Form LTC-3 "Long-Term Care Insurance Outline of Coverage" - Missouri

What Is Form LTC-3?

This is a legal form that was released by the Missouri Department of Commerce and Insurance - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 15, 2007;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LTC-3 by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form LTC-3 "Long-Term Care Insurance Outline of Coverage" - Missouri

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[COMPANY NAME]
[ADDRESS—CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Policy Number or Group Master Policy and Certificate Number]
[Except for policies or certificates which are guaranteed issue, the following caution statement, or language
substantially similar, must appear as follows in the outline of coverage.]
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]
1. This policy is [an individual policy of insurance] [a group policy] which was issued in the [indicate
jurisdiction in which group policy was issued].
2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of
the important features of the policy. You should compare this outline of coverage to outlines of coverage for
other policies available to you. This is not an insurance contract, but only a summary of coverage. Only the
individual or group policy contains governing contractual provisions. This means that the policy or group
policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if you
purchase this coverage, or any other coverage, it is important that you READ YOUR POLICY (OR
CERTIFICATE) CAREFULLY!
3. FEDERAL TAX CONSEQUENCES.
This [POLICY] [CERTIFICATE] is intended to be a federally tax-qualified long-term care insurance contract
under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.
OR
Federal Tax Implications of this [POLICY] [CERTIFICATE]. This [POLICY] [CERTIFICATE] is not intended
to be a federally tax-qualified long-term care insurance contract under Section 7702B(b) of the Internal
Revenue Code of 1986, as amended. Benefits received under the [POLICY] [CERTIFICATE] may be
taxable as income.
4. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE CONTINUED IN FORCE OR
DISCONTINUED.
(a) [For long-term care health insurance policies or certificates describe one of the following permissible
policy renewability provisions:
(1) Policies and certificates that are guaranteed renewable shall contain the following statement:]
RENEWABILITY: THIS POLICY [CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have
the right, subject to the terms of your policy, [certificate] to continue this policy as long as you pay your
premiums on time. [Company Name] cannot change any of the terms of your policy on its own, except that,
in the future, IT MAY INCREASE THE PREMIUM YOU PAY.
(2) [Policies and certificates that are noncancellable shall contain the following statement:]
RENEWABILITY: THIS POLICY [CERTIFICATE] IS NONCANCELLABLE. This means that you have the
right, subject to the terms of your policy, to continue this policy as long as you pay your premiums on time.
[Company Name] cannot change any of the terms of your policy on its own and cannot change the premium
you currently pay. However, if your policy contains an inflation protection feature where you choose to
increase your benefits, [Company Name] may increase your premium at that time for those additional
benefits.
(b) [For group coverage, specifically describe continuation/conversion provisions applicable to the
certificate and group policy;]
(c) [Describe waiver of premium provisions or state that there are not such provisions.]
[COMPANY NAME]
[ADDRESS—CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Policy Number or Group Master Policy and Certificate Number]
[Except for policies or certificates which are guaranteed issue, the following caution statement, or language
substantially similar, must appear as follows in the outline of coverage.]
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]
1. This policy is [an individual policy of insurance] [a group policy] which was issued in the [indicate
jurisdiction in which group policy was issued].
2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of
the important features of the policy. You should compare this outline of coverage to outlines of coverage for
other policies available to you. This is not an insurance contract, but only a summary of coverage. Only the
individual or group policy contains governing contractual provisions. This means that the policy or group
policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if you
purchase this coverage, or any other coverage, it is important that you READ YOUR POLICY (OR
CERTIFICATE) CAREFULLY!
3. FEDERAL TAX CONSEQUENCES.
This [POLICY] [CERTIFICATE] is intended to be a federally tax-qualified long-term care insurance contract
under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.
OR
Federal Tax Implications of this [POLICY] [CERTIFICATE]. This [POLICY] [CERTIFICATE] is not intended
to be a federally tax-qualified long-term care insurance contract under Section 7702B(b) of the Internal
Revenue Code of 1986, as amended. Benefits received under the [POLICY] [CERTIFICATE] may be
taxable as income.
4. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE CONTINUED IN FORCE OR
DISCONTINUED.
(a) [For long-term care health insurance policies or certificates describe one of the following permissible
policy renewability provisions:
(1) Policies and certificates that are guaranteed renewable shall contain the following statement:]
RENEWABILITY: THIS POLICY [CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have
the right, subject to the terms of your policy, [certificate] to continue this policy as long as you pay your
premiums on time. [Company Name] cannot change any of the terms of your policy on its own, except that,
in the future, IT MAY INCREASE THE PREMIUM YOU PAY.
