# Title 45 — Insurance, Commissioner of

## Article 45-06 — Accident and Health Insurance

## Chapter 45-06-05.1 — Long-Term Care Insurance Model Regulation

Care Insurance Policies
Policies or Certificates
Contracts
### § 45-06-05.1-01. Applicability and scope.

Except as otherwise specifically provided, this chapter applies to all long-term care insurance
policies, including qualified long-term care contracts and life insurance policies that accelerate benefits
for long-term care delivered or issued for delivery in this state on or after March 1, 2004, fraternal
benefit societies, nonprofit health, hospital and medical service corporations, prepaid health plans,
health maintenance organizations, and all similar organizations. Certain provisions of this chapter apply
only to qualified long-term care insurance contracts as noted. Policies delivered or issued for delivery in
this state before March 1, 2004, are governed by chapter 45-06-05.
Additionally, this chapter is intended to apply to policies having indemnity benefits triggered by
activities of daily living and sold as disability income insurance, if:
1. The benefits of the disability income policy are dependent upon or vary in amount based on
the receipt of long-term care services;

2. The disability income policy is advertised, marketed, or offered as insurance for long-term care
services; or
3. Benefits under the policy may commence after the policyholder has reached social security's
normal retirement age unless benefits are designed to replace lost income or pay for specific
expenses other than long-term care services.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-02. Definitions.

For the purpose of this chapter, the terms "long-term care insurance", "qualified long-term care
insurance", "group long-term care insurance", "commissioner", "applicant", "policy", and "certificate"
shall have the meanings set forth in North Dakota Century Code section 26.1-45-01. In addition, the
following definitions apply:
1. a. "Exceptional increase" means only those increases filed by an insurer as exceptional for
which the commissioner determines the need for the premium rate increase is justified:
(1) Due to changes in laws or regulations applicable to long-term care coverage in this
state; or
(2) Due to increased and unexpected utilization that affects the majority of insurers of
similar products.
b. Except as provided in section 45-06-05.1-18, exceptional increases are subject to the
same requirements as other premium rate schedule increases.
c. The commissioner may request a review by an independent actuary or a professional
actuarial body of the basis for a request that an increase be considered an exceptional
increase.
d. The commissioner, in determining that the necessary basis for an exceptional increase
exists, shall also determine any potential offsets to higher claims costs.
2. "Incidental", as used in subsection 10 of section 45-06-05.1-18, means that the value of the
long-term care benefits provided is less than ten percent of the total value of the benefits
provided over the life of the policy. These values shall be measured as of the date of issue.
3. "Qualified actuary" means a member in good standing of the American academy of actuaries.
4. "Similar policy forms" means all of the long-term care insurance policies and certificates
issued by an insurer in the same long-term care benefit classification as the policy form being
considered. Certificates of groups that meet the definition in subdivision a of subsection 3 of
North Dakota Century Code section 26.1-45-01 are not considered similar to certificates or
policies otherwise issued as long-term care insurance, but are similar to other comparable
certificates with the same long-term care benefit classifications. For purposes of determining
similar policy forms, long-term care benefit classifications are defined as follows: institutional
long-term care benefits only, noninstitutional long-term care benefits only, or comprehensive
long-term care benefits.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45

### § 45-06-05.1-03. Policy definitions.

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 policy and the definitions satisfy the following
requirements:
1. "Activities of daily living" means at least bathing, continence, dressing, eating, toileting, and
transferring.
2. "Acute condition" means that the individual is medically unstable. Such an individual requires
frequent monitoring by medical professionals, such as physicians and registered nurses, in
order to maintain the individual's health status.
3. "Adult day care" means a program for six or more individuals of social and health-related
services provided during the day in a community group setting for the purpose of supporting
frail, impaired elderly or other disabled adults who can benefit from care in a group setting
outside the home.
4. "Bathing" means washing oneself by sponge bath, or in either a tub or shower, including the
task of getting into or out of the tub or shower.
5. "Cognitive impairment" means a deficiency in a person's short-term or long-term memory;
orientation as to person, place, and time; deductive or abstract reasoning; or judgment as it
relates to safety awareness.
6. "Continence" means the ability to maintain control of bowel and bladder function, or, when
unable to maintain control of bowel or bladder function, the ability to perform associated
personal hygiene, including caring for catheter or colostomy bag.
7. "Dressing" means putting on and taking off all items of clothing and any necessary braces,
fasteners, or artificial limbs.
8. "Eating" means feeding oneself by getting food into the body from a receptacle such as a
plate, cup, or table or by a feeding tube or intravenously.
9. "Hands-on assistance" means physical assistance (minimal, moderate, or maximal) without
which the individual would not be able to perform the activity of daily living.
10. "Home health care services" means medical and nonmedical services provided to ill, disabled,
or infirm persons in their residences. Such services may include homemaker services,
assistance with activities of daily living, and respite care services.
11. "Medicare" means "The Health Insurance for the Aged Act, Title XVIII of the Social Security
Amendments of 1965 as Then Constituted or Later Amended" or "Title I, Part I of Public Law
89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and
popularly known as The Health Insurance for the Aged Act, as then constituted and any later
amendments or substitutes thereof", or words of similar import.
12. "Mental or nervous disorder" shall not be defined to include more than neurosis,
psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.
13. "Personal care" means the provision of hands-on services to assist an individual with activities
of daily living.
14. "Skilled nursing care", "personal care", "home care", "specialized care", "assisted living care",
and other services shall be defined in relation to the level of skill required, the nature of the
care, and the setting in which care must be delivered.

15. "Toileting" means getting to and from the toilet, getting on and off the toilet, and performing
associated personal hygiene.
16. "Transferring" means moving into or out of a bed, chair, or wheelchair.
17. All providers of services, including "skilled nursing facility", "extended care facility",
"convalescent nursing home", "personal care facility", "specialized care providers", "assisted
living facility", and "home care agency", shall be defined in relation to the services and
facilities required to be available and the licensure, certification, registration, or degree status
of those providing or supervising the services. When the definition requires the provider be
appropriately licensed, certified, or registered, it also must state what requirements a provider
must meet in lieu of licensure, certification, or registration when the state in which the service
is to be furnished does not require a provider of these services to be licensed, certified, or
registered, or when the state licenses, certifies, or registers the provider of services under
another name.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-04. Policy practices and provisions.

1. Renewability. The terms "guaranteed renewable" and "noncancelable" shall not be used in
any individual long-term care insurance policy without further explanatory language in
accordance with the disclosure requirements of section 45-06-05.1-06.
a. A policy issued to an individual shall not contain renewal provisions other than
"guaranteed renewable" or "noncancelable".
b. The term "guaranteed renewable" may be used only when the insured has the right to
continue the long-term care insurance in force by the timely payment of premiums and
when the insurer has no unilateral right to make any change in any provision of the policy
or rider while the insurance is in force, and cannot decline to renew, except that rates
may be revised by the insurer on a class basis.
c. The term "noncancelable" may be used only when the insured has the right to continue
the long-term care insurance in force by the timely payment of premiums during which
period the insurer has no right to unilaterally make any change in any provision of the
insurance or in the premium rate.
d. The term "level premium" may only be used when the insurer does not have the right to
change the premium.
e. In addition to the other requirements of this subsection, a qualified long-term care
insurance contract shall be guaranteed renewable, within the meaning of section
7702B(b)(1)(C) of the Internal Revenue Code of 1986, as amended.
2. Limitations and exclusions. A policy may not 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,
treatment, medical condition, or accident, except as follows:
a. Preexisting conditions or diseases.
b. Mental or nervous disorders; however, this shall not permit exclusion or limitation of
benefits on the basis of alzheimer's disease.
c. Alcoholism and drug addiction.

d. Illness, treatment, or medical condition arising out of:
(1) War or act of war (whether declared or undeclared);
(2) Participation in a felony, riot, or insurrection;
(3) Service in the armed forces or units auxiliary thereto;
(4) Suicide (sane or insane), attempted suicide, or intentionally self-inflicted injury; or
(5) Aviation (this exclusion applies only to non-fare-paying passengers).
e. Treatment provided in a government facility, unless otherwise required by law, services
for which benefits are available under Medicare or other governmental program, except
Medicaid, any state or federal workers' compensation, employer's liability or occupational
disease law, or any motor vehicle no-fault law, services provided by a member of the
covered person's immediate family, and services for which no charge is normally made in
the absence of insurance.
f. In the case of a qualified long-term care insurance contract, expenses for services or
items to the extent that the expenses are reimbursable under title XVIII of the Social
Security Act or would be so reimbursable but for the application of a deductible or
coinsurance amount.
g. (1) This subsection is not intended to prohibit exclusions and limitations by type of
provider. However, a long-term care issuer may not deny a claim because services
are provided in a state other than the state of policy issued under the following
conditions:
(a) When the state other than the state of policy issue does not have the provider
licensing, certification, or registration required in the policy, but where the
provider satisfies the policy requirements outlined for providers in lieu of
licensure, certification, or registration; or
(b) When the state other than the state of policy issue licenses, certifies, or
registers the provider under another name.
(2) For purposes of this subdivision, "state of policy issue" means the state in which the
individual policy or certificate was originally issued.
h. This subsection is not intended to prohibit territorial limitations.
3. Extension of benefits. Termination of long-term care insurance shall be without prejudice to
any benefits payable for institutionalization if the institutionalization began while the long-term
care insurance was in force and continues without interruption after termination. The extension
of benefits beyond the period the long-term care insurance was in force may be limited to the
duration of the benefit period, if any, or to payment of the maximum benefits and may be
subject to any policy waiting period, and all other applicable provisions of the policy.
4. Continuation or conversion.
a. Group long-term care insurance issued in this state on or after the effective date of this
section shall provide covered individuals with a basis for continuation or conversion of
coverage.
b. For the purposes of this section, "a basis for continuation of coverage" means a policy
provision that maintains coverage under the existing group policy when the coverage
would otherwise terminate and which is subject only to the continued timely payment of

premium when due. Group policies that restrict provision of benefits and services to, or
contain incentives to use certain providers or facilities, may provide continuation benefits
that are substantially equivalent to the benefits of the existing group policy. The
commissioner shall make a determination as to the substantial equivalency of benefits,
and in doing so, shall take into consideration the differences between managed care and
non-managed care plans, including, but not limited to, provider system arrangements,
service availability, benefit levels, and administrative complexity.
c. For the purposes of this section, "a basis for conversion of coverage" means a policy
provision that an individual whose coverage under the group policy would otherwise
terminate or has been terminated for any reason, including discontinuance of the group
policy in its entirety or with respect to an insured class, and who has been continuously
insured under the group policy, and any group policy which it replaced, for at least six
months immediately prior to termination, shall be entitled to the issuance of a converted
policy by the insurer under whose group policy the individual is covered, without
evidence of insurability.
d. For the purposes of this section, "converted policy" means an individual policy of
long-term care insurance providing benefits identical to or benefits determined by the
commissioner to be substantially equivalent to or in excess of those provided under the
group policy from which conversion is made. When the group policy from which
conversion is made restricts provision of benefits and services to, or contains incentives
to use certain providers or facilities, the commissioner, in making a determination as to
the substantial equivalency of benefits, shall take into consideration the differences
between managed care and non-managed care plans, including provider system
arrangements, service availability, benefit levels, and administrative complexity.
e. Written application for the converted policy shall be made and the first premium due, if
any, shall be paid as directed by the insurer not later than thirty-one days after
termination of coverage under the group policy. The converted policy shall be issued
effective on the day following the termination of coverage under the group policy, and
shall be renewable annually.
f. Unless the group policy from which conversion is made replaced previous group
coverage, the premium for the converted policy shall be calculated on the basis of the
insured's age at inception of coverage under the group policy from which conversion is
made. When the group policy from which conversion is made replaced previous group
coverage, the premium for the converted policy shall be calculated on the basis of the
insured's age at inception of coverage under the group policy replaced.
g. Continuation of coverage or issuance of a converted policy shall be mandatory, except
when:
(1) Termination of group coverage resulted from an individual's failure to make any
required payment of premium or contribution when due; or
(2) The terminating coverage is replaced not later than thirty-one days after termination,
by group coverage effective on the day following the termination of coverage:
(a) Providing benefits identical to or benefits determined by the commissioner to
be substantially equivalent to or in excess of those provided by the terminating
coverage; and
(b) The premium for which is calculated in a manner consistent with the
requirements of subdivision f.

