Form FIS2310 "Partnership Program Notice and Long-Term Care Partnership Policy Certification Form" - Michigan

What Is Form FIS2310?

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

Form Details:

  • Released on December 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • 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 fillable version of Form FIS2310 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS2310 "Partnership Program Notice and Long-Term Care Partnership Policy Certification Form" - Michigan

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Partnership Program Notice
Important Consumer Information Regarding the Michigan Long-Term Care Insurance
Partnership Program
Some long-term care insurance policies and certificates (hereinafter referred to as “insurance
policies”) sold in Michigan may qualify for the Michigan Long-Term Care Insurance Partnership
Program (“Partnership Program”). The Partnership Program is a partnership between state
government and private insurance companies to assist individuals in planning their long-term
care needs. Insurance companies must follow state and federal guidelines, and agents must be
licensed and trained to sell partnership policies. Insurance companies voluntarily agree to
participate in the Partnership Program. Long-term care insurance that qualifies for the
Partnership Program may protect the policyholder’s or certificate holder’s assets through a
feature known as “Asset Disregard” under Michigan’s Medicaid program.
Asset Disregard means that an amount of the policyholder’s or certificate holder’s assets, equal
to the amount of long-term care benefits received under a qualified Partnership Program
insurance policy, will be disregarded for the purpose of determining the insured’s eligibility for
Medicaid. This generally allows a person to keep assets equal to the insurance benefits paid on
your behalf under a qualified Partnership Program insurance policy. All other Medicaid
eligibility criteria will apply and special rules may apply to persons whose home equity exceeds
a certain dollar limit. Therefore, you should consider if Asset Disregard is important to you, and
whether a Partnership Program insurance policy meets your needs. The purchase of a
Partnership Program insurance policy does not automatically qualify you for Medicaid.
A qualified Partnership Program insurance policy must, at a minimum:
 Be issued to an individual after December 31, 2007;
 Cover an individual who was a resident of Michigan when coverage first becomes
effective under the insurance policy;
 Be tax-qualified under Section 7702(B)(b) of the Internal Revenue Code of 1986;
 Meet prescribed consumer protection standards, and
 Provide the following inflation protections:
o For ages 60 and younger – provide compound annual inflation protection,
o For ages 61 through 75 – provide some level of inflation protection,
o For ages 76 and older – inflation protection may be offered but is not required.
If you apply for and are approved for long-term care insurance coverage, the insurance
company will provide you with written documentation as to whether your insurance policy
qualifies for the Partnership Program.
Partnership Program Notice
Important Consumer Information Regarding the Michigan Long-Term Care Insurance
Partnership Program
Some long-term care insurance policies and certificates (hereinafter referred to as “insurance
policies”) sold in Michigan may qualify for the Michigan Long-Term Care Insurance Partnership
Program (“Partnership Program”). The Partnership Program is a partnership between state
government and private insurance companies to assist individuals in planning their long-term
care needs. Insurance companies must follow state and federal guidelines, and agents must be
licensed and trained to sell partnership policies. Insurance companies voluntarily agree to
participate in the Partnership Program. Long-term care insurance that qualifies for the
Partnership Program may protect the policyholder’s or certificate holder’s assets through a
feature known as “Asset Disregard” under Michigan’s Medicaid program.
Asset Disregard means that an amount of the policyholder’s or certificate holder’s assets, equal
to the amount of long-term care benefits received under a qualified Partnership Program
insurance policy, will be disregarded for the purpose of determining the insured’s eligibility for
Medicaid. This generally allows a person to keep assets equal to the insurance benefits paid on
your behalf under a qualified Partnership Program insurance policy. All other Medicaid
eligibility criteria will apply and special rules may apply to persons whose home equity exceeds
