Filings Made Easy for Life, Health and Licensing

2. Filings Made Easy for Life, Health and Licensing What�s Wrong With My Form Filings?

3. What�s Wrong With My Form Filings? Presenters John Carter Marie Garcia Janice Haney

4. What�s 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

5. What�s 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

6. What�s 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

7. What�s 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

8.  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

9.  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

10.  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

11.  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

12.  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

13.  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

14.  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

15.  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

16.  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

17.  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)

18. What�s 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

19. What�s 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

20. What�s 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

21. What�s Wrong With My Form Filings? Frequent Objections � Accident and Health Dependent Definition � �1501.002(2), TIC Mandated Benefits

22. What�s 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

23. What�s 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

24. What�s 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

25. What�s 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

26. What�s 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

27. What�s 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

28. What�s 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

29. What�s 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

30. What�s 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

31. What�s 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

32. What�s Wrong With My Form Filings? QUESTIONS?????? AND MAYBE�������.. SOME ANSWERS!!!!