h. Notwithstanding any other provision of this section, a converted policy issued to an
individual who at the time of conversion is covered by another long-term care insurance
policy that provides benefits on the basis of incurred expenses may contain a provision
that results in a reduction of benefits payable if the benefits provided under the additional
coverage, together with the full benefits provided by the converted policy, would result in
payment of more than one hundred percent of incurred expenses. The provision shall
only be included in the converted policy if the converted policy also provides for a
premium decrease or refund which reflects the reduction in benefits payable.
i. The converted policy may provide that the benefits payable under the converted policy,
together with the benefits payable under the group policy from which conversion is made,
shall not exceed those that would have been payable had the individual's coverage under
the group policy remained in force and effect.
j. Notwithstanding any other provision of this section, an insured individual whose eligibility
for group long-term care coverage is based upon the insured individual's relationship to
another person shall be entitled to continuation of coverage under the group policy upon
termination of the qualifying relationship by death or dissolution of marriage.
k. For the purposes of this section, a "managed care plan" is a health care or assisted living
arrangement designed to coordinate patient care or control costs through utilization
review, case management, or use of specific provider networks.
5. Discontinuance and replacement. If a group long-term care policy is replaced by another
group long-term care policy issued to the same policyholder, the succeeding insurer shall offer
coverage to all persons covered under the previous group policy on its date of termination.
Coverage provided or offered to individuals by the insurer and premiums charged to persons
under the new group policy:
a. Shall not result in an exclusion for preexisting conditions that would have been covered
under the group policy being replaced; and
b. Shall not vary or otherwise depend on the individual's health or disability status, claim
experience, or use of long-term care services.
6. a. The premium charged to an insured shall not increase due to either:
(1) The increasing age of the insured at ages beyond sixty-five; or
(2) The duration the insured has been covered under the policy.
b. The purchase of additional coverage shall not be considered a premium rate increase,
but for purposes of the calculation required under section 45-06-05.1-24, the portion of
the premium attributable to the additional coverage shall be added to and considered
part of the initial annual premium.
c. A reduction in benefits shall not be considered a premium change, but for purpose of the
calculation required under section 45-06-05.1-24, the initial annual premium shall be
based on the reduced benefits.
7. Electronic enrollment for group policies.
a. In the case of a group defined in subdivision a of subsection 3 of North Dakota Century
Code section 26.1-45-01, any requirement that a signature of an insured be obtained by
an agent or insurer shall be deemed satisfied if:

(1) The consent is obtained by telephonic or electronic enrollment by the group
policyholder or insurer. A verification of enrollment information shall be provided to
the enrollee;
(2) The telephonic or electronic enrollment provides necessary and reasonable
safeguards to assure the accuracy, retention, and prompt retrieval of records; and
(3) The telephonic or electronic enrollment provides necessary and reasonable
safeguards to assure that the confidentiality of nonpublic personal financial
information and nonpublic personal health information as defined by chapter
b. The insurer shall make available, upon request of the commissioner, records that will
demonstrate the insurer's ability to confirm enrollment and coverage amounts.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-05. Unintentional lapse.

Each insurer offering long-term care insurance shall, as a protection against unintentional lapse,
comply with the following:
1. a. Notice before lapse or termination. No individual long-term care policy or certificate shall
be issued until the insurer has received from the applicant either a written designation of
at least one person, in addition to the applicant, who is to receive notice of lapse or
termination of the policy or certificate for nonpayment of premium, or a written waiver
dated and signed by the applicant electing not to designate additional persons to receive
notice. The applicant has the right to designate at least one person who is to receive the
notice of termination, in addition to the insured. Designation shall not constitute
acceptance of any liability on the third party for services provided to the insured. The
form used for the written designation must provide space clearly designated for listing at
least one person. The designation shall include each person's full name and home
address. In the case of an applicant who elects not to designate an additional person, the
waiver shall state: "Protection against unintended lapse. I understand that I have the right
to designate at least one person other than myself to receive notice of lapse or
termination of this long-term care insurance policy for nonpayment of premium. I
understand that notice will not be given until thirty (30) days after a premium is due and
unpaid. I elect NOT to designate a person to receive this notice."
The insurer shall notify the insured of the right to change this written designation, no less
often than once every two years.
b. When the policyholder or certificate holder pays premium for a long-term care insurance
policy or certificate through a payroll or pension deduction plan, the requirements
contained in subdivision a need not be met until sixty days after the policyholder or
certificate holder is no longer on such a payment plan. The application or enrollment form
for such policies or certificates shall clearly indicate the payment plan selected by the
applicant.
c. Lapse or termination for nonpayment of premium. No individual long-term care policy or
certificate shall lapse or be terminated for nonpayment of premium unless the insurer, at
least thirty days before the effective date of the lapse or termination, has given notice to
the insured and to those persons designated pursuant to subdivision a, at the address
provided by the insured for purposes of receiving notice of lapse or termination. Notice

shall be given by first-class United States mail, postage prepaid, and notice may not be
given until thirty days after a premium is due and unpaid. Notice shall be deemed to have
been given as of five days after the date of mailing.
2. Reinstatement. In addition to the requirement in subsection 1, a long-term care insurance
policy or certificate shall include a provision that provides for reinstatement of coverage, in the
event of lapse if the insurer is provided proof that the policyholder or certificate holder was
cognitively impaired or had a loss of functional capacity before the grace period contained in
the policy expired. This option shall be available to the insured if requested within five months
after termination and shall allow for the collection of past-due premium, when appropriate. The
standard of proof of cognitive impairment or loss of functional capacity shall not be more
stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional
capacity contained in the policy and certificate.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-06. Required disclosure provisions.

1. Renewability. Individual long-term care insurance policies shall contain a renewability
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
noncancelable. This provision shall not apply to policies that do 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 which increases benefits or coverage with a
concomitant increase in premium during the policy term must be agreed to in writing signed by
the insured, except if the increased benefits or coverage are required by law. If 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 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
subsection 2 of North Dakota Century Code section 26.1-45-07 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 such 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
subsection shall 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 and 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 this section. 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 too shall be specified.
8. A qualified long-term care insurance contract shall include a disclosure statement in the policy
and in the outline of coverage as contained in subsection 5 of section 45-06-05.1-27, federal
tax consequences, 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 disclosure statement in the
policy and in the outline of coverage as contained in subsection 5 of section 45-06-05.1-27,
federal tax consequences, that the policy is not intended to be a qualified long-term care
insurance contract.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-07. Required disclosure of rating practices to consumers.

1. This section shall apply as follows:
a. Except as provided in subdivision b, this section applies to any long-term care policy or
certificate issued in this state on or after September 1, 2004.
b. For certificates issued on or after the effective date of this amended regulation under a
group long-term care insurance policy as defined in subdivision a of subsection 3 of
North Dakota Century Code section 26.1-45-01, which policy was in force at the time this
amended regulation became effective, the provisions of this section shall apply on the
policy anniversary following March 1, 2005.
2. Other than policies for which no applicable premium rate or rate schedule increases can be
made, insurers shall provide all of the information listed in this subsection to the applicant at
the time of application or enrollment, unless the method of application does not allow for
delivery at that time. In such a case, an insurer shall provide all of the information listed in this
section to the applicant no later than at the time of delivery of the policy or certificate.
a. A statement that the policy may be subject to rate increases in the future;
b. An explanation of potential future premium rate revisions, and the policyholder's or
certificate holder's option in the event of a premium rate revision;

c. The premium rate or rate schedules applicable to the applicant that will be in effect until a
request is made for an increase;
d. A general explanation for applying premium rate or rate schedule adjustments that shall
include:
(1) A description of when premium rate or rate schedule adjustments will be effective,
e.g., next anniversary date, next billing date, etc.; and
(2) The right to a revised premium rate or rate schedule as provided in subdivision c if
the premium rate or rate schedule is changed; and
e. (1) Information regarding each premium rate increase on this policy form or similar
policy forms over the past ten years for this state or any other state that, at a
minimum, identifies:
(a) The policy forms for which premium rates have been increased;
(b) The calendar years when the form was available for purchase; and
(c) The amount or percent of each increase. The percentage may be expressed
as a percentage of the premium rate prior to the increase, and may also be
expressed as minimum and maximum percentages if the rate increase is
variable by rating characteristics.
(2) The insurer may, in a fair manner, provide additional explanatory information related
to the rate increases.
(3) An insurer shall have the right to exclude from the disclosure premium rate
increases that only apply to blocks of business acquired from other nonaffiliated
insurers or the long-term care policies acquired from other nonaffiliated insurers
when those increases occurred prior to the acquisition.
(4) If an acquiring insurer files for a rate increase on a long-term care policy form
acquired from nonaffiliated insurers or a block of policy forms acquired from
nonaffiliated insurers on or before the later of the effective date of this section or the
end of a twenty-four-month period following the acquisition of the block or policies,
the acquiring insurer may exclude that rate increase from the disclosure. However,
the nonaffiliated selling company shall include the disclosure of that rate increase in
accordance with paragraph 1.
(5) If the acquiring insurer in paragraph 4 files for a subsequent rate increase, even
within the twenty-four-month period, on the same policy form acquired from
nonaffiliated insurers or block of policy forms acquired from nonaffiliated insurers
referenced in paragraph 4, the acquiring insurer shall make all disclosures required
by this subdivision, including disclosure of the earlier rate increase referenced in
paragraph 4.
3. An applicant shall sign an acknowledgment at the time of application, unless the method of
application does not allow for signature at that time, that the insurer made the disclosure
required under subdivisions a and e of subsection 2. If due to the method of application the
applicant cannot sign an acknowledgment at the time of application, the applicant shall sign
no later than at the time of delivery of the policy or certificate.
4. An insurer shall use the forms in appendices B and F to comply with the requirements of
subsections 2 and 3.

5. An insurer shall provide notice of an upcoming premium rate schedule increase to all
policyholders or certificate holders, if applicable, at least forty-five days prior to the
implementation of the premium rate schedule increase by the insurer. The notice shall include
the information required by subsection 2 when the rate increase is implemented.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-08. Initial filing requirements.

1. This section applies to any long-term care policy issued in this state on or after September 1,
2004.
2. An insurer shall provide the information listed in this subsection to the commissioner
sixty days prior to making a long-term care insurance form available for sale.
a. A copy of the disclosure documents required in section 45-06-05.1-07; and
b. An actuarial certification consisting of at least the following:
(1) A statement that the initial premium rate schedule is sufficient to cover anticipated
costs under moderately adverse experience and that the premium rate schedule is
reasonably expected to be sustainable over the life of the form with no future
premium increases anticipated;
(2) A statement that the policy design and coverage provided have been reviewed and
taken into consideration;
(3) A statement that the underwriting and claims adjudication processes have been
reviewed and taken into consideration;
(4) A complete description of the basis for contract reserves that are anticipated to be
held under the form, to include:
(a) Sufficient detail or sample calculations provided so as to have a complete
depiction of the reserve amounts to be held;
(b) A statement that the assumptions used for reserves contain reasonable
margins for adverse experience;
(c) A statement that the net valuation premium for renewal years does not
increase, except for attained-age rating where permitted; and
(d) A statement that the difference between the gross premium and the net
valuation premium for renewal years is sufficient to cover expected renewal
expenses; or if such a statement cannot be made, a complete description of
the situations in which this does not occur:
[1] An aggregate distribution of anticipated issues may be used as long as
the underlying gross premiums maintain a reasonably consistent
relationship; and
[2] If the gross premiums for certain age groups appear to be inconsistent
with this requirement, the commissioner may request a demonstration
under subsection 3 based on a standard age distribution; and

(5) (a) A statement that the premium rate schedule is not less than the premium rate
schedule for existing similar policy forms also available from the insurer except
for reasonable differences attributable to benefits; or
(b) A comparison of the premium schedules for similar policy forms that are
currently available from the insurer with an explanation of the differences.
3. a. The commissioner may request an actuarial demonstration that benefits are reasonable
in relation to premiums. The actuarial demonstration shall include either premium and
claim experience on similar policy forms, adjusted for any premium or benefit differences,
relevant and credible data from other studies, or both.
b. In the event the commissioner asks for additional information under this provision, the
period in subsection 2 does not include the period during which the insurer is preparing
the requested information.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-08.1. Initial filing requirements for policies issued after March 1, 2020.

1. This section applies to any long-term care policy issued in this state on or after March 1, 2020.
2. An insurer shall provide the information listed in this subsection to the commissioner sixty
days prior to making a long-term care insurance form available for sale.
a. A copy of the disclosure documents required in section 45-06-05.1-07.
b. An actuarial certification consisting of at least the following:
(1) A statement that the initial premium rate schedule is sufficient to cover anticipated
costs under moderately adverse experience and that the premium rate schedule is
reasonably expected to be sustainable over the life of the form with no future
premium increases anticipated.
(2) A statement that the policy design and coverage provided have been reviewed and
taken into consideration.
(3) A statement that the underwriting and claims adjudication processes have been
reviewed and taken into consideration.
(4) A statement that the premiums contain at least the minimum margin for moderately
adverse experience defined in subparagraphs a and b:
(a) A composite margin may not be less than ten percent of lifetime claims.
(b) A greater margin may be appropriate in circumstances where the company has
less credible experience to support its assumptions used to determine the
premium rates.
(5) (a) A statement that the premium rate schedule is not less than the premium rate
schedule for existing similar policy forms also available from the insurer except
for reasonable differences attributable to benefits; or
(b) A comparison of the premium schedules for similar policy forms currently
available from the insurer with an explanation of the differences.

