Form LTC-5 "Partnership Program Policy Certification Form" - Missouri

What Is Form LTC-5?

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-5 by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form LTC-5 "Partnership Program Policy Certification Form" - Missouri

891 times
Rate (4.3 / 5) 62 votes
“Partnership Program Policy Certification Form”
DIRECTIONS: This certification must be completed and submitted with each long-term
care policy or certificate that is intended to qualify under the state long-term care
partnership program. The certification must be signed by an officer of the company with
authority to bind the company. A separate certification must be completed for each
policy form. A long-term care policy or certificate may not be issued in Missouri as a
partnership program policy or certificate unless and until this certification has been
submitted to the Department of Insurance, Financial Institutions & Professional
Registration and the policy or certificate has been approved by the Director.
For newly-filed policy forms intended to qualify for the partnership program, this
certification must be filed as part of the policy form filing. With respect to a previously
filed form that qualifies for the partnership program, this certification shall be filed with
the Department identifying by form number and filing date the previously filed form. If
an insurer is filing an endorsement or rider to amend a previously filed form in order to
make the form compliant with the partnership program, this Certification must be filed
with the endorsement or rider filing, and must identify the previously filed form by form
number and filing date.
CERTIFICATION
Under Section 1917(b)(5)(B)(iii) of the Social Security Act (42 U.S.C.
1396p(b)(5)(B)(iii)) and in accordance with sections 208.690 to 208.698 RSMo., the
following insurer ________________________________ (name) hereby submits
information related to policy or certificate form _____________________ (form number)
filed on __________________ (date) to substantiate that the form includes all consumer
protection requirements set forth in section 1917(b)(5)(A) of the Social Security Act (42
U.S.C. 1396p(b)(5)(A)) and that it includes certain specified provisions of the Long-Term
Care Insurance Model Regulation and Long-Term Care Insurance Model Act
promulgated by the National Association of Insurance Commissioners (NAIC), as
adopted as of October 2000, hereinafter referred to herein as the “Model Regulation” and
“Model Act,” respectively, which have been incorporated into Missouri law as provided
for in sections 208.690 to 208.698 RSMo, sections 376.1100 to 376.1130 RSMo. and
Mo. Reg. 20 CSR 400-4.100
Part I. General Information.
A. Name, address, and telephone number of issuer:_______________________________
B. Policy form(s) covered by this certification, including the form number and filing date:
________________________________
Specimen copies of each of the above policy forms, including any riders and
endorsements, shall be provided with this certification if they have not been previously
approved by the Department of Insurance, Financial Institutions & Professional
1
“Partnership Program Policy Certification Form”
DIRECTIONS: This certification must be completed and submitted with each long-term
care policy or certificate that is intended to qualify under the state long-term care
partnership program. The certification must be signed by an officer of the company with
authority to bind the company. A separate certification must be completed for each
policy form. A long-term care policy or certificate may not be issued in Missouri as a
partnership program policy or certificate unless and until this certification has been
submitted to the Department of Insurance, Financial Institutions & Professional
Registration and the policy or certificate has been approved by the Director.
For newly-filed policy forms intended to qualify for the partnership program, this
certification must be filed as part of the policy form filing. With respect to a previously
filed form that qualifies for the partnership program, this certification shall be filed with
the Department identifying by form number and filing date the previously filed form. If
an insurer is filing an endorsement or rider to amend a previously filed form in order to
make the form compliant with the partnership program, this Certification must be filed
with the endorsement or rider filing, and must identify the previously filed form by form
number and filing date.
CERTIFICATION
Under Section 1917(b)(5)(B)(iii) of the Social Security Act (42 U.S.C.
1396p(b)(5)(B)(iii)) and in accordance with sections 208.690 to 208.698 RSMo., the
following insurer ________________________________ (name) hereby submits
information related to policy or certificate form _____________________ (form number)
filed on __________________ (date) to substantiate that the form includes all consumer
protection requirements set forth in section 1917(b)(5)(A) of the Social Security Act (42
U.S.C. 1396p(b)(5)(A)) and that it includes certain specified provisions of the Long-Term
Care Insurance Model Regulation and Long-Term Care Insurance Model Act
promulgated by the National Association of Insurance Commissioners (NAIC), as
adopted as of October 2000, hereinafter referred to herein as the “Model Regulation” and
“Model Act,” respectively, which have been incorporated into Missouri law as provided
for in sections 208.690 to 208.698 RSMo, sections 376.1100 to 376.1130 RSMo. and
Mo. Reg. 20 CSR 400-4.100
Part I. General Information.
A. Name, address, and telephone number of issuer:_______________________________
B. Policy form(s) covered by this certification, including the form number and filing date:
________________________________
Specimen copies of each of the above policy forms, including any riders and
endorsements, shall be provided with this certification if they have not been previously
approved by the Department of Insurance, Financial Institutions & Professional
1
Registration for use in Missouri. Policy forms that have been previously approved by the