(2) [Policies and certificates that are noncancellable shall contain the following statement:]
RENEWABILITY: THIS POLICY [CERTIFICATE] IS NONCANCELLABLE. This means that you have the
right, subject to the terms of your policy, to continue this policy as long as you pay your premiums on time.
[Company Name] cannot change any of the terms of your policy on its own and cannot change the premium
you currently pay. However, if your policy contains an inflation protection feature where you choose to
increase your benefits, [Company Name] may increase your premium at that time for those additional
benefits.
(b) [For group coverage, specifically describe continuation/conversion provisions applicable to the
certificate and group policy;]
(c) [Describe waiver of premium provisions or state that there are not such provisions.]
5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.
[In bold type larger than the maximum type required to be used for the other provisions of the outline of
coverage, state whether or not the company has a right to change the premium, and if a right exists,
describe clearly and concisely each circumstance under which the premium may change.]
6. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE RETURNED AND PREMIUM
REFUNDED.
(a) [Provide a brief description of the right to return—“free look”—provision of the policy.]
(b) [Include a statement that the policy either does or does not contain provisions providing for a refund or
partial refund of premium upon the death of an insured or surrender of the policy or certificate. If the policy
contains such provisions, include a description of them.]
7. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the
Medicare Supplement Buyer’s Guide available from the insurance company.
(a) [For producers] Neither [insert company name] nor its producers represent Medicare, the federal
government or any state government.
(b) [For direct response] [insert company name] is not representing Medicare, the federal government or
any state government.
8. LONG-TERM CARE COVERAGE. Policies of this category are designed to provide coverage for one (1)
or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance,
or personal care services, provided in a setting other than an acute care unit of a hospital, such as in a
nursing home, in the community or in the home.
This policy provides coverage in the form of a fixed dollar indemnity benefit for covered long-term care
expenses, subject to policy [limitations] [waiting periods] and [coinsurance] requirements. [Modify this
paragraph if the policy is not an indemnity policy.]
9. BENEFITS PROVIDED BY THIS POLICY.
(a) [Covered services, related deductibles, waiting periods, elimination periods and benefit maximums.]
(b) [Institutional benefits, by skill level.]
(c) [Non-institutional benefits, by skill level.]
(d) Eligibility for Payment of Benefits
[Activities of daily living and cognitive impairment shall be used to measure an insured’s need for long-
term care and must be defined and described as part of the outline of coverage.]
[Any additional benefit triggers must also be explained. If these triggers differ for different benefits,
explanation of the triggers should accompany each benefit description. If an attending physician or other
specified person must certify a certain level of functional dependency in order to be eligible for benefits, this
too must be specified.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a) Preexisting conditions;
(b) Non-eligible facilities and provider;
(c) Non-eligible levels of care (e.g., unlicensed providers, care or treatment provided by a family member,
etc.);
(d) Exclusions and exceptions;
(e) Limitations.]
[This section should provide a brief specific description of any policy provisions which limit, exclude, restrict,
reduce, delay, or in any other manner operate to qualify payment of the benefits described in Number 6
above.]
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG-TERM CARE
NEEDS.
11. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of long-term care services
will likely increase over time, you should consider whether and how the benefits of this plan may be
adjusted. [As applicable, indicate the following:
(a) That the benefit level will not increase over time;
(b) Any automatic benefit adjustment provisions;
(c) Whether the insured will be guaranteed the option to buy additional benefits and the basis upon which
benefits will be increased over time if not by a specified amount or percentage;
(d) If there is such a guarantee, include whether additional underwriting or health screening will be
required, the frequency and amounts of the upgrade options, and any significant restrictions or limitations;
(e) And finally, describe whether there will be any additional premium charge imposed, and how that is to
be calculated.]
12. ALZHEIMER’S DISEASE AND OTHER ORGANIC BRAIN DISORDERS.
[State that the policy provides coverage for insureds clinically diagnosed as having Alzheimer’s disease or
related degenerative and dementing illnesses. Specifically describe each benefit screen or other policy
provision which provides preconditions to the availability of policy benefits for such an insured.]
13. PREMIUM.
[(a) State the total annual premium for the policy;
(b) If the premium varies with an applicant’s choice among benefit options, indicate the portion of annual
premium which corresponds to each benefit option.]
14. ADDITIONAL FEATURES.
[(a) Indicate if medical underwriting is used;
(b) Describe other important features.]
15. CONTACT THE STATE SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM IF YOU HAVE
GENERAL QUESTIONS REGARDING LONG-TERM CARE INSURANCE. CONTACT THE INSURANCE
COMPANY IF YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR LONG-TERM CARE INSURANCE
POLICY OR CERTIFICATE.
Form LTC-3
(Rev 11/15/2007)
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