(6) A statement that reserve requirements have been reviewed and considered.
Support for this statement must include:
(a) Sufficient detail or sample calculations provided so as to have a complete
depiction of the reserve amounts to be held; and
(b) A statement that the difference between the gross premium and the net
valuation premium for renewal years is sufficient to cover expected renewal
expenses; or if such a statement cannot be made, a complete description of
the situations where this does not occur. An aggregate distribution of
anticipated issues may be used as long as the underlying gross premiums
maintain a reasonably consistent relationship.
c. An actuarial memorandum prepared, dated, and signed by the member of the academy
of actuaries must be included and must address and support each specific item required
as part of the actuarial certification and provide at least the following information:
(1) An explanation of the review performed by the actuary prior to making the
statements in paragraphs 2 and 3 of subdivision b.
(2) A complete description of pricing assumptions.
(3) Sources and levels of margins incorporated into the gross premiums that are the
basis for the statement in paragraph 1 of subdivision b of the actuarial certification
and an explanation of the analysis and testing performed in determining the
sufficiency of the margins. Deviations in margins between ages, sexes, plans, or
states must be clearly described. Deviations in margins required to be described are
other than those produced utilizing generally accepted actuarial methods for
smoothing and interpolating gross premium scales.
(4) A demonstration that the gross premiums include the minimum composite margin
specified in paragraph 4 of subdivision b.
History: Effective October 1, 2019; amended effective April 1, 2021.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-09. Prohibition against post-claims underwriting.

1. All applications for long-term care insurance policies or certificates except those that are
guaranteed issue shall contain clear and unambiguous questions designed to ascertain the
health condition of the applicant.
2. a. If an application for long-term care insurance contains a question that asks whether the
applicant has had medication prescribed by a physician, it must also ask the applicant to
list the medication that has been prescribed.
b. If the medications listed in the application were known by the insurer, or should have
been known at the time of application, to be directly related to a medical condition for
which coverage would otherwise be denied, then the policy or certificate shall not be
rescinded for that condition.
3. Except for policies or certificates which are guaranteed issue:
a. The following language shall be set out conspicuously and in close conjunction with the
applicant's signature block on an application for a long-term care insurance policy or
certificate:

Caution: If your answers on this application are incorrect or untrue, [company] has
the right to deny benefits or rescind your policy.
b. The following language, or language substantially similar to the following, shall be set out
conspicuously on the long-term care insurance policy or certificate at the time of delivery:
Caution: The issuance of this long-term care insurance [policy] [certificate] is based
upon your responses to the questions on your application. A copy of your
[application] [enrollment form] [is enclosed] [was retained by you when you applied].
If your answers are incorrect or untrue, the company has the right to deny benefits
or rescind your policy. The best time to clear up any questions is now, before a
claim arises! If, for any reason, any of your answers are incorrect, contact the
company at this address: [insert address]
c. Prior to issuance of a long-term care policy or certificate to an applicant age eighty or
older, the insurer shall obtain one of the following:
(1) A report of a physical examination;
(2) An assessment of functional capacity;
(3) An attending physician's statement; or
(4) Copies of medical records.
4. A copy of the completed application or enrollment form, whichever is applicable, shall be
delivered to the insured no later than at the time of delivery of the policy or certificate unless it
was retained by the applicant at the time of application.
5. Every insurer or other entity selling or issuing long-term care insurance benefits shall maintain
a record of all policy or certificate rescissions, both state and countrywide, except those that
the insured voluntarily effectuated and shall annually furnish this information to the insurance
commissioner in the format prescribed by the national association of insurance commissioners
in appendix A.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-10. Minimum standards for home health and community care benefits in

long-term care insurance policies.
1. A long-term care insurance policy or certificate shall not, if it provides benefits for home health
care or community care services, limit or exclude benefits:
a. By requiring that the insured or claimant would need care in a skilled nursing facility if
home health care services were not provided;
b. By requiring that the insured or claimant first or simultaneously receive nursing or
therapeutic services, or both, in a home, community, or institutional setting before home
health care services are covered;
c. By limiting eligible services to services provided by registered nurses or licensed
practical nurses;
d. By requiring that a nurse or therapist provide services covered by the policy that can be
provided by a home health aide, or other licensed or certified home care worker acting
within the scope of the worker's licensure or certification;

e. By excluding coverage for personal care services provided by a home health aide;
f. By requiring that the provision of home health care services be at a level of certification
or licensure greater than that required by the eligible service;
g. By requiring that the insured or claimant have an acute condition before home health
care services are covered;
h. By limiting benefits to services provided by Medicare-certified agencies or providers; or
i. By excluding coverage for adult day care services.
2. A long-term care insurance policy or certificate, if it provides for home health or community
care services, shall provide total home health or community care coverage that is a dollar
amount equivalent to at least one-half of one year's coverage available for nursing home
benefits under the policy or certificate, at the time covered home health or community care
services are being received. This requirement shall not apply to policies or certificates issued
to residents of continuing care retirement communities.
3. Home health care coverage may be applied to the nonhome health care benefits provided in
the policy or certificate when determining maximum coverage under the terms of the policy or
certificate.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-11. Requirement to offer inflation protection.

1. No insurer may offer a long-term care insurance policy unless the insurer also offers to the
policyholder in addition to any other inflation protection the option to purchase a policy that
provides for benefit levels to increase with benefit maximums or reasonable durations which
are meaningful to account for reasonably anticipated increases in the costs of long-term care
services covered by the policy. Insurers must offer to each policyholder, at the time of
purchase, the option to purchase a policy with an inflation protection feature no less favorable
than one of the following:
a. Increases benefit levels annually in a manner so that the increases are compounded
annually at a rate not less than five percent;
b. Guarantees the insured individual the right to periodically increase benefit levels without
providing evidence of insurability or health status so long as the option for the previous
period has not been declined. The amount of the additional benefit shall be no less than
the difference between the existing policy benefit and that benefit compounded annually
at a rate of at least five percent for the period beginning with the purchase of the existing
benefit and extending until the year in which the offer is made; or
c. Covers a specified percentage of actual or reasonable charges and does not include a
maximum specified indemnity amount or limit.
2. Where the policy is issued to a group, the required offer in subsection 1 shall be made to the
group policyholder; except, if the policy is issued to a group defined in subdivision d of
subsection 3 of North Dakota Century Code section 26.1-45-01 other than to a continuing care
retirement community, the offering shall be made to each proposed certificate holder.
3. The offer in subsection 1 shall not be required of life insurance policies or riders containing
accelerated long-term care benefits.

4. a. Insurers shall include the following information in or with the outline of coverage:
(1) A graphic comparison of the benefit levels of a policy that increases benefits over
the policy period with a policy that does not increase benefits. The graphic
comparison shall show benefit levels over at least a twenty-year period.
(2) Any expected premium increases or additional premiums to pay for automatic or
optional benefit increases.
b. An insurer may use a reasonable hypothetical, or a graphic demonstration, for the
purposes of this disclosure.
5. Inflation protection benefit increases under a policy which contains these benefits shall
continue without regard to an insured's age, claim status or claim history, or the length of time
the person has been insured under the policy.
6. An offer of inflation protection that provides for automatic benefit increases shall include an
offer of a premium which the insurer expects to remain constant. The offer shall disclose in a
conspicuous manner that the premium may change in the future unless the premium is
guaranteed to remain constant.
7. a. Inflation protection as provided in subdivision a of subsection 1 shall be included in a
long-term care insurance policy unless an insurer obtains a rejection of inflation
protection signed by the policyholder as required in this subsection. The rejection may be
either in the application or on a separate form.
b. The rejection shall be considered a part of the application and shall state:
I have reviewed the outline of coverage and the graphs that compare the benefits
and premiums of this policy with and without inflation protection. Specifically, I have
reviewed Plans ______, and I reject inflation protection.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-12. Requirements for application forms and replacement coverage.

1. Application forms shall include the following questions designed to elicit information as to
whether, as of the date of the application, the applicant has another long-term care insurance
policy or certificate in force or whether a long-term care policy or certificate is intended to
replace any other accident and sickness or long-term care policy or certificate presently in
force. A supplementary application or other form to be signed by the applicant and agent,
except when the coverage is sold without an agent, containing the questions may be used.
With regard to a replacement policy issued to a group defined by subdivision a of subsection 3
of North Dakota Century Code section 26.1-45-01, the following questions may be modified
only to the extent necessary to elicit information about health or long-term care insurance
policies other than the group policy being replaced, provided that the certificate holder has
been notified of the replacement.
a. Do you have another long-term care insurance policy or certificate in force (including
health care service contract, health maintenance organization contract)?
b. Did you have another long-term care insurance policy or certificate in force during the
last twelve months?
(1) If so, with which company?

(2) If that policy lapsed, when did it lapse?
c. Are you covered by Medicaid?
d. Do you intend to replace any of your medical or health insurance coverage with this
policy [certificate]?
2. Agents shall list any other health insurance policies they have sold to the applicant.
a. List policies sold that are still in force.
b. List policies sold in the past five years that are no longer in force.
3. Solicitations other than direct response. Upon determining that a sale will involve replacement,
an insurer, other than an insurer using direct response solicitation methods, or its agent shall
furnish the applicant, prior to issuance or delivery of the individual long-term care insurance
policy, a notice regarding replacement of accident and sickness or long-term care coverage.
One copy of the notice shall be retained by the applicant and an additional copy signed by the
applicant shall be retained by the insurer. The required notice shall be provided in the
following manner:
[Insurance company's name and address]
According to [your application] [information you have furnished], you intend to lapse or otherwise
terminate existing accident and sickness or long-term care insurance and replace it with an individual
long-term care insurance policy to be issued by [company name] Insurance Company. Your new policy
provides thirty (30) days within which you may decide, without cost, whether you desire to keep the
policy. For your own information and protection, you should be aware of and seriously consider certain
factors which may affect the insurance protection available to you under the new policy.
You should review this new coverage carefully, comparing it with all accident and sickness or long-term
care insurance coverage you now have, and terminate your present policy only if, after due
consideration, you find that purchase of this long-term care coverage is a wise decision.
(Use additional sheets, as necessary.)
I have reviewed your current medical or health insurance coverage. I believe the replacement of
insurance involved in this transaction materially improves your position. My conclusion has taken into
account the following considerations, which I call to your attention:
1. Health conditions that you may presently have (preexisting conditions) may not be
immediately or fully covered under the new policy. This could result in denial or delay in
payment of benefits under the new policy, whereas a similar claim might have been payable
under your present policy.
2. State law provides that your replacement policy or certificate may not contain new preexisting
conditions or probationary periods. The insurer will waive any time periods applicable to
preexisting conditions or probationary periods in the new policy (or coverage) for similar
benefits to the extent such time was spent (depleted) under the original policy.

3. If you are replacing existing long-term care insurance coverage, you may wish to secure the
advice of your present insurer or its agent regarding the proposed replacement of your
present policy. This is not only your right, but it is also in your best interest to make sure you
understand all the relevant factors involved in replacing your present coverage.
4. If, after due consideration, you still wish to terminate your present policy and replace it with
new coverage, be certain to truthfully and completely answer all questions on the application
concerning your medical health history. Failure to include all material medical information on
an application may provide a basis for the company to deny any future claims and to refund
your premium as though your policy had never been in force. After the application has been
completed and before you sign it, reread it carefully to be certain that all information has been
properly recorded.
(Signature of Agent, Broker, or Other Representative)
[Typed Name and Address of Agent or Broker]
The above "Notice to Applicant" was delivered to me on:
(Applicant's Signature) (Date)
4. Direct response solicitations. Insurers using direct response solicitation methods shall deliver
a notice regarding replacement of accident and sickness or long-term care coverage to the
applicant upon issuance of the policy. The required notice shall be provided in the following
manner:
[Insurance company's name and address]
According to [your application] [information you have furnished], you intend to lapse or otherwise
terminate existing accident and sickness or long-term care insurance and replace it with the long-term
care insurance policy delivered herewith issued by [company name] Insurance Company. Your new
policy provides thirty (30) days within which you may decide, without cost, whether you desire to keep
the policy. For your own information and protection, you should be aware of and seriously consider
certain factors which may affect the insurance protection available to you under the new policy.
You should review this new coverage carefully, comparing it with all accident and sickness or long-term
care insurance coverage you now have, and terminate your present policy only if, after due
consideration, you find that purchase of this long-term care coverage is a wise decision.
1. Health conditions which you may presently have (preexisting conditions), may not be
immediately or fully covered under the new policy. This could result in denial or delay in
payment of benefits under the new policy, whereas a similar claim might have been payable
under your present policy.
2. State law provides that your replacement policy or certificate may not contain new preexisting
conditions or probationary periods. Your insurer will waive any time periods applicable to
preexisting conditions or probationary periods in the new policy (or coverage) for similar
benefits to the extent such time was spent (depleted) under the original policy.

3. If you are replacing existing long-term care insurance coverage, you may wish to secure the
advice of your present insurer or its agent regarding the proposed replacement of your
present policy. This is not only your right, but it is also in your best interest to make sure you
understand all the relevant factors involved in replacing your present coverage.
4. [To be included only if the application is attached to the policy.] If, after due consideration, you
still wish to terminate your present policy and replace it with new coverage, read the copy of
the application attached to your new policy and be sure that all questions are answered fully
and correctly. Omissions or misstatements in the application could cause an otherwise valid
claim to be denied. Carefully check the application and write to [company name and address]
within thirty (30) days if any information is not correct and complete, or if any past medical
history has been left out of the application.
[Company Name]
5. If replacement is intended, the replacing insurer shall notify, in writing, the existing insurer of
the proposed replacement. The existing policy shall be identified by the insurer, name of the
insured and policy number or address, including zip code. Notice shall be made within
five working days from the date the application is received by the insurer or the date the policy
is issued, whichever is sooner.
6. Life insurance policies that accelerate benefits for long-term care shall comply with this section
if the policy being replaced is a long-term care insurance policy. If the policy being replaced is
a life insurance policy, the insurer shall comply with the requirements of article 45-04. If a life
insurance policy that accelerates benefits for long-term care is replaced by another such
policy, the replacing insurer shall comply with both the long-term care and the life insurance
replacement requirements.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-13. Reporting requirements.

