0990-PLTC File Specifications

0990-PLTC File Specifications.xls

Partnership for Long Term Care Insurer Reporting Requirements

0990-PLTC File Specifications

OMB: 0990-0333

Document [xlsx]
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Overview

File 1
File 2
File 3
File 4


Sheet 1: File 1

File 1 - Registry File




For Individual and Voluntary or Partially Voluntary Group Coverage










Field Number Field Name Field Type Field Length Field Definition Field Values
1 Company Code 5 Unique company identifier using NAIC company code. If the block of business was purchased from another carrier, the company code of the acquiring company should be provided. The HHS data repository will develop a unique code for self-funded and FLTCIP plans that do not have NAIC codes. 5 Digit NAIC Code or a uniquely assigned company code for self-funded plans and Federal Employees Long Term Care Insurance program (FLTCIP)
2 Report Date N 8 Date on which the report was submitted to HHS. Format: MMDDYYYY
3 Reporting Period N 16 Begin date and end date of reporting period. In general, the reporting period for File 1 will be a six-month period, either January 1 through June 30, or July 1 through December 31. Format: MMDDYYYYMMDDYYYY
4 Insured’s Social Security Number N 10 Social security number of the person insured under the Partnership Qualified (PQ) policy. 10 digit numeric code (no dashes)
999999999 if not available
5 Policy Number AN 30 The unique certificate or policy number assigned by the carrier A/N
6 First Name A 30 First name of insured First Name
7 Middle Initial A 1 Middle initial in name of insured Middle Initial
8 Last Name A 40 Last name of insured Last name; include generational suffixes here i.e., JR SR
9 Date of Birth N 8 Birth date of insured Format: MMDDYYYY
10 Gender A 1 Gender of insured M = Male
F = Female
U = Unknown
11 Current Address Line 1 AN 50 Insured's current street address Street name and number
12 Current Address Line 2 AN 50 Insured's current street address line 2 Additional Address Line
13 Current City of Residence A 40 Insured’s current city of residence Insured’s city of residence during reporting period
14 Current State A 2 Insured’s current state of residence USPS state code.
15 Current ZIP Code N 9 Postal zip code of insured’s current residence 5-digit numeric code
9-digit numeric code optional (no hyphen for zip+4).
16 Policy Issue State A 2 State in which the individual or group policy was originally issued. USPS state code.
17 Certificate Issue State A 2 For group business, this is the original residence state. The state where the certificateholder lived at the time of original purchase. USPS state code.
18 Current Annual Premium N 6 The current annualized premium for the policy/certificate. Numeric code without commas, decimals or dollar signs. The premium amount may be zero for policies in waiver of premium, in a paid up status or in nonforfeiture status.
19 Original Coverage Effective Date as Partnership Qualified (PQ) Policy N 8 Indicates date on which the insured’s coverage first became effective as a PQ policy under his or her individual policy or group certificate. Based on each state’s rules for exchanges, this could be a date prior to the date on which the exchange takes place. Format: MMDDYYYY
20 Policy Exchange to PQ N 1 Indicates whether the policy is a PQ policy as a result of an exchange from a non-PQ policy, rather than as an original purchase. 1 = Yes
0 = No
21 Policy Benefit Type A 2 Indicates the major type of benefits allowed under the policy. CP = Comprehensive
NH = Nursing Home Only
FC = Facility Care Only (includes NH and ALF)
HC = Home Health Care Only
OT = Other
22 Coverage Basis A 1 Indicates whether the policy is a group or an individual policy. For multi-life groups, the value selected should be based on how the policy was filed with the Department of Insurance. G = Group Policy
I = Individual Policy
23 Ported Coverage from Group to Individual Policy N 1 Indicates whether the policy was originally purchased on a group basis, and then coverted to an individual policy at a later date (e.g. when the insured individual left his or her employer where the coverage was originally purchased). 1 = Yes
0 = No
24 Lifetime Maximum Structure A 1 Indicates whether the Lifetime Maximum is expressed as a single benefit pool across all covered services (Integrated Lifetime Maximum) or whether there are separate Lifetime Maximums for two or more covered benefits. S = Single lifetime maximum for all covered services (although there may be inner limits on some benefits provided over and above the lifetime maximum)
M = Multiple lifetime maximums by covered service (one or more)
25 Lifetime Maximum Structure Detail A 2 Indicates whether the policy counts Dollars or Days of benefits used as the Lifetime Maximum. DL = Dollars (pool(s) of dollars design)
DY = Days and not pool of dollars design
26 Lifetime Policy Maximum for Nursing Home Coverage (Dollars) N 9 Indicates the whole dollar amount of the Policy Lifetime Maximum for Nursing Home Benefits, or indicates an “unlimited” Policy Lifetime Maximum. Nearest whole dollar amount. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
27 Lifetime Policy Maximum for Home Health Care (Dollars) N 9 If policy has multiple pools and pays in dollars, this field indicates the current dollar amount of the Lifetime Policy Maximum for Home Health Care Benefits, or indicates an “unlimited” Lifetime Maximum. Nearest whole dollar amount. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
888888888 = Policy/certificate only has one pool
28 Lifetime Policy Maximum for ALF/Other Facility Care (Dollars) N 9 If policy has multiple pools and pays in dollars, this field indicates the current dollar amount of the Lifetime Policy Maximum for ALF/Other Facility Benefits, or indicates an “unlimited” Lifetime Maximum. Nearest whole dollar amount. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
888888888 = Policy/certificate only has one or two pools
29 Lifetime Policy Maximum for Nursing Home Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the current Lifetime Policy Maximum for number of days of Nursing Home Coverage. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum expressed in dollars
30 Lifetime Policy Maximum for Home Health Care Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the current lifetime maximum number of Home Health Care days. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum expressed in dollars
