questions will be asked, such as asking for a driver’s license (if they cannot drive, why not?), in case of an emergency, who will take care of you?
In asking medical questions, sometimes applicants get upset as they had supplied such information to the agent and feel that any further questions is questioning their honesty. However, it is very important that the applicant be able to answer questions about hearing loss, disabling headache, etc., as anyone who cannot answer questions about such conditions is simply not a good risk.
One other word about medication – an agent should asks the applicant to make sure that they have all of their medication bottles (containers) present when the interviewer arrives as that will speed up the interview and what better proof of an individual being able to take care of themselves than managing a complex arrangement of medications efficiently?
In respect to underwriting guides, every insurer has their own and they can differ. Agents should be familiar with the underwriting guides of every company that they represent and they should be reviewed before meeting with the prospect. The agent also has the responsibility of reviewing the completed application and all other necessary paperwork before forwarding it to the insurer.
Agents should never “guess” as to how an application will be underwritten if the applicant does not have some condition that would cause an outright rejection. Seniors, in particular, will normally have some medical problems or conditions which will be underwritten with decisions ranging from a decline to issuing the policy with an extra premium or with a medical rider of some sort, depending upon the company’s procedure and underwriting philosophy.
"A copy of the completed application shall be delivered to the insured at the time of delivery of the policy or certificate."245
The underwriting of an application starts with the agent. The first and most important function of the agent in underwriting is the careful completion of the application particularly as it becomes part of the policy.
Applications universally consist of three sections:
Additional information regarding underwriting information is often requested. In the “senior market” it is a rare application for LTCI (or other health or life insurance) that does not require additional information, normally APS information. Personal history interviews have been previously discussed. In addition, it is quite common to obtain information from other sources.
An insurance company determines the net level premium of a policy in order to determine how much premium must be charged for the insurer to make a profit. The actual calculation is an actuarial function and beyond the scope of this text. In order to determine the premium it is necessary to establish the level of morbidity (the frequency of illnesses, sicknesses and diseases contracted118) of the particular policy. The loss ratio method of establishing morbidity costs is based on the ratio of benefits (claims) incurred to premiums earned, and this method is used when business is based on a one-year term basis (as opposed to a level premium basis).119 The incurred loss ratio is simply the proportion of each premium dollar actually used to the purpose of discussion here, the “incurred loss ratio” and the “expected” loss ratio pay claims.
The expected loss ratio represents the proportion of each premium dollar assumed to be used to pay claims, with the remainder assumed to be used for taxes and expenses. Comparing the expected loss ratio with the incurred loss ratio produces the percentage rate increase of decrease needed to bring the pricing in line with evolving experience. Regardless of the method used, all take into account expected future claims, a margin for higher than anticipated claims, expected future expenses, taxes, and the profit of the insurer. The loss ratio determines whether the company is experiencing an underwriting profit or loss, and whether to tighten underwriting guideline or increase premiums.
In order to monitor underwriting experience and adjust underwriting guidelines, insurance companies calculate loss and expense ratios. They also look at the combined ratio to determine whether they are experiencing an underwriting profit or loss and whether to tighten underwriting standards or increase premiums.
A loss ratio is combined with the expense ratio—simply dividing the operating expense with the premiums received—to produce a “combined loss ratio.” The result is that if the ratio is 100%, the company is breaking even; if it exceeds 100%, it is profitable; if it is less than 100%, then it is unprofitable.
States, including California, have minimum loss ratio standards so that policyholders can be assured that the companies will pay out a reasonable amount in benefits compared with the premiums that they receive. The stated intent of these regulations is to prevent companies from receiving “windfall” profits while policyholders receive no benefit from the insurer’s experience.
California (and other states) consider benefits to be reasonable if the expected loss ratio is at least 60%, taking into consideration reasonable and adequate reserving for future claims.251 In evaluating the expected loss ratio, the companies must illustrate that due consideration has been given to all relevant factors, including the following:
Post-claims underwriting, now defunct, was the practice used by some insurers in the past, where applications were scrutinized only to “make sure the applicant is breathing.” But, when a claim arose, there was a complete investigation and if health problems were discovered, the claim was denied, premiums adjusted or coverage for certain conditions was excluded. This allowed for rapid issue of the policies, less underwriting expense and lower premiums. Without a doubt, it is highly unethical and states acted rapidly to make it illegal, and California has been in the forefront of determining the illegality of such actions..
