CHAPTER 2.6. Long-Term Care Insurance [10231. - 10237.6.]

Chapter 2.6 added by Stats. 1988, Ch. 1342, Sec. 1.

§§ 10231–10237.6 · 87 sections

1. ARTICLE 1. Definitions §§ 10231–10231.8 · 7 sections

   • § 10231 Unless the context requires otherwise, the definitions in this article shall govern the construction of this chapter.
   • § 10231.2 “Long-term care insurance” includes any insurance policy, certificate, or rider advertised, marketed, offered, solicited, or designed to provide coverage for…
   • § 10231.3 (a) For the purposes of this section, the following definitions apply: (1) An “alternate plan of care” means a plan of care that includes a specification of…
   • § 10231.4 “Applicant” means either of the following: (a) In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits. (b)…
   • § 10231.5 “Certificate” means any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this state.
   • § 10231.6 “Group long-term care insurance” means a long-term care insurance policy which is delivered or issued for delivery in this state and issued to any of the…
   • § 10231.8 “Policy” means any policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery in this state by an insurer, fraternal benefit…
2. ARTICLE 3. General Provisions §§ 10232–10233.8 · 26 sections

   • § 10232 (a) No group long-term care insurance coverage may be offered or sold to a resident of this state under a group policy issued in another state to a group…
   • § 10232.1 (a) Every policy that is intended to be a qualified long-term care insurance contract as provided by Public Law 104-191 shall be identified as such by…
   • § 10232.2 (a) Every insurer that offers policies or certificates that are intended to be federally qualified long-term care insurance contracts, including riders to life…
   • § 10232.3 (a) All applications for long-term care insurance except that which is guaranteed issue, shall contain clear, unambiguous, short, simple questions designed to…
   • § 10232.4 (a) No long-term care insurance policy or certificate other than a group policy or certificate, as described in subdivision (a) of Section 10231.6, shall use a…
   • § 10232.5 On or after January 1, 1990, no long-term care insurance policy may be delivered or issued for delivery in this state which does any of the following: (a)…
   • § 10232.6 The commissioner may adopt regulations establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term…
   • § 10232.65 In addition to any other requirements of law, the following shall apply to a long-term care insurance policy: (a) The insurer shall not require an amount…
   • § 10232.7 (a) An applicant for a long-term care insurance policy or a certificate, other than an applicant for a certificate issued under a group long-term care…
   • § 10232.8 (a) In every long-term care policy or certificate that is not intended to be a federally qualified long-term care insurance contract and provides home care…
   • § 10232.81 Every long-term care policy, certificate, or rider that purports to provide benefits of home care, community-based services, and residential care facility…
   • § 10232.9 (a) Every long-term care policy or certificate that purports to provide benefits of home care or community-based services, shall provide at least the…
   • § 10232.92 Every long-term care policy or certificate covering confinement in a nursing facility shall also include a provision with the following features: (a) Care in a…
   • § 10232.93 Every long-term care policy or certificate shall define the maximum lifetime benefit as a single dollar amount that may be used interchangeably for any home-…
   • § 10232.95 Every long-term care policy or certificate that provides reimbursement for care in a nursing facility shall cover and reimburse for per diem expenses, as well…
   • § 10232.96 When a policy or certificate holder of an insurance contract issued prior to December 31, 1996, requests a material modification to the contract as defined by…
   • § 10232.97 In every long-term care policy or certificate that covers care in a nursing facility, the threshold establishing eligibility for nursing facility care shall be…
   • § 10233 Precedent to the payment of benefits for any care covered by the terms of the policy, any insurer offering long-term care insurance as described in Section…
   • § 10233.2 Long-term care insurance may not: (a) Be canceled, nonrenewed, or otherwise terminated on the grounds of the age or the deterioration of the mental or physical…
   • § 10233.25 No long-term care policy or certificate that is issued, amended, renewed, or delivered on and after January 1, 2002, shall contain a provision that prohibits…
   • § 10233.3 If a policy or certificate replaces another long-term care policy or certificate, the replacing insurer shall waive any time periods applicable to preexisting…
   • § 10233.4 No long-term care insurance benefits may be reduced because of out-of-pocket expenditures by the insured or on behalf of the insured by a family member of the…
   • § 10233.5 (a) An outline of coverage shall be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means which…
   • § 10233.6 A certificate issued pursuant to a group long-term care insurance policy, which policy is delivered or issued for delivery in this state, shall include all of…
   • § 10233.7 No policy may be advertised, marketed, or offered as long-term care or nursing home insurance unless it complies with this chapter.
   • § 10233.8 (a) A long-term care insurance policy or certificate issued, amended, renewed, or delivered on or after January 1, 2020, shall not do any of the following…
3. ARTICLE 3. Administration and Enforcement §§ 10234–10234.7 · 7 sections

