Filings Made Easy for Life, Health and Licensing

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(No Transcript)
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Filings Made Easy for Life, Health and Licensing
Whats Wrong With My Form Filings?
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Whats Wrong With My Form Filings?

• Presenters
• John Carter
• Marie Garcia
• Janice Haney

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Whats Wrong With My Form Filings?

• Presentation Topics
• Common Objections
• Blanket Accident and Health
• Medicare Supplement
• Medicare Select
• Individual Accident and Health
• Group Accident and Health

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Whats Wrong With My Form Filings?

• Presentation Topics (continued)
• Frequently Omitted Certifications
• Small and Large Employer Plans
• Frequent Objections Accident and Health
• Frequent Objections Life and Annuities

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Whats Wrong With My Form Filings?

• Common Objections
• Texas Insurance Code (TIC)
• Texas Administrative Code (TAC)
• Toll-Free Notice
• Guaranty Fund Disclosure Summary Document
• Bracketed/Variable Language - 28 TAC 3.4(e)
• The Statement of Variability shall contain a
  clear explanation of how the material will vary
• Specimen language and fill-in material shall
  reflect the most restrictive option available
  under variability and any other additional
  descriptions of variability options

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Whats Wrong With My Form Filings?

• Common Objections (continued)
• Workers Comp Disclaimer Statement
• Revisions to disapproval and noncompliant forms
  must be underlined and crossed out as applicable
  28 TAC 3.6
• Letters of Commitment and Actuarial
  Certifications
• Submission of a single policy and certificate for
  use with more than one group type
• Form and actuarial memorandum conflicts

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Whats Wrong With My Form Filings?

• Blanket Accident and Health Insurance Eligible
  Policyholders
• 1251.351, TIC, Common Carrier or Motor Vehicle
  Rental or Leasing Company
• 1251.352, TIC, Employers
• 1251.353, TIC, Educational Institutions
• 1251.354, TIC, Religious, Charitable,
  Recreational, Educational, or Civic Organizations
• 1251.355, TIC, Sports Team Camp

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Whats Wrong With My Form Filings?

• Blanket Accident and Health Insurance Eligible
  Policyholders (continued)
• 1251.356, TIC, Governmental or Volunteer
  Emergency Services Organization
• 1251.357, TIC, Newspaper or Other Publisher
• 1251.358, TIC, Association
• 1251.359, TIC, Coverage for Other Risks
  (Discretionary)
• Products issued to Blanket Groups are Exempt
  unless they contain PPO benefits

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Whats Wrong With My Form Filings?

• Minimum Standards for Medicare Supplement
  Policies
• 28 TAC 3.3301-3.3324
• Must be guaranteed renewable
• Cannot file more than one type of
  policy/certificate form
• Limitations and exclusions cannot be more
  restrictive than those of Medicare
• Cannot contain benefits provided by Medicare

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Whats Wrong With My Form Filings?

• Medicare Select Policies, Certificates and Plans
  of Operation
• 28 TAC 3.3325
• No policy or certificate may be advertised as a
  Medicare Select policy or certificate unless it
  meets the requirements of this section
• A proposed plan of operation must be filed for
  review and approval

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Whats Wrong With My Form Filings?

• Minimum Standards and Benefits for Individual
  Accident and Health
• 28 TAC 3.3001-3.3111
• Must be one of the recognized categories of
  coverage listed in 1201.104, TIC
• Certain riders/endorsements added after date of
  issue require signed acceptance by policyholder

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Whats Wrong With My Form Filings?

• Group Accident and Health Insurance Eligible
  Policyholders
• 1251.052, TIC Associations
• Members of an association or an organization of
  labor unions, membership corporation organized or
  holding a certificate of authority
• Have a constitution and bylaws
• Have been organized and have actively existed for
  at least two years
• Be maintained in good faith for purposes other
  than that of obtaining insurance

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Whats Wrong With My Form Filings?

• Group Accident and Health Insurance Eligible
  Policyholders (continued)
• 1251.053, TIC - Funds Established by Employers,
  Labor Unions or Associations
• Issue to the trustee of a fund established by two
  or more employers in the same or related
  industry, by one or more labor unions, by one or
  more associations

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Whats Wrong With My Form Filings?

• Group Accident and Health Insurance Eligible
  Policyholders (continued)
• 1251.055, TIC - Fund for Former Employees and
  Members
• Issue to a trustee of a fund to insure former
  employees, former members

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Whats Wrong With My Form Filings?

• Group Accident and Health Insurance Eligible
  Policyholders (continued)
• 1251.056, TIC - Other Groups (Discretionary)
• Issue to cover a group other than a group
  described by Sections 1251.051-1251.055
• Commonality in the make-up of the group
• Case specific

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Whats Wrong With My Form Filings?

• Group Accident and Health Insurance Eligible
  Policyholders (continued)
• 1251.051, TIC - Employers
• An officer, manager or employee of the employer
• Small Employer (an average of at least 2
  employees but not more than 50 eligible
  employees)
• Larger Employer (an average of at least 51
  eligible employee)

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Whats Wrong With My Form Filings?

• Frequently Omitted Certifications
• Small Employer Market
• 1212 CERT SECHC STATUS or Figure 40
• 28 TAC 26.6 (a), and 1501.006, TIC
• 1212 Risk-Assuming or Reinsured Carrier or Figure
  42
• 28 TAC 26.18, and 1501.310 - 1501.312, TIC
• 1212 CERT SEHC GEOG or Figure 44
• 28 TAC 26.6, 26.19, and Chapter 1501.101, TIC

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Whats Wrong With My Form Filings?