a certain dollar limit. Therefore, you should consider if Asset Disregard is important to you, and
whether a Partnership Program insurance policy meets your needs. The purchase of a
Partnership Program insurance policy does not automatically qualify you for Medicaid.
A qualified Partnership Program insurance policy must, at a minimum:
 Be issued to an individual after December 31, 2007;
 Cover an individual who was a resident of Michigan when coverage first becomes
effective under the insurance policy;
 Be tax-qualified under Section 7702(B)(b) of the Internal Revenue Code of 1986;
 Meet prescribed consumer protection standards, and
 Provide the following inflation protections:
o For ages 60 and younger – provide compound annual inflation protection,
o For ages 61 through 75 – provide some level of inflation protection,
o For ages 76 and older – inflation protection may be offered but is not required.
If you apply for and are approved for long-term care insurance coverage, the insurance
company will provide you with written documentation as to whether your insurance policy
qualifies for the Partnership Program.
Certain types of changes to the insurance policy may disqualify you as eligible for the
Partnership Program. If you purchase Partnership Program coverage and later decided to make
any changes, you should first consult with your insurance company to determine the effect of a
proposed change. For example, if you choose to lower your inflation protection or drop it
altogether, the insurance policy will no longer be a Partnership Program insurance policy.
Moving to a state without a Partnership Program or one that has not agreed to accept long-
term care insurance issued in a different state (reciprocity) as being eligible as Partnership
Program coverage is another way that your Partnership Program insurance policy loses its
Partnership eligibility. State and/or federal laws can change which could also affect your
Partnership Program status.
The information contained in this disclosure is based on current Michigan and federal laws,
which may be subject to change. Any change in law could reduce or eliminate the beneficial
treatment of your insurance policy under Michigan’s Medicaid program.
If you have questions regarding long-term care insurance, please contact your insurance
company or your agent. If you have questions regarding current laws governing Medicaid
eligibility, please contact the Michigan Department of Health and Human Services.
FIS 2310 (12/15) Department of Insurance and Financial Services Page 1 of 3
LONG-TERM CARE PARTNERSHIP POLICY CERTIFICATION FORM
I. DIRECTIONS
This certification must be completed and submitted, via SERFF, with each long-term care policy or
certificate that is intended to qualify under the Michigan Long-Term Care Insurance Partnership
Program. A separate certification must be completed for each policy or certificate.
An issuer may request certification of a policy or certificate which has been previously approved by
the Department of Insurance and Financial Services (DIFS), or request certification of a new policy
or certificate. No long-term care policy or certificate may be issued in Michigan as a Partnership
Policy or certificate unless and until this Certification has been submitted to the Director of DIFS and
the policy or certificate has been approved.
II. CERTIFICATION PROCESS
Pursuant to Section 1917 of the Social Security Act, Michigan Compiled Laws (MCL) 400.112 and
chapter 39A of the Michigan Insurance Code, the State of Michigan has implemented a Long-Term
Care Insurance Partnership Program. Under this program, a person receiving benefits under a
qualified Long-Term Care Insurance Partnership Policy (“Partnership Policy”) may be entitled to
have assets equivalent to the benefits received under the Partnership Policy disregarded for the
purpose of determining Medicaid Eligibility
The Director of DIFS may certify that long-term care insurance policies (including certificates issued
under a group insurance contract) meet certain consumer protection requirements required of
Partnership Policies. These requirements are set forth in Section 1917(b)(5)(A) of the Social
Security Act (42 U.S.C. 1396p(b)(5)(A)) and principally include 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). Applicable sections
of the Model Act and the Model Regulation may be found in chapters 39 and 39A of the Michigan
Insurance Code.
An issuer wishing to have a long-term care insurance policy certified by the Director as meeting the
requirements for treatment as a Partnership Policy must fully and accurately complete this Policy
Certification Form. The certification must be made by an authorized representative of the issuer with