1. Every insurer shall maintain records for each agent of that agent's amount of replacement
sales as a percentage of the agent's total annual sales and the amount of lapses of long-term
care insurance policies sold by the agent as a percentage of the agent's total annual sales.
2. Every insurer shall report annually by June thirtieth the ten percent of its agents with the
greatest percentages of lapses and replacements as measured by subsection 1. (Appendix G)
3. Reported replacement and lapse rates do not alone constitute a violation of insurance laws or
necessarily imply wrongdoing. The reports are for the purpose of reviewing more closely agent
activities regarding the sale of long-term care insurance.
4. Every insurer shall report annually by June thirtieth the number of lapsed policies as a
percentage of its total annual sales and as a percentage of its total number of policies in force
as of the end of the preceding calendar year. (Appendix G)
5. Every insurer shall report annually by June thirtieth the number of replacement policies sold as
a percentage of its total annual sales and as a percentage of its total number of policies in
force as of the preceding calendar year. (Appendix G)

6. Every insurer shall report annually by June thirtieth, for qualified long-term care insurance
contracts, the number of claims denied for each class of business, expressed as a percentage
of claims denied. (Appendix E)
7. For purposes of this section:
a. Subject to subdivision c, "claim" means a request for payment of benefits under an
in-force policy regardless of whether the benefit claimed is covered under the policy or
any terms or conditions of the policy have been met;
b. "Denied" means the insurer refuses to pay a claim for any reason other than for claims
not paid for failure to meet the waiting period or because of an applicable preexisting
condition;
c. "Policy" means only long-term care insurance; and
d. "Report" means on a statewide basis.
8. Reports required under this section shall be filed with the commissioner.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-14. Licensing.

A producer is not authorized to sell, solicit, or negotiate with respect to long-term care insurance
except as authorized by chapter 45-02-02 and North Dakota Century Code chapter 26.1-26.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-15. Discretionary powers of commissioner.

The commissioner may, upon written request and after an administrative hearing, issue an order to
modify or suspend a specific provision or provisions of this chapter with respect to a specific long-term
care insurance policy or certificate upon a written finding that:
1. The modification or suspension would be in the best interest of the insureds;
2. The purposes to be achieved could not be effectively or efficiently achieved without the
modification or suspension; and
3. a. The modification or suspension is necessary to the development of an innovative and
reasonable approach for insuring long-term care;
b. The policy or certificate is to be issued to residents of a life care or continuing care
retirement community or some other residential community for the elderly and the
modification or suspension is reasonably related to the special needs or nature of such a
community; or
c. The modification or suspension is necessary to permit long-term care insurance to be
sold as part of, or in conjunction with, another insurance product.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45

### § 45-06-05.1-16. Reserve standards.

1. When long-term care benefits are provided through the acceleration of benefits under group or
individual life policies or riders to such policies, policy reserves for the benefits shall be
determined in accordance with North Dakota Century Code section 26.1-35-02. Claim
reserves shall also be established in the case when the policy or rider is in claim status.
Reserves for policies and riders subject to this subsection should be based on the multiple
decrement model utilizing all relevant decrements except for voluntary termination rates.
Single decrement approximations are acceptable if the calculation produces essentially similar
reserves, if the reserve is clearly more conservative, or if the reserve is immaterial. The
calculations may take into account the reduction in life insurance benefits due to the payment
of long-term care benefits. However, in no event shall the reserves for the long-term care
benefit and the life insurance benefit be less than the reserves for the life insurance benefit
assuming no long-term care benefit.
In the development and calculation of reserves for policies and riders subject to this
subsection, due regard shall be given to the applicable policy provisions, marketing methods,
administrative procedures, and all other considerations which have an impact on projected
claim costs, including, but not limited to, the following:
a. Definition of insured events;
b. Covered long-term care facilities;
c. Existence of home convalescence care coverage;
d. Definition of facilities;
e. Existence or absence of barriers to eligibility;
f. Premium waiver provision;
g. Renewability;
h. Ability to raise premiums;
i. Marketing method;
j. Underwriting procedures;
k. Claims adjustment procedures;
l. Waiting period;
m. Maximum benefit;
n. Availability of eligible facilities;
o. Margins in claim costs;
p. Optional nature of benefit;
q. Delay in eligibility for benefit;
r. Inflation protection provisions; and
s. Guaranteed insurability option.

Any applicable valuation morbidity table shall be certified as appropriate as a statutory
valuation table by a member of the American academy of actuaries.
2. When long-term care benefits are provided other than as in subsection 1, reserves shall be
determined in accordance with generally accepted accounting and reserve practices.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-17. Life insurance long-term care benefits.

1. A life insurance policy that funds long-term care benefits entirely by accelerating the death
benefit is considered to provide reasonable benefits in relation to premiums paid, if the policy
complies with all of the following provisions:
a. The interest credited internally to determine cash value accumulations, including
long-term care, if any, are guaranteed not to be less than the minimum guaranteed
interest rate for cash value accumulations without long-term care set forth in the policy;
b. The portion of the policy that provides life insurance benefits meets the nonforfeiture
requirements of North Dakota Century Code sections 26.1-33-18 through 26.1-33-28;
c. The policy meets the disclosure requirements of subsections 4, 5, and 6 of North Dakota
Century Code section 26.1-45-09;
d. Any policy illustration that meets the applicable requirements of the national association
of insurance commissioners life insurance illustrations model regulation; and
e. An actuarial memorandum is filed with the insurance department that includes:
(1) A description of the basis on which the long-term care rates were determined;
(2) A description of the basis for the reserves;
(3) A summary of the type of policy, benefits, renewability, general marketing method,
and limits on ages of issuance;
(4) A description and a table of each actuarial assumption used. For expenses, an
insurer must include a percentage of premium dollars per policy and dollars per unit
of benefits, if any;
(5) A description and a table of the anticipated policy reserves and additional reserves
to be held in each future year for active lives;
(6) The estimated average annual premium per policy and the average issue age;
(7) A statement as to whether underwriting is performed at the time of application. The
statement shall indicate whether underwriting is used and, if used, the statement
shall include a description of the type or types of underwriting used, such as medical
underwriting or functional assessment underwriting. Concerning a group policy, the
statement shall indicate whether the enrollee or any dependent will be underwritten
and when underwriting occurs; and
(8) A description of the effect of the long-term care policy provision on the required
premiums, nonforfeiture values, and reserves on the underlying life insurance policy,
both for active lives and those in long-term care claim status.

History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-18. Premium rate schedule increases.

1. This section shall apply as follows:
a. Except as provided in subdivision b, this section applies to any long-term care policy or
certificate issued in this state on or after September 1, 2004.
b. For certificates issued on or after the effective date of this amended regulation under a
group long-term care insurance policy as defined in subdivision a of subsection 3 of
North Dakota Century Code section 26.1-45-01, which policy was in force at the time this
amended regulation became effective, the provisions of this section shall apply on the
policy anniversary following March 1, 2005.
2. An insurer shall request approval of a pending premium rate schedule increase, including an
exceptional increase, to the commissioner at least thirty days prior to the notice to the
policyholders and shall include:
a. Information required by section 45-06-05.1-07;
b. Certification by a qualified actuary that:
(1) If the requested premium rate schedule increase is implemented and the underlying
assumptions, which reflect moderately adverse conditions, are realized, no further
premium rate schedule increases are anticipated; and
(2) The premium rate filing is in compliance with the provisions of this section;
c. An actuarial memorandum justifying the rate schedule change request that includes:
(1) Lifetime projections of earned premiums and incurred claims based on the filed
premium rate schedule increase; and the method and assumptions used in
determining the projected values, including reflection of any assumptions that
deviate from those used for pricing other forms currently available for sale;
(a) Annual values for the five years preceding and the three years following the
valuation date shall be provided separately;
(b) The projections shall include the development of the lifetime loss ratio, unless
the rate increase is an exceptional increase;
(c) The projections shall demonstrate compliance with subsection 3; and
(d) For exceptional increases:
[1] The projected experience should be limited to the increases in claims
expenses attributable to the approved reasons for the exceptional
increase; and
[2] In the event the commissioner determines as provided in subdivision d of
subsection 1 of section 45-06-05.1-02 that offsets may exist, the insurer
shall use appropriate net projected experience;
(2) Disclosure of how reserves have been incorporated in this rate increase whenever
the rate increase will trigger contingent benefit upon lapse;

(3) Disclosure of the analysis performed to determine why a rate adjustment is
necessary, which pricing assumptions were not realized and why, and what other
actions taken by the company have been relied on by the actuary;
(4) A statement that policy design, underwriting, and claims adjudication practices have
been taken into consideration;
(5) In the event that it is necessary to maintain consistent premium rates for new
certificates and certificates receiving a rate increase, the insurer will need to file
composite rates reflecting projections of new certificates; and
(6) A demonstration that actual and projected costs exceed costs anticipated at the time
of initial pricing under moderately adverse experience and that the composite
margin specified in paragraph 4 of subdivision b of subsection 2 of section
d. A statement that renewal premium rate schedules are not greater than new business
premium rate schedules except for differences attributable to benefits, unless sufficient
justification is provided to the commissioner; and
e. Sufficient information for review and approval of the premium rate schedule increase by
the commissioner.
3. All premium rate schedule increases shall be determined in accordance with the following
requirements:
a. Exceptional increases shall provide that seventy percent of the present value of projected
additional premiums from the exceptional increase will be returned to policyholders in
benefits;
b. Premium rate schedule increases shall be calculated such that the sum of the
accumulated value of incurred claims, without the inclusion of active life reserves, and
the present value of future projected incurred claims, without the inclusion of active life
reserves, will not be less than the sum of the following:
(1) The accumulated value of the initial earned premium times fifty-eight percent;
(2) Eighty-five percent of the accumulated value of prior premium rate schedule
increases on an earned basis;
(3) The present value of future projected initial earned premiums times fifty-eight
percent; and
(4) Eighty-five percent of the present value of future projected premiums not in
paragraph 3 on an earned basis;
c. In the event that a policy form has both exceptional and other increases, the values in
paragraphs 2 and 4 of subdivision b will also include seventy percent for exceptional rate
increase amounts; and
d. All present and accumulated values used to determine rate increases shall use the
maximum valuation interest rate permitted by law in the valuation of whole life insurance
issued on the same date as the health insurance contract. The actuary shall disclose as
part of the actuarial memorandum the use of any appropriate averages.
4. For each rate increase that is implemented, the insurer shall file for approval by the
commissioner updated projections, as defined in paragraph 1 of subdivision c of subsection 2,

annually for the next three years and include a comparison of actual results to projected
values. The commissioner may extend the period to greater than three years if actual results
are not consistent with projected values from prior projections. For group insurance policies
that meet the conditions in subsection 11, the projections required by this subsection shall be
provided to the policyholder in lieu of filing with the commissioner.
5. If any premium rate in the revised premium rate schedule is greater than two hundred percent
of the comparable rate in the initial premium schedule, lifetime projections, as defined in
paragraph 1 of subdivision c of subsection 2, shall be filed for approval by the commissioner
every five years following the end of the required period in subsection 4. For group insurance
policies that meet the conditions in subsection 11, the projections required by this subsection
shall be provided to the policyholder in lieu of filing with the commissioner.
6. a. If the commissioner has determined that the actual experience following a rate increase
does not adequately match the projected experience and that the current projections
under moderately adverse conditions demonstrate that incurred claims will not exceed
proportions of premiums specified in subsection 3, the commissioner may require the
insurer to implement any of the following:
(1) Premium rate schedule adjustments; or
(2) Other measures to reduce the difference between the projected and actual
experience.
b. In determining whether the actual experience adequately matches the projected
experience, consideration should be given to paragraph 5 of subdivision c of
subsection 2, if applicable.
7. If the majority of the policies or certificates to which the increase is applicable are eligible for
the contingent benefit upon lapse, the insurer shall file:
a. A plan, subject to commissioner approval, for improved administration or claims
processing designed to eliminate the potential for further deterioration of the policy form
requiring further premium rate schedule increases, or both, or to demonstrate that
appropriate administration and claims processing have been implemented or are in
effect; otherwise the commissioner may impose the condition in subsection 8; and
b. The original anticipated lifetime loss ratio and the premium rate schedule increase that
would have been calculated according to subsection 3 had the greater of the original
anticipated lifetime loss ratio or fifty-eight percent been used in the calculations described
in paragraphs 1 and 3 of subdivision b of subsection 3.
8. a. For a rate increase filing that meets the following criteria, the commissioner shall review,
for all policies included in the filing, the projected lapse rates and past lapse rates during
the twelve months following each increase to determine if significant adverse lapsation
has occurred or is anticipated:
(1) The rate increase is not the first rate increase requested for the specific policy form
or forms;
(2) The rate increase is not an exceptional increase; and
(3) The majority of the policies or certificates to which the increase is applicable are
eligible for the contingent benefit upon lapse.
b. In the event significant adverse lapsation has occurred and is anticipated in the filing or is
evidenced in the actual results as presented in the updated projections provided by the

