OAR 836-052-0546
Required Policy Provisions

(1)

Renewability. Each individual long-term care insurance policy shall contain a renewability provision. The following requirements apply to such a provision:

(a)

The provision shall be appropriately captioned, shall appear on the first page of the policy and shall clearly state that the coverage is guaranteed renewable or noncancellable. This provision does not apply to a policy that does not contain a renewability provision, and under which the right to nonrenew is reserved solely to the policyholder.

(b)

A long-term care insurance policy or certificate, other than one in which the insurer does not have the right to change the premium, shall include a statement that premium rates may change.

(2)

Riders and Endorsements. Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual long-term care insurance policy, all riders or endorsements added to an individual long-term care insurance policy after date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the individual insured. After the date of policy issue, any rider or endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in a writing that is signed by the insured, unless the increased benefits or coverage is required by law. When a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy, rider or endorsement.

(3)

Payment of Benefits. A long-term care insurance policy that provides for the payment of benefits based on standards described as “usual and customary,” “reasonable and customary” or words of similar import shall include a definition of these terms and an explanation of the terms in its accompanying outline of coverage.

(4)

Limitations. If a long-term care insurance policy or certificate contains any limitations with respect to preexisting conditions, the limitations of preexisting condition shall appear as a separate paragraph of the policy or certificate and shall be labeled as “Preexisting Condition Limitations.”

(5)

Other limitations or conditions on eligibility for benefits. A long-term care insurance policy or certificate containing any limitations or conditions for eligibility other than those prohibited in ORS 743.655 (Rules)(5) shall set forth a description of the limitations or conditions, including any required number of days of confinement, in a separate paragraph of the policy or certificate and shall label the paragraph “Limitations or Conditions on Eligibility for Benefits.”

(6)

Disclosure of Tax Consequences. With regard to life insurance policies that provide an accelerated benefit for long-term care, a disclosure statement is required at the time of application for the policy or rider and at the time the accelerated benefit payment request is submitted that receipt of these accelerated benefits may be taxable and that assistance should be sought from a personal tax advisor. The disclosure statement shall be prominently displayed on the first page of the policy or rider and any other related documents. This section does not apply to qualified long-term care insurance contracts.

(7)

Benefit Triggers. Activities of daily living and cognitive impairment shall be used to measure an insured’s need for long term care, shall be described in the policy or certificate in a separate paragraph and shall be labeled “Eligibility for the Payment of Benefits.” Any additional benefit triggers shall also be explained in the same paragraph. If these triggers differ for different benefits, explanation of the trigger shall 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 requirement too shall be specified.

(8)

A qualified long-term care insurance contract shall include a statement in the policy and in the outline of coverage as contained in OAR 836-052-0776 (Standard Format Outline of Coverage) that the policy is intended to be a qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.

(9)

A nonqualified long-term care insurance contract shall include a statement in the policy and in the outline of coverage as contained in OAR 836-052-0776 (Standard Format Outline of Coverage) that the policy is not intended to be a qualified long-term care insurance contract.

Source: Rule 836-052-0546 — Required Policy Provisions, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0546.

836‑052‑0103
Purpose 836‑052‑0107
Authority 836‑052‑0114
Applicability and Scope 836‑052‑0119
Definitions 836‑052‑0124
Policy Definitions and Terms 836‑052‑0129
Policy Provisions 836‑052‑0132
Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010 836‑052‑0133
Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 836‑052‑0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992 836‑052‑0136
Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 836‑052‑0138
Open Enrollment 836‑052‑0139
Medicare Select Policies and Certificates 836‑052‑0140
Standards for Claims Payment 836‑052‑0141
Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010 836‑052‑0142
Guaranteed Issue for Eligible Persons 836‑052‑0143
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate 836‑052‑0144
Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020. 836‑052‑0145
Loss Ratio Standards and Refund or Credit of Premium 836‑052‑0151
Filing and Approval of Policies and Certificates and Premium Rates 836‑052‑0156
Permitted Compensation Arrangements 836‑052‑0160
Required Disclosure Provisions 836‑052‑0165
Requirements for Application Forms, Replacement Coverage 836‑052‑0170
Filing Requirements for Advertising 836‑052‑0175
Standards for Marketing 836‑052‑0180
Appropriateness of Recommended Purchase and Excessive Insurance 836‑052‑0185
Reporting of Multiple Policies 836‑052‑0190
Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates 836‑052‑0192
Prohibition Against Use of Genetic Information and Requests for Genetic Testing 836‑052‑0194
Separability 836‑052‑0225
Durational Limits for Health Maintenance Organizations 836‑052‑0230
Provider Services Limits for Insurers and Health Care Contractors 836‑052‑0500
Statutory Authority 836‑052‑0508
Definitions 836‑052‑0516
Policy Definitions 836‑052‑0526
Policy Practices and Provisions 836‑052‑0531
Long Term Care Insurance Partnership Program 836‑052‑0546
Required Policy Provisions 836‑052‑0556
Required Disclosure of Rating Practices to Consumers 836‑052‑0566
Initial Rate Filing Requirements 836‑052‑0576
Prohibition Against Post-Claims Underwriting, Applications 836‑052‑0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies 836‑052‑0596
Standards for Covered Services 836‑052‑0606
Use and Definition of “Home” or Similar Wording 836‑052‑0616
Requirement to Offer Inflation Protection 836‑052‑0626
Requirements for Application Forms and Replacement Coverage 836‑052‑0636
Reporting Requirements 836‑052‑0637
Annual Rate Certification Requirements 836‑052‑0639
Training for Insurance Producers 836‑052‑0646
Benefits Provided Through Advancement of Life Insurance Proceeds 836‑052‑0656
Reserve Standards 836‑052‑0666
Loss Ratio 836‑052‑0676
Premium Rate Schedule Increases 836‑052‑0680
Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings 836‑052‑0686
Filing Requirements for Out-of-State Group Policies 836‑052‑0696
Filing Requirements for Advertising 836‑052‑0706
Standards for Marketing 836‑052‑0716
Disclosure Statement 836‑052‑0726
Suitability 836‑052‑0736
Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates 836‑052‑0738
Availability of New Services or Providers 836‑052‑0740
Right to Reduce Coverage and Lower Premiums 836‑052‑0746
Nonforfeiture Benefit Requirement 836‑052‑0756
Standards for Benefit Triggers 836‑052‑0766
Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts 836‑052‑0768
Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met 836‑052‑0770
Prompt Payment of Clean Claims 836‑052‑0776
Standard Format Outline of Coverage 836‑052‑0786
Requirement to Deliver Shopper’s Guide 836‑052‑0790
Disclosure of Benefits Paid 836‑052‑0800
Purpose 836‑052‑0810
Replacement Upon Termination 836‑052‑0840
Termination of Coverage 836‑052‑0850
Multiple Employer Trusts 836‑052‑0860
Form of Notice to Group Policyholder 836‑052‑1000
Prosthetic and Orthotic Devices
Last Updated

Jun. 8, 2021

Rule 836-052-0546’s source at or​.us