   • § 10234 The commissioner shall, as required by this chapter, or from time to time as conditions warrant, pursuant to Chapter 3.5 (commencing with Section 11340) of…
   • § 10234.2 (a) In addition to all other powers and remedies vested in the commissioner by law, the commissioner shall have administrative authority to assess the…
   • § 10234.3 (a) Any broker, agent, or other entity determined by the commissioner to engage in the business of insurance, other than an insurer, who violates this chapter…
   • § 10234.4 In addition to the assessment of penalties and other applicable remedies, the commissioner may take the following actions upon determination that a violation…
   • § 10234.5 (a) Any broker, agent, insurer, or other entity within the jurisdiction of the department who is charged with a violation of this chapter shall be afforded due…
   • § 10234.6 (a) The commissioner shall, by June 1 of each year, jointly design the format and content of a consumer rate guide for long-term care insurance with a working…
   • § 10234.7 The commissioner’s annual report to the Legislature, as required by Section 10234.6, shall be compiled in consultation with a task force designated by the…
4. ARTICLE 3.7. Consumer Protection §§ 10234.8–10234.97 · 8 sections

   • § 10234.8 (a) With regard to long-term care insurance, all insurers, brokers, agents, and others engaged in the business of insurance owe a policyholder or a prospective…
   • § 10234.85 No insurer, broker, agent, or other person shall cause a policyholder to replace a long term care insurance policy unnecessarily. Nothing in this section shall…
   • § 10234.86 (a) Every insurer shall maintain records for each agent of that agent’s amount of replacement sales as a percent of the agent’s total annual sales and the…
   • § 10234.87 (a) If an insurer replaces a policy or certificate that it has previously issued, the insurer shall recognize past insured status by granting premium credits…
   • § 10234.9 (a) Every insurer providing long-term care coverage in California shall provide a copy of any advertisement intended for use in California to the commissioner…
   • § 10234.93 (a) Every insurer of long-term care in California shall: (1) Establish marketing procedures to ensure that any comparison of policies by its agents or other…
   • § 10234.95 (a) Every insurer or other entity marketing long-term care insurance shall: (1) Develop and use suitability standards to determine whether the purchase or…
   • § 10234.97 (a) Any time long-term care coverage is replaced, the sales commission that is paid by the insurer and that represents the percentage of the sale normally paid…
5. ARTICLE 4. Implementation §§ 10235–10236.15 · 32 sections