Department for use in Missouri shall be provided upon request.
Part II. Questions regarding compliance with the Model Regulation, Model Act and
Missouri law.
Please answer each of the following questions with respect to the policy forms identified
in Part I (B), above.
For purposes of answering the questions below, any provision of the Model Regulation
and Model Act listed below shall be treated as including any other provisions of the
Model Regulation and Model Act necessary to implement the provision.
In order for a policy to qualify as a Long-Term Care Insurance Partnership Program
Policy, the answers to all questions below should be “Yes” (or “N/A” where all
requirements with respect to a provision cited herein are not applicable). If answers differ
between policy forms (e.g., a requirement would be answered “Yes” for one form and
“N/A” for another), you should use separate Certification for such policies.
(1) Do each of the policies identified in Part I(B) above (including certificates issued
under a group insurance contract) comply with the following requirements of the Model
Regulation, as contained in Mo. Reg. 20 CSR 400-4.100
A. Model Section 6A. Section (4)(A) relating to guaranteed renewal or noncancellability.
Yes ___ No ___ N/A ___
B. Model Section 6B. Section (4)(B) relating to prohibitions on limitations.
Yes ___ No ___ N/A ___
C. Model Section 6C. Section (4)(C) relating to extension of benefits.
Yes ___ No ___ N/A ___
D. Model Section 6D. Section (4)(D) relating to continuation or conversion of coverage
Yes ___ No ___ N/A ___
E. Model Section 6E. Section (4)(E) relating to discontinuance and replacement.
Yes ___ No ___ N/A ___
F. Model Section 7. Section (5) relating to unintentional lapse
Yes ___ No ___ N/A ___
G. Model Section 8. Section (6) relating to disclosure, other than sections (6)(F) and
(6)(I) thereof.
Yes ___ No ___ N/A ___
2
H. Model Section 9. Section (7) relating to required disclosure of rating practices to the
consumer.
Yes ___ No ___ N/A ___
I. Model Section 11. Section (9) relating to prohibitions against post-claims underwriting
Yes ___ No ___ N/A ___
J. Model Section 12. Section (10) relating to minimum standards for home health and
community care benefits.
Yes ___ No ___ N/A ___
K. Model Section 14. Section (12) relating to application forms and replacement
coverage
Yes ___ No ___ N/A ___
L. Model Section 15. Section (13) relating to reporting requirements
Yes ___ No ___ N/A ___
M. Model Section 22. Section (20) relating to filing requirements for marketing
Yes ___ No ___ N/A ___
N. Model Section 23. Section (21) relating to standards for marketing including
inaccurate completion of medical histories.
Yes ___ No ___ N/A ___
O. Model Section 24. Section (22) relating to suitability
Yes ___ No ___ N/A ___
P. Model Section 25. Section (23) relating to prohibition against preexisting conditions
and probationary periods in replacement coverage.
Yes ___ No ___ N/A ___
Q. Model Section 28. Section (24) relating to contingent nonforfeiture benefits.
Yes ___ No ___ N/A ___
R. Model Section 31. Section (30) relating to the standard format outline of coverage.
Yes ___ No ___ N/A ___
S. Model Section 32. Section (31) relating to the requirement to deliver a shopper’s
guide.
Yes ___ No ___ N/A ___
3
(2) Do each of the policies identified in Part I(B) above (including certificates issued
under a group insurance contract) comply with the following requirements of the Model
Act?
A. Model Section 6C. Section 376.1109.3, RSMo, relating to preexisting conditions
Yes ___ No ___ N/A ___
B. Model Section 6D. Section 376.1109.6, RSMo, relating to prior hospitalization
Yes ___ No ___ N/A ___
C. Model Section 8. Section 376.1127.3, RSMo, relating to contingent nonforfeiture
benefits
Yes ___ No ___ N/A ___
D. Model Section 6F. Section 376.1109.11, RSMo, relating to the right to return.
Yes ___ No ___ N/A ___
E. Model Section 6G. Section 376.1115, RSMo, relating to the outline of coverage.
Yes ___ No ___ N/A ___
F. Model Section 6H. Section 376.1115.3 RSMo, relating to requirements for certificates
under group plans.
Yes ___ No ___ N/A ___
G. Model Section 6J. Section 376.1115.5, RSMo, relating to a policy summary for long-
term care benefits funded through a life insurance vehicle by the acceleration of the death
benefit.
Yes ___ No ___ N/A ___
H. Model Section 6K. Section 376.1118 RSMo, relating to monthly reports on
accelerated death benefits.
Yes ___ No ___ N/A ___
I. Model Section 7. Section 376.1124, RSMo, relating to incontestability period.)
Yes ___ No ___ N/A ___
Part III. Inflation Protection.
Do each of the policies identified in Part I(B) above (including certificates issued under a
group insurance contract) comply with the partnership program inflation protection
requirements of sections 208.696.1(2)(b) RSMo.
Yes ___ No ___
4
Part IV. Certification.
As an officer of the insurer, I hereby certify that the answers, accompanying documents,
and other information set forth herein for certification of the listed policy form or forms
are to the best of my knowledge and belief, true, correct, and complete and that the
policies identified in this form meet all of the consumer protection requirements
pertaining to long-term care insurance partnership policies for the State of Missouri. I
understand that false, inaccurate or incomplete information on this form or accompanying
documents may result in disapproval of listed policies for use in Missouri and other
administrative sanctions.
Signature Date: _________
Name of Certifying Officer: _________________________________________
Title of Certifying Officer: _________________________________________
Signature of Certifying Officer _______________________________________
Name of Company Contact _________________________________________
(If other than certifying officer)
Phone Number: _________________________________________
Fax Number:
_________________________________________
E-mail Address: _________________________________________
Mailing Address: _________________________________________
Form LTC-5
(Rev 3/10/2008)
5
Page of 5