binding authority. Full contact information for the signing representative must be provided.
By submitting this form, you are certifying that the information contained herein is complete
and accurate. Any inaccuracies in the information you provide on this form may result in a
withdrawal of any certification made by the Director in reliance on this form, retroactive
correction of the policy to conform to certification requirements, disapproval of the policy for
use in Michigan and administrative action against the issuer on whose behalf the form is
submitted. Therefore, it is essential that you carefully review the information set forth on this
form for accuracy.
FIS 2310 (12/15) Department of Insurance and Financial Services Page 2 of 3
III. GENERAL INFORMATION
Name of Issuer
Address
City
State
Zip Code
Telephone Number
Issuer NAIC Number
Issuer Employee Contact for Information Regarding this Form
Telephone Number
Address
City
State
Zip Code
Email Address
Policy or Certificate Form Number
SERFF Tracking #/Prior Approval Date (If
Applicable)
IV. APPLICABLE PROVISIONS OF THE MODEL REGULATION AND MODEL ACT
Please answer each of the questions below with respect to the policy form identified in Section III
above. For purposes of answering the questions below, any provision of the NAIC Model Regulation
or NAIC Model Act, as adopted by the State of Michigan and listed below, shall be treated as
including any other provision of the Model Regulation or Model Act necessary to implement the
provision.
Are the following requirements of the Michigan Insurance Code met with respect to the policy
or certificate intended to be covered under the Qualified Partnership Program as listed in
Section III above?
Provision
Yes
No
N/A
1.
MCL 500.3907 (Guaranteed Renewal and Noncancellability), other than
Section (e)
2.
MCL 500.3905 (Limitations and Exclusions), other than subsection (f)
3.
MCL 500.3919 (Extension of Benefits)
4.
MCL 500.3907 (Continuation or Conversion of Coverage)
5.
MCL 500.3939 (Discontinuance and Replacement of Policies)
6.
MCL 500.3906 (Unintentional Lapse)
7.
MCL 500.3942 & MCL 500.3923 (Required Disclosure Provisions), other
than subsections (6), (7), (8) and (9).
8.
MCL 500.3925 (Required Disclosure of Rating Practices to Consumers)
9.
MCL 500.3921 (Prohibition Against Post-Claims Underwriting)
10.
MCL 500.3905 (Minimum Standards)
11.
MCL 500.3921 (Application Forms and Replacement Coverage)
12.
MCL 500.3942a (Reporting Requirements)
13.
MCL 500. 3941 (Filing Requirements for Advertising)
FIS 2310 (12/15) Department of Insurance and Financial Services Page 3 of 3
Provision
Yes
No
N/A
14.
MCL 500.3942 (Standards for Marketing), including inaccurate
completion of medical histories, other than subsections (3)(a), (3)(f), and
(3)(i).
15.
MCL 500.3941a (Suitability)
16.
MCL 500.3917 (Prohibition Against Preexisting Conditions and
Probationary Periods in Replacement Policies or Certificates)
17.
MCL 500.3910a relating to Contingent Nonforfeiture Benefits, if the
policyholder declines the offer of a nonforfeiture provision described in
Section 7702b(g)(4) of the Internal Revenue Code of 1986.
18.
MCL 500.3933 (Standard Format Outline of Coverage)
19.
MCL 500.3937 (Requirement to Deliver Shopper’s Guide)
20.
MCL 500.3903 (Certificates Issued Under Group Plan)
21.
MCL 500.3911 (Preexisting Conditions)
22.
MCL 500.3915 (Prior Hospitalization)
23.
MCL 500.3910a relating to Contingent Nonforfeiture Benefits
24.
MCL 500.3943 (Right to Return)
25.
MCL 500.3933 (Outline of Coverage)
26.
MCL 500.3903 (Certificates Under Group Plans)
27.
MCL 500.3933 (Policy Summary)
28.
MCL 500.3951 (Monthly Report on Accelerated Death Benefit)
29.
MCL 500.3906 (Incontestability Period)
V. INFLATION PROTECTION
Does the policy or certificate listed in Section III (including certificates issued under a group
insurance contract) comply with the Partnership Program inflation protection requirements set forth
in MCL 500.3909 and the DRA,
42 USC
§1396p(b)(C)(iii)(V).
____Yes ____No
VI. CERTIFICATION
I hereby certify that the answers, accompanying documents, and other information set forth herein
for certification of the listed policy form is, to the best of my knowledge and belief, true, correct and
complete and that the policy identified in this form meets all of the consumer protection standards
required of qualified Long-Term Care Insurance Partnership Policies issued in the state of Michigan.
Authorized Representative of the Issuer (Printed)
Title
Signature
Date
When submitting Partnership Filings in SERFF, please use TOI and Sub-TOI LTC031 / LTC031.004 or
LTC03G / LTC03G.004. The Filing Types available are Form, Form/Rate and Rate.