In the same vein, field issued LTCI policies are illegal in California. Often the companies that used to practice post-claim underwriting allowed for field issue, i.e. an agent would issue the policy based upon application information. All applications must be submitted to the insurer for underwriting and a copy of the application must be delivered to the applicant with the policy. By requiring insurers to complete medical underwriting and to investigate and resolve any questions prior to the issue of a policy allows for an insurer to deny or restrict coverage for individuals who do not meet the underwriting standards.
Once a policy is issued, it cannot be rescinded or a claim denied unless there is clear and convincing evidence of misrepresentation or fraud by the applicant. The following warning must be printed on all applications:120
“Caution: If your answers on this application are misstated or untrue, the insurer may have the right to deny benefits or rescind your coverage.”
There is a two-year time contestability period limitation, after which the insurer cannot rescind or deny benefits from information on the application. Every year, the insurer is required to report to the Commissioner the number of rescissions it made during that year.
"All applications for long-term care insurance except that which is guaranteed issue, shall contain clear, unambiguous, short, simple questions designed to ascertain the health condition of the applicant. Each question shall contain only one health status inquiry and shall require only a 'yes' or 'no' answer, except that the application may include a request for the name of any prescribed medication and the name of a prescribing physician. If the application requests the name of any prescribed medications or prescribing physicians, then any mistake or omission shall not be used as a basis for the denial of a claim or the rescission of a policy or certificate. …The following warning shall be printed conspicuously and in close conjunction with the applicant’s signature block: 'Caution: If your answers on this application are misstated or untrue, the insurer may have the right to deny benefits or rescind your coverage.' …Every application for long-term care insurance shall include a checklist that enumerates each of the specific documents which this chapter requires be given to the applicant at the time of solicitation."121
STUDY QUESTIONS
1. According to federal regulations, a physician, registered nurse, licensed social worker, and other individuals whom the Secretary of the Treasury Department may prescribe by regulation, are called
A. licensed health practitioners.
B. medical experts.
C. Medicare providers.
D. privileged experts.
2. When a Plan of Care is provided, it assesses the type, frequency and providers of care and the kind of care provided, which is either ___________ or ____________long-term care services.
A. Formal or Informal.
B. authorized or non-authorized.
C. recommended or “suggested.”
D. Medicare-approved or Medicaid-approved.
3. There are two criteria used to determine eligibility for benefits on TQ plans, based on
A. age and pre-existing condition.
B. benefit amount and waiting period.
C. either the inability to perform ADLS, and/or cognitive limitation.
D. medically necessity and inability to perform ADLs.
4. With federally-qualified LTCI policies and that provides home care benefits, the threshold establishing eligibility for home care benefits is that the person must be
A. determined to be chronically ill.
B. more than 50% incapacitated.
C. over age 75.
D. able to perform at least 3 of the ADLs.
5. Under a TQ LTCI policy, impairment in activities of daily living means the insured
A. must be confined to a nursing home.
B. needs substantial assistance due to loss of function capacity to perform the activity.
C. cannot be confined to a nursing home, Assisted Living facility, or other such facility.
D. is completely helpless.
6. Stand-by assistance means
A. a doctor or nurse on 24-hour call.
B. assistance in all homemaking chores.
C. another person within arms reach of the insured, so as to physically prevent injury to the
insured while performing ADLs.
D. an attendant in the house 24 hours a day.
7. There are differences between TQ and Non-TQ ADLs in defining
A. eating.
B. bathing.
C. dressing.
D. driving.
8. The most apparent difference between tax-qualified and non-tax qualified LTCI policies is
A. tax-qualified policies do not use the 7th ADL, Ambulating.
B. tax-qualified policies do not use the 6th ADL, Continence.
C. tax-qualified policies are much more expensive than non-tax qualified policies.
D. it is much, much more difficult to qualify for benefits under the non-tax qualified plans.
9. During the underwriting phase of an LTCI application, there may be an examination of the applicant, either by telephone, in person, or both, but in either case the examiner may
A. take physical measurements.
B. provide a delayed-word recall list followed later by the test.
C. never question any application answers.
D. never pry into the medical history of the applicant as that is personal.
10. The most important underwriting of an application starts with
A. the payment of the first premium in advance.
B. name, address and telephone number of attending physicians.
C. the agent.
D. the results of the MIB.
ANSWERS TO STUDY QUESTIONS
1A 2A 3C 4A 5B 6C 7A 8A 9B 10C