<html> <head> <title>Rule 20:06:21:0H Claims Denial Reporting Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:21:0H"> <META NAME="Description" Content="Administrative Rules 20:06:21:0H Claims Denial Reporting Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Times New Roman","serif";} h3 {mso-style-link:"Heading 3 Char"; margin:0in; margin-bottom:.0001pt; text-align:justify; page-break-after:avoid; font-size:12.0pt; font-family:"Times New Roman","serif"; font-weight:normal;} span.Heading3Char {mso-style-name:"Heading 3 Char"; mso-style-link:"Heading 3"; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>CLAIMS DENIAL REPORTING FORM FOR</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>LONG-TERM CARE INSURANCE POLICIES</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Chapter 20:06:21</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>APPENDIX H</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>SEE: &#167; 20:06:21:52</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b><span style='font-weight:bold'>Source:</span></b> 28 SDR 157, effective May 19, 2002; 36 SDR 209, effective July 1, 2010.</font></p> <b><font size=3 face="Times New Roman"><span style='font-size:12.0pt; font-family:"Times New Roman","serif";font-weight:bold'><br clear=all style='page-break-before:always'> </span></font></b> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Claims Denial Reporting Form</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Long-Term Care Insurance</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman">&nbsp;</font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>For the State of ____________________</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>For the Reporting Year of ____________</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Company Name: ______________________________________________ Due: June 30 annually</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Company</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Address:&nbsp; _______________________________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_______________________________________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Company NAIC</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Number:&nbsp; _______________________________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Contact Person: _____________________________________&nbsp; Phone Number:&nbsp; ______________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Line of Business:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Individual&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Group</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Instructions</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The purpose of this form is to report all long-term care claim denials under in force long-term care insurance policies.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Indicate the manner of reporting by checking one of the boxes below:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=5 face="Times New Roman"><span style='font-size:16.0pt'>&#9633;</span></font>&nbsp;&nbsp;Per Claimant -- counts each individual who makes one or a series of claim requests.</p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=5 face="Times New Roman"><span style='font-size:16.0pt'>&#9633;</span></font>&nbsp;&nbsp;Per Transaction -- counts each claim payment request.</p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&quot;Denied&quot; 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 preexisting condition. It does not include a request for payment that is in excess of the applicable contractual limits.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Inforce Data</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=470 valign=top style='width:352.25pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>State</span></font></b></p> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Data</span></font></b></p> </td> <td width=96 valign=top style='width:72.2pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Nationwide Data</span></font></b></p> </td> </tr> <tr> <td width=470 valign=top style='width:352.25pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Total Number of Inforce Policies [Certificates] as of December 31</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=96 valign=top style='width:72.2pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Claims &amp; Denial Data</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>State</span></font></b></p> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Data</span></font></b></p> </td> <td width=97 valign=top style='width:72.5pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt'> <h3><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt; font-weight:bold'>Nationwide</span></font></b></h3> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Data</span></font></b><sup>1</sup></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 1</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Total Number of Long-Term Care Claims Reported</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border-top:none;border-left:solid windowtext 1.0pt; border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 2</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border:none;border-right: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Total Number of Long-Term Care Claims Denied/Not Paid</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 3</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Number of Claims Not Paid due to Preexisting Condition</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border-top:none;border-left:solid windowtext 1.0pt; border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border:none;border-right: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Exclusion</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 4</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Number of Claims Not Paid due to Waiting (Elimination) Period</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Not Met</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border-top:none;border-left:solid windowtext 1.0pt; border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 5</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border:none;border-right: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Net Number of Long-Term Care Claims Denied for Reporting</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border-top:none;border-left:solid windowtext 1.0pt; border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border:none;border-right: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Purposes (Line 2 Minus Line 3 Minus Line 4)</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 6</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Percentage of Long-Term Care Claims Denied of Those </span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Reported (Line 5 Divided By Line 1)</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 7</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Number of Long-Term Care Claims Denied due to:</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 8</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp; " &nbsp; Long-Term Care Services Not Covered under the Policy<sup>2</sup></span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp; 9</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp; " &nbsp; Provider/Facility Not Qualified under the Policy<sup>3</sup></span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>10</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp; " &nbsp; Benefit Eligibility Criteria Not Met<sup>4</sup></span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border-top:none;border-left:solid windowtext 1.0pt; border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>11</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border:none;border-right: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp; " &nbsp; Other</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=4 face="Times New Roman"><span style='font-size:14.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=37 valign=top style='width:27.9pt;border:none;border-top:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=432 colspan=2 valign=top style='width:4.5in;border:none;border-top: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=84 valign=top style='width:63.0pt;border:none;border-top:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=97 valign=top style='width:72.5pt;border:none;border-top:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=49 colspan=2 valign=top style='width:36.9pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp; 1.</span></font></p> </td> <td width=601 colspan=3 valign=top style='width:450.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The nationwide data may be viewed as a more representative and credible indicator</span></font></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=49 colspan=2 valign=top style='width:36.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=601 colspan=3 valign=top style='width:450.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; where the data for claims reported and denied for your state are small in number.</span></font></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=49 colspan=2 valign=top style='width:36.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp; 2.</span></font></p> </td> <td width=601 colspan=3 valign=top style='width:450.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Example&#9472;home health care claim filed under a nursing home only policy.</span></font></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=49 colspan=2 valign=top style='width:36.9pt;border-top:none; border-left:solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp; 3.</span></font></p> </td> <td width=601 colspan=3 valign=top style='width:450.5pt;border:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Example&#9472;a facility that does not meet the minimum level of care requirements or the </span></font></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=49 colspan=2 valign=top style='width:36.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=601 colspan=3 valign=top style='width:450.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; licensing requirements as outlined in the policy.</span></font></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=49 colspan=2 valign=top style='width:36.9pt;border-top:none; border-left:solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp; 4.</span></font></p> </td> <td width=601 colspan=3 valign=top style='width:450.5pt;border:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Examples&#9472;a benefit trigger not met, certification by a licensed health care practitioner</span></font></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=49 colspan=2 valign=top style='width:36.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=601 colspan=3 valign=top style='width:450.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; not provided, no plan of care.</span></font></p> </td> </tr> <tr height=0> <td width=37 style='border:none'></td> <td width=12 style='border:none'></td> <td width=420 style='border:none'></td> <td width=84 style='border:none'></td> <td width=97 style='border:none'></td> </tr> </table> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>