insurer following the requested rate increase, the commissioner may determine that a
rate spiral exists. Following the determination that a rate spiral exists, the commissioner
may require the insurer to offer, without underwriting, to all in-force insureds subject to
the rate increase the option to replace existing coverage with one or more reasonably
comparable products being offered by the insurer or its affiliates.
(1) The offer shall:
(a) Be subject to the approval of the commissioner;
(b) Be based on actuarially sound principles, but not be based on attained age;
and
(c) Provide that maximum benefits under any new policy accepted by an insured
shall be reduced by comparable benefits already paid under the existing policy.
(2) The insurer shall maintain the experience of all the replacement insureds separate
from the experience of insureds originally issued the policy forms. In the event of a
request for a rate increase on the policy form, the rate increase shall be limited to
the lesser of:
(a) The maximum rate increase determined based on the combined experience;
and
(b) The maximum rate increase determined based only on the experience of the
insureds originally issued the form plus ten percent.
9. If the commissioner determines that the insurer has exhibited a persistent practice of filing
inadequate initial premium rates for long-term care insurance, the commissioner may, in
addition to the provisions of subsection 8, prohibit the insurer from either of the following:
a. Filing and marketing comparable coverage for a period of up to five years; or
b. Offering all other similar coverages and limiting marketing of new applications to the
products subject to recent premium rate schedule increases.
10. Subsections 1 through 9 shall not apply to policies for which the long-term care benefits
provided by the policy are incidental, as defined in subsection 2 of section 45-06-05.1-02, if
the policy complies with all of the following provisions:
a. The interest credited internally to determine cash value accumulations, including
long-term care, if any, are guaranteed not to be less than the minimum guaranteed
interest rate for cash value accumulations without long-term care set forth in the policy;
b. The portion of the policy that provides insurance benefits other than long-term care
coverage meets the nonforfeiture requirements as applicable in any of the following:
(1) North Dakota Century Code sections 26.1-33-18 through 26.1-33-28; and
(2) North Dakota Century Code section 26.1-34-02.
c. The policy meets the disclosure requirements of subsections 4, 5, and 6 of North Dakota
Century Code section 26.1-45-09;
d. The portion of the policy that provides insurance benefits other than long-term care
coverage meets the requirements as applicable in the following:
(1) Policy illustrations as required by chapter 45-04-01.1; and

(2) Disclosure requirements in chapter 45-04-02.
e. An actuarial memorandum is filed with the insurance department that includes:
(1) A description of the basis on which the long-term care rates were determined;
(2) A description of the basis for the reserves;
(3) A summary of the type of policy, benefits, renewability, general marketing method,
and limits on ages of issuance;
(4) A description and a table of each actuarial assumption used. For expenses, an
insurer must include a percentage of premium dollars per policy and dollars per unit
of benefits, if any;
(5) A description and a table of the anticipated policy reserves and additional reserves
to be held in each future year for active lives;
(6) The estimated average annual premium per policy and the average issue age;
(7) A statement as to whether underwriting is performed at the time of application. The
statement shall indicate whether underwriting is used and, if used, the statement
shall include a description of the type or types of underwriting used, such as medical
underwriting or functional assessment underwriting. Concerning a group policy, the
statement shall indicate whether the enrollee or any dependent will be underwritten
and when underwriting occurs; and
(8) A description of the effect of the long-term care policy provision on the required
premiums, nonforfeiture values, and reserves on the underlying insurance policy,
both for active lives and those in long-term care claim status.
11. Subsections 6 and 8 shall not apply to group insurance policies as defined in subdivision a of
subsection 3 of North Dakota Century Code section 26.1-45-01 when:
a. The policies insure two hundred fifty or more persons and the policyholder has five
thousand or more eligible employees of a single employer; or
b. The policyholder, and not the certificate holders, pays a material portion of the premium,
which shall not be less than twenty percent of the total premium for the group in the
calendar year prior to the year a rate increase is filed.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-19. Filing requirement.

Prior to an insurer or similar organization offering group long-term care insurance to a resident of
this state pursuant to North Dakota Century Code section 26.1-45-03, it shall file with the commissioner
evidence that the group policy or certificate thereunder has been approved by a state having statutory
or regulatory long-term care insurance requirements substantially similar to those adopted in this state.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45

### § 45-06-05.1-20. Filing requirements for advertising.

1. Every insurer, health care service plan, or other entity providing long-term care insurance or
benefits in this state shall provide a copy of any long-term care insurance advertisement
intended for use in this state whether through written, radio, or television medium to the
insurance commissioner of this state for review or approval by the commissioner to the extent
it may be required under state law. In addition, all advertisements shall be retained by the
insurer, health care service plan, or other entity for at least three years from the date the
advertisement was first used.
2. The commissioner may exempt from these requirements any advertising form or material
when, in the commissioner's opinion, this requirement may not be reasonably applied.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-21. Standards for marketing.

1. Every insurer, health care service plan, or other entity marketing long-term care insurance
coverage in this state, directly or through its producers, shall:
a. Establish marketing procedures and agent training requirements to assure that:
(1) Any marketing activities, including any comparison of policies, by its agents or other
producers will be fair and accurate; and
(2) Excessive insurance is not sold or issued.
b. Display prominently by type, stamp, or other appropriate means, on the first page of the
outline of coverage and policy the following:
"Notice to buyer: This policy may not cover all of the costs associated with long-term
care incurred by the buyer during the period of coverage. The buyer is advised to
review carefully all policy limitations."
c. Provide copies of the disclosure forms required in subsection 3 of section 45-06-05.1-07
(appendices B and F) to the applicant.
d. Inquire and otherwise make every reasonable effort to identify whether a prospective
applicant or enrollee for long-term care insurance already has accident and sickness or
long-term care insurance and the types and amounts of any such insurance, except that
in the case of qualified long-term care insurance contracts, an inquiry into whether a
prospective applicant or enrollee for long-term care insurance has accident and sickness
insurance is not required.
e. Every insurer or entity marketing long-term care insurance shall establish auditable
procedures for verifying compliance with subsection 1.
f. If the state in which the policy or certificate is to be delivered or issued for delivery has a
senior insurance counseling program approved by the commissioner, the insurer shall, at
solicitation, provide written notice to the prospective policyholder and certificate holder
that the program is available and the name, address, and telephone number of the
program.

g. For long-term care health insurance policies and certificates, use the terms
"noncancelable" or "level premium" only when the policy or certificate conforms to
subdivision c of subsection 1 of section 45-06-05.1-04.
h. Provide an explanation of contingent benefit upon lapse provided for in subdivision c of
subsection 4 of section 45-06-05.1-24 and, if applicable, the additional contingent benefit
upon lapse provided to policies with fixed or limited premium payment periods in
subdivision d of subsection 4 of section 45-06-05.1-24.
2. In addition to the practices prohibited in North Dakota Century Code section 26.1-04-03, the
following acts and practices are prohibited:
a. Twisting. Knowingly making any misleading representation or incomplete or fraudulent
comparison of any insurance policies or insurers for the purpose of inducing, or tending
to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign,
borrow on, or convert any insurance policy or to take out a policy of insurance with
another insurer.
b. High pressure tactics. Employing any method of marketing having the effect of or tending
to induce the purchase of insurance through force, fright, threat, whether explicit or
implied, or undue pressure to purchase or recommend the purchase of insurance.
c. Cold lead advertising. Making use directly or indirectly of any method of marketing which
fails to disclose in a conspicuous manner that a purpose of the method of marketing is
solicitation of insurance and that contact will be made by an insurance agent or
insurance company.
d. Misrepresentation. Misrepresenting a material fact in selling or offering to sell a long-term
care insurance policy.
3. a. With respect to the obligations set forth in this subsection, the primary responsibility of an
association, as defined in subdivision b of subsection 3 of North Dakota Century Code
section 26.1-45-01, when endorsing or selling long-term care insurance shall be to
educate its members concerning long-term care issues in general so that its members
can make informed decisions. Associations shall provide objective information regarding
long-term care insurance policies or certificates endorsed or sold by such associations to
ensure that members of such associations receive a balanced and complete explanation
of the features in the policies or certificates that are being endorsed or sold.
b. The insurer shall file with the insurance department the following material:
(1) The policy and certificate;
(2) A corresponding outline of coverage; and
(3) All advertisements requested by the insurance department.
c. The association shall disclose in any long-term care insurance solicitation:
(1) The specific nature and amount of the compensation arrangements, including all
fees, commissions, administrative fees, and other forms of financial support, that the
association receives from endorsement or sale of the policy or certificate to its
members; and
(2) A brief description of the process under which the policies and the insurer issuing
the policies were selected.

d. If the association and the insurer have interlocking directorates or trustee arrangements,
the association shall disclose that fact to its members.
e. The board of directors of associations selling or endorsing long-term care insurance
policies or certificates shall review and approve the insurance policies as well as the
compensation arrangements made with the insurer.
f. The association shall also:
(1) At the time of the association's decision to endorse, engage the services of a
person with expertise in long-term care insurance not affiliated with the insurer to
conduct an examination of the policies, including its benefits, features, and rates
and update the examination thereafter in the event of material change;
(2) Actively monitor the marketing efforts of the insurer and its agents; and
(3) Review and approve all marketing materials or other insurance communications
used to promote sales or sent to members regarding the policies or certificates.
(4) Paragraphs 1 through 3 shall not apply to qualified long-term care insurance
contracts.
g. No group long-term care insurance policy or certificate may be issued to an association
unless the insurer files with the state insurance department the information required in
this subsection.
h. The insurer shall not issue a long-term care policy or certificate to an association or
continue to market such a policy or certificate unless the insurer certifies annually that
the association has complied with the requirements set forth in this subsection.
i. Failure to comply with the filing and certification requirements of this section constitutes
an unfair trade practice in violation of North Dakota Century Code section 26.1-04-03.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-22. Suitability.

1. This section shall not apply to life insurance policies that accelerate benefits for long-term
care.
2. Every insurer, health care service plan, or other entity marketing long-term care insurance (the
"issuer") shall:
a. Develop and use suitability standards to determine whether the purchase or replacement
of long-term care insurance is appropriate for the needs of the applicant;
b. Train its agents in the use of its suitability standards; and
c. Maintain copies of its suitability standards and make them available for inspection upon
request by the commissioner.
3. a. To determine whether the applicant meets the standards developed by the issuer, the
agent and issuer shall develop procedures that take the following into consideration:
(1) The ability to pay for the proposed coverage and other pertinent financial
information related to the purchase of the coverage;

(2) The applicant's goals or needs with respect to long-term care and the advantages
and disadvantages of insurance to meet these goals or needs; and
(3) The values, benefits, and costs of the applicant's existing insurance, if any, when
compared to the values, benefits, and costs of the recommended purchase or
replacement.
b. The issuer and, when an agent is involved, the agent shall make reasonable efforts to
obtain the information set out in subdivision a. The efforts shall include presentation to
the applicant, at or prior to application, the "long-term care insurance personal
worksheet". The personal worksheet used by the issuer shall contain, at a minimum, the
information in the format contained in appendix B, in not less than twelve-point type. The
issuer may request the applicant to provide additional information to comply with its
suitability standards. A copy of the issuer's personal worksheet shall be filed with the
commissioner.
c. A completed personal worksheet shall be returned to the issuer prior to the issuer's
consideration of the applicant for coverage, except the personal worksheet need not be
returned for sales of employer group long-term care insurance to employees and their
spouses.
d. The sale or dissemination outside the company or agency by the issuer or agent of
information obtained through the personal worksheet in appendix B is prohibited.
4. The issuer shall use the suitability standards it has developed pursuant to this section in
determining whether issuing long-term care insurance coverage to an applicant is appropriate.
5. Agents shall use the suitability standards developed by the issuer in marketing long-term care
insurance.
6. At the same time as the personal worksheet is provided to the applicant, the disclosure form
entitled "Things You Should Know Before You Buy Long-Term Care Insurance" shall be
provided. The form shall be in the format contained in appendix C, in not less than
twelve-point type.
7. If the issuer determines that the applicant does not meet its financial suitability standards, or if
the applicant has declined to provide the information, the issuer may reject the application. In
the alternative, the issuer shall send the applicant a letter similar to appendix D. However, if
the applicant has declined to provide financial information, the issuer may use some other
method to verify the applicant's intent. Either the applicant's returned letter or a record of the
alternative method of verification shall be made part of the applicant's file.
8. The issuer shall report annually to the commissioner the total number of applications received
from residents of this state, the number of those who declined to provide information on the
personal worksheet, the number of applicants who did not meet the suitability standards, and
the number of those who chose to confirm after receiving a suitability letter.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-23. Prohibition against preexisting conditions and probationary periods in

replacement policies or certificates.
If a long-term care insurance policy or certificate replaces another long-term care policy or
certificate, the replacing insurer shall waive any time periods applicable to preexisting conditions and

probationary periods in the new long-term care policy for similar benefits to the extent that similar
exclusions have been satisfied under the original policy.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-24. Nonforfeiture benefit requirement.

