This is an obsolete version of the rule. Please click on the rule number to view the current version.


     (1) The following forms are adopted and made a part of these rules for all purposes, and the same must be used as herein directed in giving notice.


     (a) LTC Form A                                           Rescission Reporting Form


LTC Form A







Company Name: ________________________________________________
Address: ________________________________________________
Phone Number: ________________________________________________


Due: March 1 annually




The purpose of this form is to report all rescissions of long-term care insurance policies. Those rescissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.




Form #


Policy and

Certificate #


Name of


Date of







Date of











Detailed reason for rescission: _________________________________________

_________________________________________________________________                                                                                               _________________________________________________________________






                                                                                                            Name and Title (please type)





     (b)                                                             LTC Form B Long-Term Care Insurance

Personal Worksheet


Long-Term Care Insurance

Personal Worksheet


People buy long-term care insurance for many reasons. Some don't want to use their own assets to pay for long-term care. Some buy insurance to make sure they can choose the type of care they get. Others don't want their family to have to pay for care or don't want to go on Medicaid. But long-term care insurance may be expensive, and may not be right for everyone.


By state law, the insurance company must fill out part of the information on this worksheet and ask you to fill out the rest to help you and the company decide if you should buy this policy.


Premium Information 


Policy Form Numbers )                                             


The premium for the coverage you are considering will be [$_____ per month, or

$ _______ per year,] [a one-time single premium of $________.]


Type of Policy (noncancelable/guaranteed renewable):___________________


The Company's Right to Increase Premiums:


[The company cannot raise your rates on this policy.] [The company has a right to increase premiums in the future provided it raises rates for all policies in the same class in this state.][Insurers shall use appropriate bracketed statement. Rate guarantees shall not be shown on this form.]


Rate Increase History


The company has sold long-term care insurance since [year] and has sold this policy since [year]. [The last rate increase for this policy in this state was in [year], when premiums went up by an average of %]. [The company has not raised its rates for this policy.] [The company has never raised its rates for any long-term care policy it has sold in this state or any other state.] [The company has not raised its rates for this policy form or similar policy forms in this state or any other state in the last 10 years.] [The company has raised its premium rates on this policy form or similar policy forms in the last 10 years. Following is a summary of the rate increases.]


Questions Related to Your Income


[ Have you considered whether you could afford to keep this policy if the premiums were raised, for example, by 20%?]


How will you pay each year's premiums?

From my Income               From my Savings/Investments                            My Family Will Pay




What is your annual income? (check one)          Under $10,000                    $10,000-20,000

$20,000-30,000                 $30,000-50,000                      Over $50,000


How do you expect your income to change over the next 10 years? (check one)

No change                           Increase                             Decrease


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 if the premiums will be more than 7% of your income.


Will you buy inflation protection: (check one)          Yes              No 

If not, have you considered how you will pay for the difference between future costs and your daily benefit amount? 

From my Income                    From my Savings/Investments                  My Family Will Pay


The national average annual cost of care in [insert year] was [insert $ amount], but this figure varies across the country. In ten years the national average annual cost would be about [insert $ amount] if costs increase 5% annually.


What elimination period are you considering? Number of days ________

Approximate cost $_______ for that period of care.


How are you planning to pay for your care during the elimination period? (check one)

From my Income                   From my Savings/Investments                    My Family Will Pay  



Questions Related to Your Savings and Investments


Not counting your home, about how much are all of your assets (your savings and investments) worth?


(check one)

Under $20,000             $20,000-$30,000               $30,000-$50,000                  Over $50,000


How do you expect your assets to change over the next 10 years? (check one)

Stay about the same                Increase                             Decrease


If you are buying this policy to protect your assets and your assets are less than $30,000, you may wish to consider other options for financing your long-term care.

Disclosure Statement


The answers to the questions above describe my financial situation.


I choose not to complete this information.

(Check one.)

I acknowledge that the carrier and/or its producer (below) has reviewed this form with me including the premium, premium rate increase history and potential for premium increases in the future. [For direct mail situations, use the following: I acknowledge that I have reviewed this form including the premium, premium rate increase history and potential for premium increases in the future.] I understand the above disclosures. I understand that the rates for this policy may increase in the future. (This box must be checked.)



Signed: _____________________________                  _____________________

                                      (Applicant)                                                             (Date)


[ I explained to the applicant the importance of completing this information.] 

Signed: _____________________________                    ___________________

                                    (Applicant)                                                           (Date)


Producer's Printed Name: ____________________________________________]


In order for us to process your application, please return this signed statement to [name of company], along with your application.]


[My agent has advised me that this policy does not seem to be suitable for me. However, I still want the company to consider my application.]