88888 = Policy/certificate only has one pool
31 Lifetime Policy Maximum for ALF/Other Facility Care Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the lifetime maximum number of ALF/Other Facility days covered. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum expressed in dollars
88888 = Policy/certificate only has one or two pools
32 Nursing Home Benefit Amount N 4 The current daily benefit amount for nursing home coverage. If the benefit is paid as weekly or monthly, the daily amount can be derived. If the policyholder has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Nursing Home Benefit
33 Home Health Care Benefit Amount N 4 The current daily benefit amount for Home Health Care provision on the policy. If the benefit is paid as weekly or monthly, the daily amount should be derived. If the policyholder has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Home Health Care Benefit
34 Assisted Living Facility (ALF) Benefit Amount N 4 The current daily benefit amount for Assisted Living Facility/Other Facility Care. If the benefit is paid as weekly or monthly, the daily amount should be derived. If the policyholder has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No ALF Benefit
35 Automatic Inflation Protection Type A 3 Indicates the type of inflation protection provided in the policy. ABI = Automatic annual compound inflation protection, funded on level issue-age basis
ASI = Automatic annual simple inflation protection, funded on level issue-age basis
GIP = Graded inflation protection; both benefits and premiums increase by specified amount each year
SIP = Step-rated design where nature of inflation protection changes over time or at certain attained ages
CPI = General consumer price index
LCI = Long Term Care specific consumer price index
OTI = Other price index value
CDI = Carrier determined index
OTH = Other (but not to include FPO/GPO/BIO, see below)
NIP = No inflation protection
36 Inflation Protection Increase Amount or Index Value N 5 (2.2) This field provides the annual increase percentage of inflation protection provided in the policy (e.g., 2%, 3%, 5%). If the annual increase is tied to an index, as indicated in field # 35, apply the current index value. If the annual increase is tied to an index, as indicated in field # 35, apply the current index value.
Percentage value with two decimal points (e.g., 02.50)
88.88 = If field 35 equals NIP
99.99 = No annual inflation amount
37 Inflation Protection Duration: Attained Age of Insured N 1 Indicates if automatic inflation protection stops at an attained age of the insured. 1=Yes, inflation protection stops at an attained age
0=No, inflation protection does not stop at an attained age
If field 35 = NIP or there is no limit on inflation protection, this field may be zero-filled.
38 Attained Age at Which Inflation Protection Ends N 3 Indicates attained age of insured when automatic inflation protection ends. Numeric value in years
If field 35 = NIP or there is no limit on inflation protection, this field may be zero-filled.
39 Inflation Protection Duration: Attained Age of Policy/Certificate N 1 Indicates if automatic inflation protections stops at an attained age of the policy/certificate. 1=Yes, inflation protection stops at an attained age of the Policy/Certificate
0=No, inflation protection does not stop at an attained age of the Policy/Certificate
If field 35 = NIP or there is no limit on inflation protection, this field may be zero-filled.
40 Policy/Certificate Age at Which Inflation Protection Ends N 2 Indicates the attained age of policy/certificate when automatic inflation protection ends. Numeric value in years
If field 35 = NIP or there is no limit on inflation protection, this field may be zero-filled.
41 Inflation Protection Duration Type: Life of Policy/Certificate N 1 Indicates if automatic inflation projection continues for the entire duration of the policy/certificate. 1=Yes, inflation protection continues for entire duration of the policy/certificate
0=No, inflation protection does not continue for the entire duration of the policy/certificate
42 Inflation Protection Duration Type: When Benefit has Doubled N 1 Indicates if automatic inflation protection ends when the benefit has doubled. 1=Yes, inflation protection ends when benefit has doubled
0=No, inflation protection does not end when benefit has doubled
If field 35 = NIP or there is no limit on inflation protection, this field may be zero-filled.
43 Inflation Protection Duration Type: Other Trigger Type N 1 Indicates if automatic inflation protection ends by some trigger other than the triggers described in fields 37, 39, or 42. 1=Yes, inflation protection ends by some other trigger
0=No, inflation protection does not end by a trigger
If field 35 = NIP or there is no limit on inflation protection, this field may be zero-filled.
44 Future Purchase Option A 2 Indicates if the insured has elected or automatically has a Future Purchase Option (FPO) as a provision of their policy or certificate and the type of FPO structure. YA = Annual FPO
YV = FPO, but not Annual
NO = No FPO
45 Frequency of Future Purchase Option N 2 Indicates the frequency (in years) with which the FPO offer is made to the insured. 1 = Annual FPO
Other numeric value for non-annual FPO offers
(e.g. 2 for every 2 years)
0 = No FPO
46 Termination of FPO Option A 2 Indicates circumstances, if any, under which Future Purchase Option ends LT = Offers continue for the life of the policy
D1 = 1 decline triggers termination of offers
D2 = 2 declines trigger termination of offers
C2 = Offers end with 2 consecutive declines
AG = Offers end at specified age
CL = Insured goes into claim
OT = Other means of ending the offers
NO = No FPO
47 Policy Status at End of Reporting Period A 1 Indicate the status of the PQ policy at the end date of the current reporting period. Note that values E, V, R, D and O would only be reported if that status was obtained at some point during the current reporting period. I = Inforce
N = Active in non-forfeiture
E = Exhausted benefits
V = Voluntary Lapse
R = Recission
D = Death
T = Not Taken Out (NTO)
O = Other
48 Partnership Status A 2 Indicates if the policy remains Partnership Qualified at the end of the reporting period. NQ should only be reported once, since persons without PQ policies would be dropped from File 1 in subsequent reporting periods. PQ=Partnership Qualified
NQ=No longer Partnership Qualified