   • § 10235 Except as provided in Section 10235.95, this article applies to all long-term care insurance policies delivered or issued for delivery in this state on or…
   • § 10235.2 No long-term care insurance policy delivered or issued for delivery in this state shall use the terms set forth below, unless the terms are defined in the…
   • § 10235.8 No policy may be delivered or issued for delivery in this state as long-term care insurance if the policy limits or excludes coverage by type of illness,…
   • § 10235.9 (a) Every insurer shall report annually by June 30 the total number of claims denied by each class of business in the state and the number of these claims…
   • § 10235.9a For policies or certificates issued on or after January 1, 2017, that contain an alternate plan of care provision pursuant to Section 10231.3, if an insurer…
   • § 10235.10 Termination of long-term care insurance shall be without prejudice to any benefits payable for institutionalization if that institutionalization began while…
   • § 10235.14 (a) Individual long-term care insurance policies shall contain a renewability provision. This provision shall be appropriately captioned, shall appear on the…
   • § 10235.16 (a) Long-term care insurance application forms shall include a question designed to elicit information as to whether the proposed insurance is intended to…
   • § 10235.17 For purposes of this chapter, the commissioner shall define inappropriate replacement of long-term care insurance in consultation with other interested parties.
   • § 10235.18 (a) Insurers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness or long-term care coverage to the…
   • § 10235.20 The commissioner may waive a specific provision or provisions of this article with respect to a specific long-term care insurance policy or certificate upon…
   • § 10235.30 (a) No insurer may deliver or issue for delivery a long-term care policy in this state unless the insurer offers at the time of application an option to…
   • § 10235.35 (a) Notwithstanding any other law, the commissioner may require the administration by an insurer of the contingent benefit upon lapse, as described in Section…
   • § 10235.36 (a) When a shortened benefit period nonforfeiture benefit, as described in Section 10235.30, or a contingent benefit upon lapse, as described in Section…
   • § 10235.40 (a) An individual long-term care policy or certificate shall not be issued until the applicant has been given the right to designate at least one individual,…
   • § 10235.45 (a) If a life insurance policy contains long-term care benefits and permits policy loans or cash withdrawals, then access to those loans or withdrawals shall…
   • § 10235.50 (a) A policy or certificate shall include a provision that gives the policyholder or certificate holder the right, exercisable any time after the first year,…
   • § 10235.51 (a) Every policy or certificate shall include a provision that gives the insured the option to elect, no less frequently than on each anniversary date after…
   • § 10235.52 (a) Each policy shall contain a provision that, if the insurer develops new benefits or benefit eligibility or new policies with new benefits or benefit…
   • § 10235.91 In the event a non-medicaid national or state long-term care program is created through public funding that substantially duplicates benefits covered by the…
   • § 10235.94 Every policy or certificate shall include a provision giving the policyholder or certificate holder the right to appeal decisions regarding benefit…
   • § 10235.95 (a) Notwithstanding Section 10235, this section applies to all long-term care policies in force, regardless of their dates of issuance. (b) Interest shall…
   • § 10236 Every individual and group long-term care policy and certificate under a group long-term care policy shall be either guaranteed renewable or noncancelable. (a)…
   • § 10236.1 (a) Benefits under individual long-term care insurance policies issued before new premium rate schedules are approved under Section 10236.11 shall be deemed…
   • § 10236.2 Except where the provisions of a group contract provide otherwise, the provisions of subdivisions (d) and (e) of Section 10236.1 shall apply to all group…
   • § 10236.5 (a) Every certificate of group insurance issued or delivered in California shall provide for continuation or conversion coverage for the certificate holder if…
   • § 10236.8 If a group long-term care policy is replaced by another policy to the same master policyholder issued, the replacing insurer shall do all of the following: (a)…
   • § 10236.11 The premium rate schedules for all individual and group long-term care insurance policies issued in this state shall be filed with and receive the prior…
   • § 10236.12 All actuaries used by the commissioner to review rate applications submitted by insurers pursuant to this chapter who are employees of the department shall be…
   • § 10236.13 No insurer may increase the premium for an individual or group long-term care insurance policy or certificate approved for sale under this chapter unless the…
   • § 10236.14 Approval of all premium rate schedule increases shall be subject to the following requirements: (a) (1) Premium rate schedule increases shall demonstrate that…
   • § 10236.15 Premium rate schedule increases that have been approved shall be subject to the following: (a) For each rate increase that is implemented, the insurer shall…
6. ARTICLE 5. Inflation Escalator and Benefit Increases §§ 10237–10237.6 · 7 sections

   • § 10237 This article applies to all long-term care insurance policies delivered or issued for delivery in this state on or after January 1, 1991.
   • § 10237.1 No insurer may deliver or issue for delivery a long-term care insurance policy or certificate in this state unless the insurer offers to each policyholder and…
   • § 10237.2 If the policy is issued to a group, the required offering in Section 10237.1 shall be made to the group policyholder; except that if the policy is issued to a…
   • § 10237.3 The offer in Section 10237.1 shall not be required of any of the following: (a) Life insurance policies or riders containing accelerated long-term care…
   • § 10237.4 (a) Inflation protection benefit increases under a policy that contains these benefits shall continue without regard to an insured’s age, claim status or claim…
   • § 10237.5 (a) An inflation protection provision that increases benefit levels annually in a manner so that the increases are compounded annually at a rate not less than…
   • § 10237.6 (a) An insurer shall include the following information in or with the outline of coverage: (1) A graphic comparison of the benefit levels of a policy that…