1. This section does not apply to life insurance policies or riders containing accelerated long-term
care benefits.
2. To comply with the requirement to offer a nonforfeiture benefit pursuant to the provisions of
North Dakota Century Code section 26.1-45-14:
a. A policy or certificate offered with nonforfeiture benefits shall have coverage elements,
eligibility, benefit triggers, and benefit length that are the same as coverage to be issued
without nonforfeiture benefits. The nonforfeiture benefit included in the offer shall be the
benefit described in subsection 5; and
b. The offer shall be in writing if the nonforfeiture benefit is not otherwise described in the
outline of coverage or other materials given to the prospective policyholder.
3. If the offer required to be made under North Dakota Century Code section 26.1-45-14 is
rejected, the insurer shall provide the contingent benefit upon lapse described in this section.
Even if this offer is accepted for a policy with a fixed or limited premium paying period, the
contingent benefit on lapse in subdivision d of subsection 4 still applies.
4. a. After rejection of the offer required under North Dakota Century Code section 26.1-45-14,
for individual and group policies without nonforfeiture benefits issued after the effective
date of this section, the insurer shall provide a contingent benefit upon lapse.
b. In the event a group policyholder elects to make the nonforfeiture benefit an option to the
certificate holder, a certificate shall provide either the nonforfeiture benefit or the
contingent benefit upon lapse.
c. The contingent benefit on lapse shall be triggered every time an insurer increases the
premium rates to a level which results in a cumulative increase of the annual premium
equal to or exceeding the percentage of the insured's initial annual premium set forth
below based on the insured's issue age and the policy or certificate lapses within one
hundred twenty days of the due date of the premium so increased. Unless otherwise
required, policyholders shall be notified at least thirty days prior to the due date of the
premium reflecting the rate increase.
Triggers for a Substantial Premium Increase
Percentage Increase Over
Issue Age Initial Premium
29 and under 200%
30-34 190%
35-39 170%
40-44 150%
45-49 130%
50-54 110%

55-59 90%
60 70%
61 66%
62 62%
63 58%
64 54%
65 50%
66 48%
67 46%
68 44%
69 42%
70 40%
71 38%
72 36%
73 34%
74 32%
75 30%
76 28%
77 26%
78 24%
79 22%
80 20%
81 19%
82 18%
83 17%
84 16%
85 15%
86 14%
87 13%
88 12%
89 11%
90 and over 10%
d. A contingent benefit on lapse also must be triggered for policies with a fixed or limited
premium paying period every time an insurer increases the premium rates to a level that
results in a cumulative increase of the annual premium equal to or exceeding the
percentage of the insured's initial annual premium set forth below based on the insured's
issue age, the policy or certificate lapses within one hundred twenty days of the due date
of the premium so increased, and the ratio in paragraph 2 of subdivision f is forty percent

or more. Unless otherwise required, policyholders must be notified at least thirty days
prior to the due date of the premium reflecting the rate increase.
Triggers for a Substantial Premium Increase
Percent Increase Over
Issue Age Initial Premium
Under 65 50%
65-80 30%
Over 80 10%
This provision is in addition to the contingent benefit provided by subdivision c and where
both are triggered, the benefit provided must be at the option of the insured.
e. On or before the effective date of a substantial premium increase as defined in
subdivision c, the insurer shall:
(1) Offer to reduce policy benefits provided by the current coverage without the
requirement of additional underwriting so that required premium payments are not
increased;
(2) Offer to convert the coverage to a paid-up status with a shortened benefit period in
accordance with the terms of subsection 5. This option may be elected at any time
during the one hundred twenty-day period referenced in subdivision c; and
(3) Notify the policyholder or certificate holder that a default or lapse at any time during
the one hundred twenty-day period referenced in subdivision c shall be deemed to
be the election of the offer to convert in paragraph 2 unless the automatic option in
paragraph 3 of subdivision f applies.
f. On or before the effective date of a substantial premium increase as defined in
subdivision d, the insurer shall:
(1) Offer to reduce policy benefits provided by the current coverage so that required
premium payments are not increased;
(2) Offer to convert the coverage to a paid-up status where the amount payable for
each benefit is ninety percent of the amount payable in effect immediately prior to
lapse times the ratio of the number of completed months of paid premiums divided
by the number of months in the premium paying period. This option may be elected
at any time during the one hundred twenty-day period referenced in subdivision d;
and
(3) Notify the policyholder or certificate holder that a default or lapse at any time during
the one hundred twenty-day period referenced in subdivision d is deemed to be the
election of the offer to convert in paragraph 2 if the ratio is forty percent or more.
g. For any long-term care policy issued in this state on or after March 1, 2020:
(1) If the policy or certificate was issued at least twenty years before the effective date
of the increase, a value of zero percent must be used in place of all values in the
above table; and
(2) Values above one hundred percent in the table in subdivision c must be reduced to
one hundred percent.

5. Benefits continued as nonforfeiture benefits, including contingent benefits upon lapse in
accordance with subdivision c of subsection 4 but not subdivision d of subsection 4, are
described in this subsection:
a. For purposes of this subsection, attained age rating is defined as a schedule of
premiums starting from the issue date which increases age at least one percent per year
prior to age fifty, and at least three percent per year beyond age fifty.
b. For purposes of this subsection, the nonforfeiture benefit shall be of a shortened benefit
period providing paid-up long-term care insurance coverage after lapse. The same
benefits (amounts and frequency in effect at the time of lapse but not increased
thereafter) will be payable for a qualifying claim, but the lifetime maximum dollars or days
of benefits shall be determined as specified in subdivision c.
c. The standard nonforfeiture credit will be equal to one hundred percent of the sum of all
premiums paid, including the premiums paid prior to any changes in benefits. The insurer
may offer additional shortened benefit period options, as long as the benefits for each
duration equal or exceed the standard nonforfeiture credit for that duration. However, the
minimum nonforfeiture credit shall not be less than thirty times the daily nursing home
benefit at the time of lapse. In either event, the calculation of the nonforfeiture credit is
subject to the limitation of subsection 6.
d. (1) The nonforfeiture benefit shall begin not later than the end of the third year following
the policy or certificate issue date. The contingent benefit upon lapse shall be
effective during the first three years as well as thereafter.
(2) Notwithstanding paragraph 1, for a policy or certificate with attained age rating, the
nonforfeiture benefit shall begin on the earlier of:
(a) The end of the tenth year following the policy or certificate issue date; or
(b) The end of the second year following the date the policy or certificate is no
longer subject to attained age rating.
e. Nonforfeiture credits may be used for all care and services qualifying for benefits under
the terms of the policy or certificate, up to the limits specified in the policy or certificate.
6. All benefits paid by the insurer while the policy or certificate is in premium paying status and in
the paid-up status will not exceed the maximum benefits which would be payable if the policy
or certificate had remained in premium paying status.
7. There shall be no difference in the minimum nonforfeiture benefits as required under this
section for group and individual policies.
8. The requirements set forth in this section shall become effective twelve months after adoption
of this provision and shall apply as follows:
a. Except as provided in subdivisions b and c, the provisions of this section apply to any
long-term care policy issued in this state on or after the effective date of this amended
regulation.
b. For certificates issued on or after the effective date of this section, under a group
long-term care insurance policy as defined in subdivision a of subsection 3 of North
Dakota Century Code section 26.1-45-01, which policy was in force at the time this
amended regulation became effective, the provisions of this section shall not apply.

c. The last sentence in subsection 3 and subdivisions d and f of subsection 4 apply to any
long-term care insurance policy or certificate issued in this state after six months after
their adoption, except new certificates on a group policy as defined in subdivision a of
subsection 3 of North Dakota Century Code section 26.1-45-01 one year after adoption.
9. Premiums charged for a policy or certificate containing nonforfeiture benefits or a contingent
benefit on lapse shall be subject to the requirements of section 45-06-05.1-17 or
45-06-05.1-18, treating the policy as a whole.
10. To determine whether contingent nonforfeiture upon lapse provisions are triggered under
subdivision c or d of subsection 4, a replacing insurer that purchased or otherwise assumed a
block or blocks of long-term care insurance policies from another insurer shall calculate the
percentage increase based on the initial annual premium paid by the insured when the policy
was first purchased from the original insurer.
11. A nonforfeiture benefit for qualified long-term care insurance contracts that are level premium
contracts shall be offered that meets the following requirements:
a. The nonforfeiture provision shall be appropriately captioned;
b. The nonforfeiture provision shall provide a benefit available in the event of a default in
the payment of any premiums and shall state that the amount of the benefit may be
adjusted subsequent to being initially granted only as necessary to reflect changes in
claims, persistency, and interest as reflected in changes in rates for premium paying
contracts approved by the commissioner for the same contract form; and
c. The nonforfeiture provision shall provide at least one of the following:
(1) Reduced paid-up insurance;
(2) Extended term insurance;
(3) Shortened benefit period; or
(4) Other similar offerings approved by the commissioner.
History: Effective March 1, 2004; amended effective October 1, 2019.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-25. Standards for benefit triggers.

1. A long-term care insurance policy shall condition the payment of benefits on a determination
of the insured's ability to perform activities of daily living and on cognitive impairment.
Eligibility for the payment of benefits shall not be more restrictive than requiring either a
deficiency in the ability to perform not more than three of the activities of daily living or the
presence of cognitive impairment.
2. a. Activities of daily living shall include at least the following as defined in section
(1) Bathing;
(2) Continence;
(3) Dressing;
(4) Eating;

(5) Toileting; and
(6) Transferring; and
b. Insurers may use activities of daily living to trigger covered benefits in addition to those
contained in subdivision a as long as they are defined in the policy.
3. An insurer may use additional provisions for the determination of when benefits are payable
under a policy or certificate; however the provisions shall not restrict, and are not in lieu of, the
requirements contained in subsections 1 and 2.
4. For purposes of this section, the determination of a deficiency shall not be more restrictive
than:
a. Requiring the hands-on assistance of another person to perform the prescribed activities
of daily living; or
b. If the deficiency is due to the presence of a cognitive impairment, supervision or verbal
cueing by another person is needed in order to protect the insured or others.
5. Assessments of activities of daily living and cognitive impairment shall be performed by
licensed or certified professionals, such as physicians, nurses, or social workers.
6. Long-term care insurance policies shall include a clear description of the process for
appealing and resolving benefit determinations.
7. The requirements set forth in this section shall be effective March 1, 2005, and shall apply as
follows:
a. Except as provided in subdivision b, the provisions of this section apply to a long-term
care policy issued in this state on or after the effective date of the amended regulation.
b. For certificates issued on or after the effective date of this section, under a group
long-term care insurance policy as defined in subdivision a of subsection 3 of North
Dakota Century Code section 26.1-45-01 that was in force at the time this amended
regulation became effective, the provisions of this section shall not apply.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-26. Additional standards for benefit triggers for qualified long-term care

insurance contracts.
1. For purposes of this section, the following definitions apply:
a. (1) "Chronically ill individual" has the meaning prescribed for this term by section
7702B(c)(2) of the Internal Revenue Code of 1986, as amended. Under this
provision, a chronically ill individual means any individual who has been certified by
a licensed health care practitioner as:
(a) Being unable to perform, without substantial assistance from another
individual, at least two activities of daily living for a period of at least ninety
days due to a loss of functional capacity; or
(b) Requiring substantial supervision to protect the individual from threats to health
and safety due to severe cognitive impairment.

(2) The term "chronically ill individual" shall not include an individual otherwise meeting
these requirements unless within the preceding twelve-month period a licensed
health care practitioner has certified that the individual meets these requirements.
b. "Licensed health care practitioner" means a physician, as defined in section 1861(r)(1) of
the Social Security Act, a registered professional nurse, licensed social worker, or other
individual who meets requirements prescribed by the secretary of the treasury.
c. "Maintenance or personal care services" means any care the primary purpose of which is
the provision of needed assistance with any of the disabilities as a result of which the
individual is a chronically ill individual, including the protection from threats to health and
safety due to severe cognitive impairment.
d. "Qualified long-term care services" means services that meet the requirements of section
7702(c)(1) of the Internal Revenue Code of 1986, as amended, as follows: necessary
diagnostic, preventive, therapeutic, curative, treatment, mitigation and rehabilitative
services, and maintenance or personal care services which are required by a chronically
ill individual, and are provided pursuant to a plan of care prescribed by a licensed health
care practitioner.
2. A qualified long-term care insurance contract shall pay only for qualified long-term care
services received by a chronically ill individual provided pursuant to a plan of care prescribed
by a licensed health care practitioner.
3. A qualified long-term care insurance contract shall condition the payment of benefits on a
determination of the insured's inability to perform activities of daily living for an expected
period of at least ninety days due to a loss of functional capacity or to severe cognitive
impairment.
4. Certifications regarding activities of daily living and cognitive impairment required pursuant to
subsection 3 shall be performed by the following licensed or certified professionals:
physicians, registered professional nurses, licensed social workers, or other individuals who
meet requirements prescribed by the secretary of the treasury.
5. Certifications required pursuant to subsection 3 may be performed by a licensed health care
professional at the direction of the carrier as is reasonably necessary with respect to a specific
claim, except that when a licensed health care practitioner has certified that an insured is
unable to perform activities of daily living for an expected period of at least ninety days due to
a loss of functional capacity and the insured is in claim status, the certification may not be
rescinded and additional certifications may not be performed until after the expiration of the
ninety-day period.
6. Qualified long-term care insurance contracts shall include a clear description of the process
for appealing and resolving disputes with respect to benefit determinations.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-27. Standard format outline of coverage.

