The national Senior and Special Needs guide covers Medicare Parts A to D, the standardized Medigap plans, Medicaid and how long-term care insurance works. This guide covers the West Virginia rules: the Medicare supplement rule (CSR 114-24) and statute (33-16-3d), long-term care standards (Article 15A and CSR 114-32), and required LTC producer training.

Medicare supplement

Issue rights:

• Open enrollment: for the six months starting with the first month a person is both 65 and enrolled in Part B, an insurer can't deny, condition or price coverage based on health (CSR 114-24-9.1).
• Guaranteed issue periods generally end 63 days after the earlier coverage ends (114-24-10).

Policy standards:

• Preexisting conditions: claims for losses more than six months after the effective date can't be denied as preexisting. A preexisting condition is one treated or advised in the six months before coverage (33-16-3d(b)(3)).
• Replacement: if the old policy was in force at least six months, the new one can't impose new preexisting, waiting or probationary periods (114-24-21.2).
• Free look: 30 days from delivery. The refund goes directly to the applicant (33-16-3d(f)).
• Benefits can't be based on "usual and customary" or "reasonable and customary" charges.
• Medicaid suspension: benefits and premiums may be suspended for up to 24 months if requested within 90 days of Medicaid eligibility. Coverage is reinstated if requested within 90 days of losing Medicaid.
• Medicare SELECT policies use a provider network in exchange for lower premiums.

Sales rules:

• The outline of coverage is given when the application is presented. The Guide to Health Insurance for People with Medicare is given in at least 12-point type.
• The first page says: "This policy may not cover all of your medical expenses."
• No sale may leave a person with more than one Medigap policy. A Medigap policy can't be issued to a Part C enrollee unless it takes effect after Part C ends.
• A replacement notice is signed before issue. The applicant gets a copy and the insurer keeps one.
• Commissions: first-year pay is at most 200% of second-year pay. Renewal pay equals the second year's for at least 5 renewal years.
• Prohibited:
  • high-pressure tactics (force, fright, threat, undue pressure)
  • cold lead advertising that hides that an agent will call
  • calling a non-complying policy "Medigap" or "Medicare supplement"
• Insurers file every Medigap advertisement with the Commissioner.

Long-term care

Definition: LTC insurance covers at least 12 consecutive months of care in a setting other than an acute care hospital unit (33-15A-4).

Policy standards (33-15A-6):

• No cancellation or nonrenewal because of age or declining health.
• No requirement of a prior hospital stay. A policy that conditions home care benefits on a prior institutional stay can't require more than 30 days of it.
• No coverage of skilled care only.
• A preexisting condition is one treated or advised in the six months before coverage. It can be excluded only for losses starting within six months of the effective date.
• Benefit triggers can't require more than three ADL deficiencies, or cognitive impairment (114-32-27). The ADLs include bathing, continence, dressing, eating, toileting and transferring.
• Free look: 30 days. Refunds are paid within 30 days.
• Lapse protection: the applicant names someone to receive lapse notices, or waives it in writing. A lapse notice can't go out until 30 days after the premium is due, and gives at least 30 days before termination. A policy lapsed because of cognitive impairment or loss of function is reinstated if requested within five months.
• Nonforfeiture: insurers must offer a nonforfeiture benefit. If it is declined, a contingent benefit upon lapse applies after a substantial rate increase (33-15A-9).

Contestability (33-15A-8):

• Under 6 months: any misrepresentation material to acceptance.
• 6 months to 2 years: a material misrepresentation about the condition claimed.
• After 2 years: only a knowing and intentional misrepresentation about health.
• LTC can't be field issued by an agent based on health. Benefits already paid can't be recovered if the policy is rescinded.

Sales:

• The outline of coverage and the shopper's guide are given before the application is presented.
• The producer lists health policies the applicant has in force, and those sold in the past five years.
• A suitability review considers affordability and need.
• A replacement notice is given before issue.

LTC producer training (W. Va. Code 33-12-8a)

• A producer needs the accident and sickness license and a one-time course of at least 8 hours before selling LTC. After that, 4 hours each CE biennium, which count toward the 24-hour CE requirement.
• The training covers LTC services, Partnership programs, Medicaid, inflation and suitability. It may not include insurer- or product-specific material.
• Insurers verify training before allowing sales and keep the records five years.

Common exam traps

• Medigap open enrollment is 6 months from 65 plus Part B. Guaranteed issue lasts 63 days.
• The Medigap and LTC free look is 30 days.
• Preexisting-condition rules use a 6-month look-back and a 6-month limit.
• LTC triggers can't require more than 3 ADLs.
• After 2 years, an LTC policy is contestable only for knowing, intentional misrepresentation.
• LTC training is 8 hours, then 4 hours each biennium.