Form LTC-4 "Long-Term Care Partnership Exchange Notification Form" - Missouri

What Is Form LTC-4?

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 March 10, 2008;
  • 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-4 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-4 "Long-Term Care Partnership Exchange Notification Form" - Missouri

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[ Date
Company name
Address
Contact information
Other company identifiers
Insured’s name
Address
Insured’s policy/certificate number
Effective date/policy issue date ]
“The Long-Term Care Partnership Exchange Notification Form”
Our company participates in Missouri’s long-term care partnership program by offering
long-term care insurance policies that meet certain state and federal requirements. Under
the partnership program, policies that meet these requirements may allow you to protect a
portion of your assets from Medicaid’s “spend down” requirements if you should ever
need to apply for Medicaid benefits to pay for long-term care expenses in the future.
Partnership program policies may allow you to keep a dollar of your own assets for every
dollar of benefits paid by the policy for long-term care services should you need to apply
for Medicaid.
Although we sell long-term care insurance policies that qualify as partnership plan
policies, the policy you currently have with us does not qualify for the partnership
program. Therefore, we are notifying you that you may be able to exchange your current
long-term care policy for a new policy that qualifies under the partnership program.
However, before you consider exchanging your current long-term care policy for a policy
that qualifies under the partnership program, there are several things you should know:
1. You may be required to answer health questions that will determine whether we will
issue you a new policy (medical underwriting).
2. Since your current policy may be out of date and, therefore, does not qualify as a
partnership plan policy, you may be required to update your plan by adding benefits.
Carefully consider any change in benefits that may increase your costs.
3. The premium for the new policy may higher than the premium you pay for your
existing policy.
[ Date
Company name
Address
Contact information
Other company identifiers
Insured’s name
Address
Insured’s policy/certificate number
Effective date/policy issue date ]
“The Long-Term Care Partnership Exchange Notification Form”
Our company participates in Missouri’s long-term care partnership program by offering
long-term care insurance policies that meet certain state and federal requirements. Under
the partnership program, policies that meet these requirements may allow you to protect a
portion of your assets from Medicaid’s “spend down” requirements if you should ever
need to apply for Medicaid benefits to pay for long-term care expenses in the future.
Partnership program policies may allow you to keep a dollar of your own assets for every
dollar of benefits paid by the policy for long-term care services should you need to apply
for Medicaid.
Although we sell long-term care insurance policies that qualify as partnership plan
policies, the policy you currently have with us does not qualify for the partnership
program. Therefore, we are notifying you that you may be able to exchange your current
long-term care policy for a new policy that qualifies under the partnership program.
However, before you consider exchanging your current long-term care policy for a policy
that qualifies under the partnership program, there are several things you should know:
1. You may be required to answer health questions that will determine whether we will
issue you a new policy (medical underwriting).
2. Since your current policy may be out of date and, therefore, does not qualify as a
partnership plan policy, you may be required to update your plan by adding benefits.
Carefully consider any change in benefits that may increase your costs.
3. The premium for the new policy may higher than the premium you pay for your
existing policy.
4. If you move to a state that does not maintain a partnership program or does not
recognize your plan as a partnership plan, you would not receive the asset protection
under the Medicaid laws of that state.
5. Since the partnership program is based on current federal and state laws, it is subject to
change. If the laws are changed, the partnership plan policies may not offer the same
protections in the future as they do now.
If you would like more information about this offer to exchange your existing long-term
care insurance policy for a policy that qualifies under the state’s partnership program,
please call us at____________________________________ or write to us
at:_________________________________________________________________.
If, after you learn more about the partnership plan and any additional costs or benefit
updates that may be required, and you decide to accept the offer to exchange your
existing policy for a new, partnership plan policy, we may ask you to complete certain
requirements before determining whether we can issue you a policy, such as completing
an application and providing medical records.
Once you know all the additional costs, if any, and we have determined that you qualify
for any additional benefits that may be required, in order to effect the completion of the
exchange of your old long-term care policy for a new, partnership policy, we may send
you a new policy or new certificate or we may send you an endorsement or rider that will
amend your existing policy so that it qualifies under the state’s long-term care partnership
program.
If you have questions about Missouri’s long-term care partnership program or questions
about long-term care insurance in general, please call the Missouri Department of
Insurance, Financial Institutions & Professional Registration at 1-800-726-7390. You
may also access more information at the following web sites.
http://www.difp.mo.gov
http://www.dss.mo.gov
[Company’s web site]
Form LTC-4
(Rev 3/10/2008)
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