This section implements, interprets, and makes specific the provisions of subsection 2 of North
Dakota Century Code section 26.1-45-09 in prescribing a standard format and the content of an outline
of coverage.
1. The outline of coverage shall be a freestanding document, using no smaller than ten-point
type.

2. The outline of coverage shall contain no material of an advertising nature.
3. Text that is capitalized or underscored in the standard format outline of coverage may be
emphasized by other means that provide prominence equivalent to the capitalization or
underscoring.
4. Use of the text and sequence of text of the standard format outline of coverage is mandatory,
unless otherwise specifically indicated.
5. Format for outline of coverage:
[Policy Number or Group Master Policy and Certificate Number]
[Except for policies or certificates which are guaranteed issue, the following caution statement, or
language substantially similar, must appear as follows in the outline of coverage.]
Caution: The issuance of this long-term care insurance [policy] [certificate] is based upon your
responses to the questions on your application. A copy of your [application] [enrollment form] [is
enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue, the
company has the right to deny benefits or rescind your policy. The best time to clear up any
questions is now, before a claim arises! If, for any reason, any of your answers are incorrect,
contact the company at this address: [insert address]
1. This policy is [an individual policy of insurance] ([a group policy] which was issued in the
[indicate jurisdiction in which group policy was issued]).
2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief
description of the important features of the policy. You should compare this outline of
coverage to outlines of coverage for other policies available to you. This is not an
insurance contract, but only a summary of coverage. Only the individual or group policy
contains governing contractual provisions. This means that the policy or group policy sets
forth in detail the rights and obligations of both you and the insurance company.
Therefore, if you purchase this coverage, or any other coverage, it is important that you
3. FEDERAL TAX CONSEQUENCES.
This [POLICY] [CERTIFICATE] is intended to be a federally tax-qualified, long-term care
insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as
amended.
Federal Tax Implications of this [POLICY] [CERTIFICATE]. This [POLICY]
[CERTIFICATE] is not intended to be a federally tax-qualified, long-term care insurance
contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.
Benefits received under the [POLICY] [CERTIFICATE] may be taxable as income.

4. Terms Under Which the Policy OR Certificate May Be Continued in Force or
Discontinued.
a. [For long-term care health insurance policies or certificates describe one of the
following permissible policy renewability provisions:
(1) Policies and certificates that are guaranteed renewable shall contain the
following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS
GUARANTEED RENEWABLE. This means you have the right, subject to the
terms of your policy [certificate], to continue this policy as long as you pay your
premiums on time. [Company Name] cannot change any of the terms of your
policy on its own, except that, in the future, IT MAY INCREASE THE
(2) [Policies and certificates that are noncancelable shall contain the following
statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS
NONCANCELABLE. This means that you have the right, subject to the terms
of your policy, to continue this policy as long as you pay your premiums on
time. [Company Name] cannot change any of the terms of your policy on its
own and cannot change the premium you currently pay. However, if your policy
contains an inflation protection feature where you choose to increase your
benefits, [Company Name] may increase your premium at that time for those
additional benefits.
b. [For group coverage, specifically describe continuation/conversion provisions
applicable to the certificate and group policy.]
c. [Describe waiver of premium provisions or state that there are not such provisions.]
5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.
[In bold type larger than the maximum type required to be used for the other provisions of
the outline of coverage, state whether or not the company has a right to change the
premium, and if a right exists, describe clearly and concisely each circumstance under
which the premium may change.]
6. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE RETURNED AND
a. [Provide a brief description of the right to return - "free look" provision of the policy.]
b. [Include a statement that the policy either does or does not contain provisions
providing for a refund or partial refund of premium upon the death of an insured or
surrender of the policy or certificate. If the policy contains such provisions, include a
description of them.]
7. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare,
review the Medicare Supplement Buyer's Guide available from the insurance company.
a. [For agents] Neither [insert company name] nor its agents represent Medicare, the
federal government, or any state government.
b. [For direct response] [insert company name] is not representing Medicare, the
federal government, or any state government.
8. LONG-TERM CARE COVERAGE. Policies of this category are designed to provide
coverage for one or more necessary or medically necessary diagnostic, preventive,

therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting
other than an acute care unit of a hospital, such as in a nursing home, in the community,
or in the home.
This policy provides coverage in the form of a fixed dollar indemnity benefit for covered
long-term care expenses, subject to policy [limitations] [waiting periods] and
[coinsurance] requirements. [Modify this paragraph if the policy is not an indemnity
policy.]
9. BENEFITS PROVIDED BY THIS POLICY.
a. [Covered services, related deductibles, waiting periods, elimination periods, and
benefit maximums.]
b. [Institutional benefits, by skill level.]
c. [Noninstitutional benefits, by skill level.]
d. Eligibility for Payment of Benefits.
[Activities of daily living and cognitive impairment shall be used to measure an insured's
need for long-term care and must be defined and described as part of the outline of
coverage.]
[Any additional benefit triggers must also be explained. If these triggers differ for different
benefits, explanation of the triggers should 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 too must be specified.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
a. Preexisting conditions;
b. Noneligible facilities and provider;
c. Noneligible levels of care (e.g., unlicensed providers, care, or treatment provided by
a family member, etc.);
d. Exclusions and exceptions; and
e. Limitations.].
[This section should provide a brief specific description of any policy provisions which
limit, exclude, restrict, reduce, delay, or in any other manner operate to qualify payment
of the benefits described in Number 9 above.]
11. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of long-term
care services will likely increase over time, you should consider whether and how the
benefits of this plan may be adjusted. [As applicable, indicate the following:
a. That the benefit level will not increase over time;
b. Any automatic benefit adjustment provisions;

c. Whether the insured will be guaranteed the option to buy additional benefits and the
basis upon which benefits will be increased over time if not by a specified amount or
percentage;
d. If there is such a guarantee, include whether additional underwriting or health
screening will be required, the frequency and amounts of the upgrade options, and
any significant restrictions or limitations; and
e. And finally, describe whether there will be any additional premium charge imposed,
and how that is to be calculated.].
12. ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS.
[State that the policy provides coverage for insureds clinically diagnosed as having
Alzheimer's disease or related degenerative and dementing illnesses. Specifically
describe each benefit screen or other policy provision which provides preconditions to
the availability of policy benefits for such an insured.]
13. PREMIUM.
[a. State the total annual premium for the policy; and
b. If the premium varies with an applicant's choice among benefit options, indicate the
portion of annual premium which corresponds to each benefit option.]
14. ADDITIONAL FEATURES.
[a. Indicate if medical underwriting is used; and
b. Describe other important features.]
15. CONTACT THE STATE SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM IF
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-28. Requirement to deliver shopper's guide.

1. A long-term care insurance shopper's guide in the format developed by the national
association of insurance commissioners, or a guide developed or approved by the
commissioner, shall be provided to all prospective applicants of a long-term care insurance
policy or certificate.
a. In the case of agent solicitations, an agent must deliver the shopper's guide prior to the
presentation of an application or enrollment form.
b. In the case of direct response solicitations, the shopper's guide must be presented in
conjunction with any application or enrollment form.
2. Life insurance policies or riders containing accelerated long-term care benefits are not
required to furnish the above-referenced guide, but shall furnish the policy summary required
under North Dakota Century Code section 26.1-45-09.
History: Effective March 1, 2004.

General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
### § 45-06-05.1-29. Penalties.

In addition to any other penalties provided by the laws of this state, any insurer and any agent
found to have violated any requirement of this state relating to the regulation of long-term care
insurance or the marketing of such insurance shall be subject to a fine of up to three times the amount
of any commissions paid for each policy involved in the violation or up to ten thousand dollars,
whichever is greater.
History: Effective March 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45

Appendix A
Rescission Reporting Form
Company Name: ________________________________________
Address: _______________________________________________
_______________________________________________
Telephone Number: ______________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of long-term care insurance policies or
certificates. Those rescissions voluntarily effectuated by an insured are not required to be included in
this report. Please furnish one form per rescission.
Policy and Name of Date of Policy Date/s Claim/s Date of
Policy Form # Certificate # Insured Issuance Submitted Rescission
Detailed reason for rescission: ______________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Signature
Name and title (please type)
Date

Appendix B
Personal Worksheet
Long-Term Care Insurance
Personal Worksheet
This worksheet will help you understand some important information about this type of insurance. State
law requires companies issuing this [policy] [certificate] [rider] to give you some important facts about
premiums and premium increases and to ask you some important questions to help you and the
company decide if you should buy this [policy] [certificate] [rider]. Long-term care insurance can be
expensive and it may not be right for everyone.
Premium Information
The premium for the coverage you are considering will be [$ ______ per [insert payment interval]
or a total of [$ _____ per year] [a one-time single premium of $ ______.]
The premium quoted in this worksheet is not guaranteed and may change during the
underwriting process and in the future while this [policy] [certificate] [rider] is in force.
Type of Policy and The Company's Right to Increase Premiums on the Coverage You Choose:
[Noncancellable - The company cannot increase your premiums on this [policy] [certificate] [rider].]
[Guaranteed renewable - The company can increase your premiums on this [policy] [certificate] [rider]
in the future if it increases the premiums for all [policies] [certificates] [riders] like yours in this state.]
[Paid-up - This [policy] [certificate] [rider] will be paid-up after you have paid all of the premiums
specified in your [policy] [certificate] [rider].]
Premium Increase History
[Name of company] has sold long-term care insurance since [year] and has sold this [policy] [certificate]
[rider] since [year].
[The company has never increased its premiums for any long-term care [policy] [certificate] [rider] it has
sold in this state or any other state.]
[The company has not increased its premiums for this [policy] [certificate] [rider] or similar [policies]
[certificates] [riders] in this state or any other state in the last 10 years.]
[The company has increased its premiums on this [policy] [certificate] [rider] or similar [policies]
[certificates] [riders] in the last 10 years. A summary of those premium increases follows.]
Questions About Your Income
You do not have to answer the questions that follow. They are intended to make sure you have thought
about how you'll pay premiums and the cost of care your insurance does not cover. If you do not want
to answer these questions, you should understand that the company might refuse to insure you.
What resources will you use to pay your premium?
Current income from employment Current income from investments Other current income
Savings Sell investments Sell other assets Money from my family Other _______

If you will be paying premiums with money received only from your own income, a rule of thumb is that
you may not be able to afford this [policy] [certificate] [rider] if the premiums will be more than 7% of
your income.
Could you afford to keep this [policy] [certificate] [rider] if your spouse or partner dies first?
Yes No Had not thought about it Do not know Does not apply
What would you do if the premiums went up, for example, by 50%?
Pay the higher premium Call the company/agent Reduce benefits
Drop the [policy] [certificate] [rider] Do not know
What is your household annual income from all sources? (check one)
[Less than $10,000] [$10,000-$19,999] [$20,000-$29,999] [$30,000-$50,000]
[More than $50,000]
Do you expect your income to change over the next 10 years? (check one)
No Yes, expect increase Yes, expect decrease
If you plan to pay premiums from your income, have you thought about how a change in your
income would affect your ability to continue to pay the premium?
Yes No Do not know
Will you buy inflation protection? (check one)
Yes No
Inflation may increase the cost of long-term care in the future.
If you do not buy inflation protection, how will you pay for the difference between future costs
and your daily benefit amount?
From my income From savings From investments Sell other assets
Money from my family Other
The national average annual cost of long-term care in [insert year] was [insert $ amount], but this figure
varies across the country. In 10 years the national average annual cost would be about [insert
$ amount] if costs increase 5% annually.
What [elimination period] [waiting period] [cash deductible] are you considering?
[Number of days _______ in [elimination period] [waiting period]
Approximate cost of care for that period: $ ________
($xxx per day times number of days in [elimination period] [waiting period], where "xxx" represents the
most recent estimate of the national daily average cost of long-term care)]
[Cash Deductible $ _______]
How are you planning to pay for your care during the [elimination period] [waiting period]
[deductible period]? (check all that apply)
From my income From my savings/investments My family will pay

Questions About Your Savings and Investments
Not counting your home, about how much are all of your assets (your savings and investments)
worth? (check one)
[Less than $20,000] [$20,000-$29,999] [$30,000-$50,000] [More than $50,000]
Do you expect your assets to change over the next 10 years? (check one)
No Yes, expect to increase Yes, expect to decrease
If you are buying this [policy] [certificate] [rider] to protect your assets and your assets are less than
$50,000, experts suggest you think about other ways to pay for your long-term care.

Disclosure Statement
The answers to the questions above describe my financial situation.
Or
I choose not to complete this information.
(Check one.)
I agree that the company and/or its agent (below) has reviewed this worksheet with me, including the
premium, premium increase history, and potential for premium increases in the future. I understand
the information contained in this worksheet. (This box must be checked.)
Signed: __________________________ ____________________________
(Applicant) (Date)
[ I explained to the applicant the importance of completing this information.
Signed: __________________________ ____________________________
(Agent) (Date)
Agent's Printed Name: ]
[In order for us to process your application, please return this signed worksheet to [name of company],
along with your application.]
[My agent has advised me that this long-term care insurance [policy] [certificate] [rider] does not seem
to be suitable for me. However, I still want the company to consider my application.]
Signed: __________________________ ____________________________
(Applicant) (Date)
Someone from the company may contact you to discuss your answers and the suitability of this [policy]
[certificate] [rider] for you.

