No later than January 1, 1996, the disclosure form shall be substantially as follows:

(Company Name)

Disclosure Form

Long-term Care Insurance

The decision to buy a new long-term care policy is very important. It should be carefully considered.

The following data give you some general tips and furnish you with a summary of benefits available under our policy.

Your long-term care policy provides thirty days (sixty days for direct response insurers) within which you may decide without cost whether you wish to keep it. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available under your policy.

If you now have insurance which provides benefits for long-term care, read your policy carefully. Look for what is said about renewing it. See if it contains waiting periods before benefits are paid. Note how it covers preexisting conditions (health conditions you already have). Compare these features with similar ones in any new policy. Use this information to measure the value of any insurance or health care plans you now have.

don't buy more insurance than you really need. One policy that meets your needs is usually less expensive than several limited policies.

If you are eligible for state medical assistance coupons (medicaid), you should not purchase a long-term care insurance policy.

After you receive your policy, make sure you have received the coverage you thought you bought. If you are not satisfied with the policy, you may return it within thirty days (sixty days for direct response insurer) for a full refund of premium.

LTC DISCLOSURE FORM
1. INSTITUTIONAL CARE

What levels of care are covered by the policy?		YES		NO
Does the policy provide benefits for these levels of care?
Skilled Nursing Care?
Intermediate Nursing Care?
Custodial/Personal Care?
(By state law, all long-term care policies in Washington State must cover all three of the above levels of care.)

Where can care be received and be covered under the policy?
Does the policy pay for care in any licensed facility?
If no, define the restrictions on where care can be obtained:
Is the alternative plan of care benefit available with institutional part of policy?			If yes, see section 2
Does the alternative plan of care benefit include home care?			If yes, see section 2
Does the alternative plan of care benefit include structural home improvements?

2. HOME/COMMUNITY BASED CARE

What types of care are covered by the policy?
Does the policy provide home care benefit for:
Check all that apply
Adult day care
Adult day health care
Chore services
Home health aides
Homemaker services
Hospice
Hygiene/personal care
Laboratory services
Meals/nutrition services
Medical equipment/supplies
Prescription drugs
Physician/nursing services
Respite care
Social workers
Therapies (List)
Transportation
Other:
Are these separate or post-confinement benefits?	Separate		Post - Confinement
Where can home/community-based care be received?
Check all that apply
Adult day care centers
Alternative care facilities
Assisted living facilities
Boarding homes
Community centers
Congregate care facilities
Multiple family residences
Single family residences
Other:
Does the alternative plan of care benefit include home care?
Does the alternative plan of care benefit include structural improvements?
Must the alternative plan of care be pre-certified? If yes, by whom?

3. BOTH INSTITUTIONAL AND COMMUNITY-BASED CARE

What is the maximum daily benefit amount for:		YES/NO/COMMENTS
Institutional/nursing home care?
Home/Community Based Care?
Are there limits on the number of days (or visits) per year for which benefits will be paid for:
Institutional/nursing home care?
Home/Community based care?
What are the dollar limits the policy will pay during the policyholder's lifetime for:
Institutional/Nursing home care?
Home/Community based care?
Total lifetime limit?
What basic features and benefits does the policy offer?
Is the policy guaranteed renewable?
Can you purchase additional increments of coverage? If yes:
When can additional coverage be purchased?
How much can be purchased?
When is additional coverage no longer available for purchase?
Does the policy have inflation protection?
If yes, what is the % amount of the increase?
Is the rate of increase simple or compound?
When do increases stop?
If policy includes inflation coverage, what is the daily benefit for:
Institutional/nursing home care.
5 years from policy effective date?
10 years from policy effective date?
Home/Community based care.
5 years from policy effective date?
10 years from policy effective date?
After the limits have been reached for inflation adjustments, what is the maximum daily benefit for:
Institutional/nursing home care
Home/community based care
After the limits have been reached for inflation adjustments, what is the maximum lifetime benefit for:
Institutional/nursing home care
Home/community based care
Is there a waiver of premium provision for:
Institutional/nursing home care?
Home/community based care?
How many days of confinement in an institution are required before the waiver of premium benefit is available?
How many days of confinement at home are required before the waiver of premium benefit is available?
How many days of benefits must be paid before waiver is effective?
Does the policy have a nonforfeiture benefit?
If yes, how many years must policy be in effect before the insured benefits from nonforfeiture values?
What would the benefit value be in terms of dollars after 20 years?
What does the nonforfeiture benefit promise? (give an appropriate example showing dollars and time limits)
Does the policy have a death benefit?
If yes, specify value (in dollars of %)
What conditions or limitations apply, if any?
Does the policy have a restoration of benefits provision?
If yes, give amount of benefit and minimum required # of days between benefits.
If disability recurs, is there a new elimination or waiting period before benefits begin again?
If yes, after how long?
How long is the waiting period for preexisting conditions?
How is the preexisting condition defined?
When do benefits begin?
How long is the elimination or waiting period before benefits begin for:
Institutional/nursing home care?
Home/community based care?
What gatekeepers are required before benefits start?
Doctor certification
Case management
If yes, by whom?
Medical necessity
Plan of treatment
If yes, by whom?
Inability to perform activities of daily living (ADLs)
If yes, how many ADLs must fail before benefits begin?
If the policy uses an ADL gatekeeper(s), define "inability to perform ADL."
Is there a separate benefit qualification requirement if there is a cognitive impairment?
Who determines a qualifying event?
Define any separate benefit qualification requirement if there is a cognitive impairment:
What does the policy cost?
How often can the premium increase?
By how much annually can the premium increase?
Is there a discount if both spouses buy policies?
If so, how much?
Do you lose the discount if one spouse dies?

4. ADDITIONAL POLICY INFORMATION
Use this space to outline additional benefits, further explanations or clarifications


5. POLICY DEFINITIONS
(Include definitions of policy provisions)

WHAT DOES THE POLICY COST?

company name . . . . . . . .	POLICY OPTION 1 _____	POLICY OPTION 2 _____	POLICY OPTION 3 _____	POLICY OPTION 4 _____
elimination (deductible) period benefit period $ benefit for day $ maximum benefit	_____ _____ _____ _____	_____ _____ _____ _____	_____ _____ _____ _____	_____ _____ _____ _____
Institutional/Nursing Home Home Health/Community Based	_____ _____	_____ _____	_____ _____	_____ _____
premium subtotal $	_____	_____	_____	_____
optional benefits Inflation Non Forfeiture Spousal Discount Death Benefit Other _____ Other _____ Other _____	_____ _____ _____ _____ _____ _____ _____ _____	_____ _____ _____ _____ _____ _____ _____ _____	_____ _____ _____ _____ _____ _____ _____ _____	_____ _____ _____ _____ _____ _____ _____ _____
premium total $	_____	_____	_____	_____
BENEFIT "TRIGGERS" (qualification requirements) List _____ List _____ List _____	_____ _____ _____	_____ _____ _____	_____ _____ _____	_____ _____ _____

PDFWAC 284-54-350

Form to be used—Long-term care insurance disclosure form.