Signed: ___________________________                        _____________________________

                                   (Applicant)                                                                   (Date)

The company may contact you to verify your answers.


(c) LTC Form C                   Things You Should Know Before You Buy Long-Term Care Insurance



Things You Should Know Before You Buy

Long-Term Care Insurance


Long-Term ▪  


A long-term care insurance policy may pay most of the costs for your care 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.


(d) LTC Form D                            Long-Term Care Insurance Suitability 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. 


APPLICANT'S SIGNATURE                                                                DATE_____________


Please return to [issuer] at [address] by [date]


(e)                                            LTC Form E Claims Denial Reporting Form



Claims Denial Reporting Form

Long-Term Care Insurance


For the State of Montana

For the Reporting Year of __________


Company Name : ___________________________ Due: June 30 annually

Company Address: _________________________

Company NAIC: ___________________________ Number:                                

Contact Person: _________________________ Phone Number: ___________

Line of Business:                 Individual                                                       Group




The purpose of this form is to report all long-term care claim denials under in-force long-term care insurance policies. "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 preexisting condition.  



State Data

Nationwide Data


Total Number of Long-Term Care Claims Reported



Total Number of Long-Term Care Claims Denied/Not Paid



Number of Claims Not Paid due to Preexisting Condition Exclusion


Number of Claims Not Paid due to Waiting (Elimination) Period Not Met



Net Number of Long-Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)



Percentage of Long-Term Care Claims Denied of Those Reported (Line 5 Divided by Line 1)



Number of Long-Term Care Claims Denied due to:



          ▪ Long-Term Care Services  



          ▪ Provider/Facility Not Qualified under the Policy 



          ▪ Benefit Eligibility Criteria Not Met  



          ▪ 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. Examplehome health care claim filed under a nursing home only policy.

3. Examplea facility that does not meet the minimum level of care requirements or the licensing requirements as outlined in the policy.

4. Examplesa benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care. 


(f)                                     LTC Form F Potential Rate Increase Reporting Form


LTC Form F




This form provides information to the applicant regarding premium rate schedules, rate schedule adjustments, potential rate revisions, and policy holder 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


[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 [filed][approved] for an increase [is][are][on the application][$_______]


1. The [premium] [premium rate schedule] for this policy [will be shown on the schedule page of] [will be attached to] your policy. 


2. 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): ____________________________.


3. Potential Rate Revisions: 


This policy is Guaranteed Renewable. This means that the rates for this product may be increased in the future. Your rates can NOT 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 didn't buy a nonforfeiture option, you may be eligible for contingent nonforfeiture. Here's 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 (do 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've 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. 




$          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.)


Issue Age

Percent Increase Over Initial Premium

29 and under










































































90 and over



[The following contingent nonforfeiture disclosure need only be included for those limited pay policies to which ARM 6.6.3119(4)(c) and (e) of the regulation 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 chose 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

Issue Age


Over Initial Premium

Under 65




Over 80



2. You stop paying your premiums within 120 days of when the premium increase took effect; and 


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. 




▪ 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 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.


(g)                                        LTC Form G Replacement and Lapse Reporting Form


LTC Form G


Long-Term Care Insurance

Replacement and Lapse Reporting Form


For the State of Montana                                                              For the Reporting Year of __________


Company Name: ______________                                    Due: June 30 annually

Company Address: ___________________                    Company NAIC # _______

Company NAIC Number: ____________________

Contact Person: ____________________________

Phone Number: __(___)______________________




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 percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent's total annual sales. The tables below should be used to report the 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  


Agent's Name

Number of Policies Sold by This Agent

Number of Policies Replaced by This Agent

Number of Replacements as % of Number Sold by this Agent


Listing of the 10% of Agents with the Great Percentage of Lapses


Agent's Name

Number of Policies Sold by This Agent

Number of Policies Lapsed by This Agent

Number of Lapses as % of Number Sold by This Agent



Company Totals:

Percentage of Replacement Policies Sold to Total 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) _____%



History: 33-1-313, 33-22-1121, MCA; IMP, 33-22-1101, 33-22-1102, 33-22-1103, 33-22-1107, 33-22-1108, 33-22-1111, 33-22-1112, 33-22-1113, 33-22-1114, 33-22-1115, 33-22-1116, 33-22-1117, 33-22-1119, 33-22-1120, 33-22-1121, MCA; NEW, 1995 MAR p. 2242, Eff. 1/1/96; TRANS & AMD, from ARM 6.6.5604, 1998 MAR p. 3271, Eff. 12/18/98; AMD, 2008 MAR p. 615, Eff. 10/1/08.

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