Appendix C
Disclosure Form
Things You Should Know Before You Buy
Long-Term Care Insurance
Long-Term Care • A long-term care insurance policy may pay most of the costs for your care
Insurance in a nursing home. Many policies also pay for care at home or other
community settings. Since policies can vary in coverage, you should read
this policy and make sure you understand what it covers before you buy it.
• [You should not buy this insurance policy unless you can afford to pay the
premiums every year.] [Remember that the company can increase
premiums in the future.]
• The personal worksheet includes questions designed to help you and the
company determine whether this policy is suitable for your needs.
Medicare • Medicare does not pay for most long-term care.
Medicaid • Medicaid will generally pay for long-term care if you have very little income
and few assets. You probably should not buy this policy if you are now
eligible for Medicaid.
• Many people become eligible for Medicaid after they have used up their
own financial resources by paying for long-term care services.
• When Medicaid pays your spouse's nursing home bills, you are allowed to
keep your house and furniture, a living allowance, and some of your joint
assets.
• Your choice of long-term care services may be limited if you are receiving
Medicaid. To learn more about Medicaid, contact your local or state
Medicaid agency.
Shopper's Guide • Make sure the insurance company or agent gives you a copy of a book
called the National Association of Insurance Commissioners' "Shopper's
Guide to Long-Term Care Insurance". Read it carefully. If you have decided
to apply for long-term care insurance, you have the right to return the
policy within 30 days and get back any premium you have paid if you are
dissatisfied for any reason or choose not to purchase the policy.
Counseling • Free counseling and additional information about long-term care insurance
are available through your state's insurance counseling program. Contact
your state insurance department or department on aging for more
information about the senior health insurance counseling program in your
state.
Facilities • Some long-term care insurance contracts provide for benefit payments in
certain facilities only if they are licensed or certified, such as in assisted
living centers. However, not all states regulate these facilities in the same
way. Also, many people move into a different state from where they
purchased their long-term care insurance policy. Read the policy carefully
to determine what types of facilities qualify for benefit payments, and to
determine that payment for a covered service will be made if you move to a
state that has a different licensing scheme for facilities than the one in
which you purchased the policy.

Appendix D
Response Letter
Long-Term Care Insurance Suitability Letter
Dear [Applicant]:
Your recent application for long-term care insurance included a "personal worksheet", which asked
questions about your finances and your reasons for buying long-term care insurance. For your
protection, state law requires us to consider this information when we review your application, to avoid
selling a policy to those who may not need coverage.
[Your answers indicate that long-term care insurance may not meet your financial needs. We suggest
that you review the information provided along with your application, including the booklet "Shopper's
Guide to Long-Term Care Insurance" and the page titled "Things You Should Know Before Buying
Long-Term Care Insurance". Your state insurance department also has information about long-term
care insurance and may be able to refer you to a counselor free of charge who can help you decide
whether to buy this policy.]
[You chose not to provide any financial information for us to review.]
We have suspended our final review of your application. If, after careful consideration, you still believe
this policy is what you want, check the appropriate box below and return this letter to us within the next
60 days. We will then continue reviewing your application and issue a policy if you meet our medical
standards.
If we do not hear from you within the next 60 days, we will close your file and not issue you a policy.
You should understand that you will not have any coverage until we hear back from you, approve your
application, and issue you a policy.
Please check one box and return in the enclosed envelope.
[ ] Yes, [although my worksheet indicates that long-term care insurance may not be a suitable
purchase,] I wish to purchase this coverage. Please resume review of my application.
[ ] No. I have decided not to buy a policy at this time.
______________________________ _____________________
Please return to [issuer] at [address] by [date].

Appendix E
Sample Claims Denial Format
Claims Denial Reporting Form
Long-Term Care Insurance
For the State of _______________________________
For the Reporting Year of ______________________
Company Name: ______________________________Due: June 30 annually
Company Address: ______________________________________________
______________________________________________________________
Company NAIC Number: __________________________________________
Contact Person: ___________________ Telephone Number: ________________
Line of Business: Individual Group
Instructions
The purpose of this form is to report all long-term care claim denials under in-force long-term care
insurance policies. Indicate the manner of reporting by checking one of the boxes below:
□ Per Claimant - Counts each individual who makes one or a series of claim requests.
□ Per Transaction - Counts each claim payment request.
"Denied" means a claim that is not paid for any reason other than for claims not paid for failure to meet
the waiting period or because of an applicable pre-existing condition. It does not include a request for
payment that is in excess of the applicable contractual limits.
In-force Data
State Data Nationwide Data1
1 Total Number of In-force Policies [Certificates] as of
December 31st
Claims and Denial Data
State Data Nationwide Data1
1 Total Number of Long-Term Care Claims Reported
2 Total Number of Long-Term Care Claims Denied/Not
Paid
3 Number of Claims Not Paid Due to Preexisting
Condition Exclusion
4 Number of Claims Not Paid Due to Waiting
(Elimination) Period Not Met
5 Net Number of Long-Term Care Claims Denied for

Reporting Purposes (line 2 minus line 3 minus line 4)
6 Percentage of Long-Term Care Claims Denied of
Those Reported (line 5 divided by line 1)
7 Number of Long-Term Care Claims Denied Due to:
8 Long-Term Care Services Not Covered Under the
policy2
9 Provider/Facility Not Qualified Under the Policy3
10 Benefit Eligibility Criteria Not Met4
11 Other
1. The nationwide data may be viewed as a more representative and credible indicator where
the data for claims reported and denied for your state are small in number.
2. Example - Home health care claim filed under a nursing home only policy.
3. Example - A facility that does not meet the minimum level of care requirements or the licensing
requirements as outlined in the policy.
4. Examples - A benefit trigger not met, certification by a licensed health care practitioner not
provided, no plan of care.

Appendix F
Potential Rate Increase Disclosure Form
Instructions:
This form provides information to the applicant regarding premium rate schedules, rate schedule
adjustments, potential rate revisions, and policyholder options in the event of a rate increase.
Insurers shall provide all of the following information to the applicant:
Long-Term Care Insurance
Potential Rate Increase Disclosure Form
1. [Premium Rate] [Premium Rate Schedules]: [Premium rate] [Premium rate schedules] that
[is][are] applicable to you and that will be in effect until a request is made and approved for an
increase [is][are] [on the application] [$_____].
2. The [premium] [premium rate schedule] for this policy [will be shown on the schedule page of]
[will be attached to] your policy.
3. Rate Schedule Adjustments:
The company will provide a description of when premium rate or rate schedule
adjustments will be effective (e.g., next anniversary date, next billing date, etc.) (fill in the
blank): __________.
4. Potential Rate Revisions:
This policy is Guaranteed Renewable. This means that the rates for this product may be
increased in the future. Your rates CANNOT be increased due to your increasing age or
declining health, but your rates may go up based on the experience of all policyholders with a
policy similar to yours.
If you receive a premium rate or premium rate schedule increase in the future, you will
be notified of the new premium amount and you will be able to exercise at least one of
the following options:
• Pay the increased premium and continue your policy in force as is.
• Reduce your policy benefits to a level such that your premiums will not increase. (Subject to
state law minimum standards.)
• Exercise your nonforfeiture option if purchased. (This option is available for purchase for an
additional premium.)
• Exercise your contingent nonforfeiture rights.* (This option may be available if you do not
purchase a separate nonforfeiture option.)
Contingent Nonforfeiture
If the premium rate for your policy goes up in the future and you did not buy a nonforfeiture option, you
may be eligible for contingent nonforfeiture. Here is how to tell if you are eligible:
You will keep some long-term care insurance coverage, if:
• Your premium after the increase exceeds your original premium by the percentage shown (or
more) in the following table; and

• You lapse (not pay more premiums) within 120 days of the increase.
The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will equal the total
amount of premiums you have paid since your policy was first issued. If you have already received
benefits under the policy, so that the remaining maximum benefit amount is less than the total amount
of premiums you've paid, the amount of coverage will be that remaining amount.
Except for this reduced lifetime maximum benefit amount, all other policy benefits will remain at the
levels attained at the time of the lapse and will not increase thereafter.
Should you choose this Contingent Nonforfeiture option, your policy, with this reduced maximum benefit
amount, will be considered "paid-up" with no further premiums due.
Example:
• You bought the policy at age 65 and paid the $1,000 annual premium for 10 years, so you
have paid a total of $10,000 in premium.
• In the eleventh year, you receive a rate increase of 50%, or $500 for a new annual premium
of $1,500, and you decide to lapse the policy (not pay any more premiums).
• Your "paid-up" policy benefits are $10,000 (provided you have at least $10,000 of benefits
remaining under your policy.)
Contingent Nonforfeiture
Cumulative Premium
Increase Over Initial
Premium
That Qualifies for
Contingent Nonforfeiture
(Percentage increase is
cumulative from date of
original issue. It does NOT
represent a one-time
increase.)
Percentage
Increase Over
Initial
Issue Age Premium
29 and under 200%
30-34 190%
35-39 170%
40-44 150%
45-49 130%
50-54 110%
55-59 90%
60 70%
61 66%

62 62%
63 58%
64 54%
65 50%
66 48%
67 46%
68 44%
69 42%
70 40%
71 38%
72 36%
73 34%
74 32%
75 30%
76 28%
77 26%
78 24%
79 22%
80 20%
81 19%
82 18%
83 17%
84 16%
85 15%
86 14%
87 13%
88 12%
89 11%
90 and over 10%
[The following contingent nonforfeiture disclosure need only be included for those limited pay policies to
which subdivisions d and f of subsection 4 of section 45-06-05.1-24 are applicable.]
In addition to the contingent nonforfeiture benefits described above, the following reduced "paid-up"
contingent nonforfeiture benefit is an option in all policies that have a fixed or limited premium payment
period, even if you selected a nonforfeiture benefit when you bought your policy. If both the reduced
"paid-up" benefit AND the contingent benefit described above are triggered by the same rate increase,
you can choose either of the two benefits.

You are eligible for the reduced "paid-up" contingent nonforfeiture benefit when all three conditions
shown below are met:
1. The premium you are required to pay after the increase exceeds your original premium by the
same percentage or more shown in the chart below:
Triggers for a Substantial Premium Increase
Percent Increase Over
Issue Age Initial Premium
Under 65 50%
65-80 30%
Over 80 10%
2. You stop paying your premiums within 120 days of when the premium increase took effect;
3. The ratio of the number of months you already paid premiums is 40% or more than the
number of months you originally agreed to pay.
If you exercise this option your coverage will be converted to reduced "paid-up" status. That
means there will be no additional premiums required. Your benefits will change in the following
ways:
a. The total lifetime amount of benefits your reduced paid-up policy will provide can be
determined by multiplying 90% of the lifetime benefit amount at the time the policy
becomes paid up by the ratio of the number of months you already paid premiums to the
number of months you agreed to pay them.
b. The daily benefit amounts you purchased will also be adjusted by the same ratio.
If you purchased lifetime benefits, only the daily benefit amounts you purchased will be adjusted by the
applicable ratio.
Example:
• You bought the policy at age 65 with an annual premium payable for 10 years.
• In the sixth year, you receive a rate increase of 35% and you decide to stop paying
premiums.
• Because you have already paid 50% of your total premium payments and that is more than
the 40% ratio, your "paid-up" policy benefits are .45 (.90 times .50) times the total benefit
amount that was in effect when you stopped paying your premiums. If you purchased inflation
protection, it will not continue to apply to the benefits in the reduced "paid-up" policy.

Appendix G
Replacement and Lapse Reporting Form
Long-Term Care Insurance
Replacement and Lapse Reporting Form
For the State of _____________ For the Reporting Year of _______
Company Name: __________________ Due: June 30 annually
Company Address: ________________ Company NAIC Number: ______
Contact Person: ___________________ Telephone Number: (___)______
Instructions
The purpose of this form is to report on a statewide basis information regarding long-term care
insurance policy replacements and lapses. Specifically, every insurer shall maintain records for each
agent on that agent's amount of long-term care insurance replacement sales as a percentage of the
agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the
agent as a percentage of the agent's total annual sales. The tables below should be used to report the
ten percent (10%) of the insurer's agents with the greatest percentages of replacements and lapses.
Listing of the 10% of Agents With the Greatest Percentage of Replacements
Number of
Number of Policies Replacements as
Number of Policies Replaced by This Percentage of Number
Agent's Name Sold by This Agent Agent Sold by This Agent
Listing of the 10% of Agents With the Greatest Percentage of Lapses
Number of
Number of Policies Replacements as
Number of Policies Replaced by This Percentage of Number
Agent's Name Sold by This Agent Agent Sold by This Agent
Company Totals
Percentage of Replacement Policies Sold to Total Annual Sales _____%
Percentage of Replacement Policies Sold to Policies in Force (as of the end of the preceding calendar
year) _____%
Percentage of Lapsed Policies to Total Annual Sales _____%
Percentage of Lapsed Policies to Policies in Force (as of the end of the preceding calendar year)
_____%
