The national guide covers Medicare Parts A through D, Medigap plan letters and long-term care basics. Delaware has its own Medicare supplement statute (18 Del. C. Chapter 34) and regulation (Reg. 1501), including an annual birthday rule. Its long-term care law is in Chapter 71 and Regulation 1404.

Medicare supplement in Delaware

• Outline of coverage: delivered when the application is made (3405).
• Free look: 30 days after delivery, for any reason (3406).
• Preexisting conditions: the look-back is at most six months. Losses more than six months after the effective date can't be excluded (3403(b)).
• Open enrollment at 65: no denial, conditions or health-based pricing during the six months starting with the first month the person is both 65+ and enrolled in Part B (Reg. 1501-14).
• Under 65: every Medigap plan the insurer sells must be offered without medical underwriting to disabled beneficiaries who apply within six months of enrolling in Part B (3410).
• Birthday rule (3411):
  • Each year, a policyholder may switch to a Medigap policy with the same or lesser benefits. The window starts 30 days before the birthday and lasts at least 30 days after it.
  • During that window, the issuer may not deny, condition or price on health and may not impose a preexisting-condition exclusion.
  • The issuer sends notice 30 to 60 days before the window opens.
• Guaranteed issue periods generally end 63 days after prior coverage ends (Reg. 1501-15).
• Replacing a Medigap policy: if the old policy was in force at least six months, the new one can't impose new preexisting, waiting, elimination or probationary periods for similar benefits (Reg. 1501-26).
• Required notice on page one: "Notice to buyer: This policy may not cover all of your medical expenses."
• Sales conduct:
  • No sale that leaves someone with two Medigap policies.
  • Twisting, high-pressure tactics and cold-lead advertising are prohibited.
  • First-year commission may be no more than 200% of the second year's, with level renewals for five years (Reg. 1501).

Long-term care in Delaware

• Definition: LTC coverage lasts at least 12 consecutive months for care outside an acute-care hospital unit (7103).
• Benefit triggers:
  • A policy can't require more than 3 deficient activities of daily living, or a cognitive impairment.
  • The ADLs are bathing, continence, dressing, eating, toileting and transferring (Reg. 1404-26).
• Preexisting conditions: an exclusion applies only to a loss that begins within six months of coverage (7105(c)).
• No prior hospitalization requirement. A rider may require a prior institutional stay of no more than 30 days before paying noninstitutional benefits (7105(d)).
• No termination because of age or declining health (7105(b)).
• Free look: 30 days (7105(f)).
• Point of sale:
  • In agent sales, the outline of coverage comes before the application is presented.
  • The personal worksheet is presented at or before application and must be returned before the insurer considers the applicant.
• Inflation protection must be offered at 5% compounded annually (Reg. 1404-13).
• Nonforfeiture must be offered (7106). If the buyer rejects it, the contingent benefit upon lapse applies.
• Lapse protection:
  • The applicant names someone to receive lapse notices, or signs a waiver.
  • The lapse notice goes out at least 30 days before lapse, and only after premium has gone unpaid 30 days.
  • Reinstatement is allowed if the insured was cognitively impaired, when requested within five months (Reg. 1404-9).
• Loss ratios: at least 60% for individual policies and 65% for group (Reg. 1404-19).
• Commissions: no more than 35% of first-year premium on a new sale, and 25% on a replacement (Reg. 1404-30).
• Producer CE: health producers who sell LTC complete 3 hours of Delaware LTC training each biennium (Reg. 504).

Exam traps

• 30-day free look for both Medigap and LTC. Life and A&H free looks are shorter.
• The birthday rule allows a switch to equal or lesser benefits, from 30 days before to 30 days after the birthday.
• LTC benefit triggers can require no more than 3 ADLs. Any required prior stay can be no more than 30 days.
• LTC commissions are capped at 35%, or 25% on a replacement.