• Frequently Omitted Certifications
• Large Employer Market
• 1212 CERT LEHC STATUS or Figure 50
• 28 TAC 26.302, and Chapter 1501, TIC
• 1212 CERT LEHC GEOG or Figure 51
• 28 TAC 26.302, and 1501.101, TIC

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Whats Wrong With My Form Filings?

• Small and Large Employer Plans
• Forms must not use Actively at work language
• Eligible Employee - 1501.002(3), TIC
• One who usually works at least 30 hours per week

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Whats Wrong With My Form Filings?

• Frequent Objections Accident and Health
• Dependent Definition 1501.002(2), TIC
• Mandated Benefits

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Whats Wrong With My Form Filings?

• Dependent Definitions
• If a policy includes or is required to include
  dependent coverage, then coverage must be
  extended to
• Newborn Children -
• 28 TAC 3.3401-3.3403, 1367.003, TIC
• Adopted Children including,
• Party to a suit to seek adoption
• 1251.154, TIC
• Spouse - 1501.002, TIC
• Step Children - 1201.064, TIC

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Whats Wrong With My Form Filings?

• Dependent Definitions (continued)
• If a policy includes or is required to include
  dependent coverage, then coverage must be
  extended to
• Grandchildren - 1251.151, TIC
• Court Mandated Children - 1201.062, TIC
• Handicap Children - 1201.059, TIC
• Medically Certified Child - 1501.002(2), TIC

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Whats Wrong With My Form Filings?

• Mandated Benefits
• Required for Large Employer Health Benefit Plans
• Hospital Stay Following Mastectomy - 1357.054,
  TIC
• A health benefit plan that provides coverage for
  the treatment of breast cancer must provide for
  inpatient care for a minimum of
• 48 hours following a mastectomy, and
• 24 hours following a lymph node dissection

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Whats Wrong With My Form Filings?

• Mandated Benefits (continued)
• Contraceptive Drugs and Devices
• 1369.101-1369.109, TIC
• A health benefit plan that provides prescription
  drugs or devices may not exclude or limit
  benefits for
• A prescription contraceptive drug or device
  approved by the FDA or
• An outpatient contraceptive service

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Whats Wrong With My Form Filings?

• Mandated Benefits (continued)
• Acquired Brain Injury - 1352.003, TIC
• A health benefit plan may not exclude coverage
  for any of the therapies or services related to
  an acquired brain injury listed in 1352.003, TIC
  and HB 1919
• Each of the therapies must be defined in the
  insurance policy/certificate as specified in 28
  TAC 21.3102

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Whats Wrong With My Form Filings?

• Mandated Benefits (continued)
• Required for Large and Small Employer Health
  Benefit Plans, not required for Consumer Choice
  Plans
• May be subject to annual deductibles, co-pays and
  co-insurance that are consistent with
  annual deductibles
• Enacted by HB 1919, 80th Legislative Session
  (2007)
• Autism Spectrum Disorder - 1355.001(3) and
  1355.015, TIC
• Neurobiological Disorder - 1355.001(4), TIC
• Co-pays and co-insurance required for other
  coverage under 1355.015, TIC

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Whats Wrong With My Form Filings?

• Frequent Objections Life and Annuities
• Universal Life
• Risk Classes Defined
• Substandard
• Unisex Justification
• Surrender charges as a percentage of account
  value
• Surrender and expense charge adjustments for
  increases in specified amount
• Cannot bracket the guaranteed minimum interest
  rate
• Cannot bracket the CSO Mortality Table

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Whats Wrong With My Form Filings?

• Frequent Objections Life and Annuities
  (continued)
• Universal Life
• Itemized monthly calculations for the 1st and
  50th years showing the beginning values, maximum
  expense charges, maximum cost-of-insurance
  deductions, monthly expense and/or policy fees,
  interest accumulations and the ending values for
  the specimen policy
• The 2001 CSO Mortality Table may be used for
  policies issued on or after May 1, 2003
• The 2001 CSO Mortality Table shall be used for
  policies issued on and after January 1, 2009

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Whats Wrong With My Form Filings?

• Frequent Objections Life and Annuities
  (continued)
• Annuities
• Fixed maturity date versus optional maturity date
• Compliance with prospective (present value) test
• Bracketed surrender charges
• Initial Interest Rates/Additional
  Interest/Premium Bonuses
• Must be guaranteed
• May be bracketed with a Statement of Variability
  and a reasonable range that does not begin with
  zero
• Must be administered in a manner which is not
  unfairly discriminatory

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Whats Wrong With My Form Filings?

• Frequent Objections Life and Annuities
  (continued)
• Annuities
• Guaranteed Minimum Interest Rate (GMIR)
  Methodology
• The GMIR must be determinable at any point in the
  future
• Will always equal the minimum nonforfeiture
  interest rate at issue
• Will always equal the minimum nonforfeiture
  interest rate plus 25 basis points
• Will always equal the minimum nonforfeiture
  interest rate rounded to the next higher quarter
  percent
• Any other factor you can come up with
• Reserve Basis

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Whats Wrong With My Form Filings?

• QUESTIONS??????
• AND MAYBE..
• SOME ANSWERS!!!!