Sheet 2: File 2

File 2 - Claimant File




For Individual and Voluntary or Partially Voluntary Group Coverage










Field Number Field Name Field Type Field Length Field Definition Field Values
1 Company Code 5 Unique company identifier using NAIC company code. If the block of business was purchased from another carrier, the company code of the acquiring company should be provided. The HHS data repository will develop a unique code for self-funded and FLTCIP plans that do not have NAIC codes. 5 Digit NAIC Code or a uniquely assigned company code for self-funded plans and Federal Employees Long Term Care Insurance program (FLTCIP)
2 Report Date N 8 Date on which the report was submitted to HHS. Format: MMDDYYYY
3 Reporting Period N 16 Begin date and end date of reporting period. In general, the reporting period for File 2 will be a calendar year quarter (e.g. January 1 to March 31) Format: MMDDYYYYMMDDYYYY
4 Claimant Social Security Number N 10 Social security number of insured claimant. 10 digit numeric code (no dashes)
999999999 if not available
5 Policy Number AN 30 The unique certificate or policy number assigned by the carrier. Any alphanumeric combination as determined by the carrier.
6 First Name A 30 First name of insured First Name
7 Middle Initial A 1 Middle initial in name of insured Middle Initial
8 Last Name A 40 Last name of insured Last name
9 Date of Birth N 8 Birth date of insured Format: MMDDYYYY
10 Qualifying Condition A 1 Indicates whether claimant became eligible for benefits based on ADL deficits, Cognitive Impairment, Both ADL and Cognitive Impairments, or some other benefit trigger. A = ADL Dependency
C = Cognitive Impairment
B = ADL and Cognitive Impairment
O = Other Benefit Eligibility Trigger(s)
11 Benefit Start Date of the Current Claim Period N 8 Indicates date on which benefit payments begin for the current claim period. This date should occur after any elimination period has been satisfied. Format: MMDDYYYY
12 Nursing Home Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits for nursing home services paid during the current reporting period. Numeric value (in dollars) rounded to the nearest dollar amount.
13 Home Health Care Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits paid during the reporting period for home health care and related home health care services. Numeric value (in dollars) rounded to the nearest dollar amount.
14 Assisted Living/Other Facility Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits paid during the reporting period for assisted living or other non-nursing home facility care. Numeric value (in dollars) rounded to the nearest dollar amount.
15 Total Cash Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits paid during the reporting period for cash benefits. Numeric value (in dollars) rounded to the nearest dollar amount.
16 Other Benefit Amounts Paid During Reporting Period N 9 Indicates the total amount of benefits paid during the reporting period for all benefits paid other than nursing home, home and community care, assisted living/other facility care, or cash benefits. Numeric value (in dollars) rounded to the nearest dollar amount.
17 Total Lifetime Benefits Paid to Date N 9 Indicates the total amount of benefits paid under the certificate to date as of the end of the reporting period. Numeric value (in dollars) rounded to the nearest dollar amount.
18 Remaining Lifetime Benefits for all Pools Combined (Dollars) N 9 Indicates the total amount of benefits remaining under the lifetime maximum (for all pools combined) as of the end of the reporting period. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime benefit expressed in days
19 Remaining Lifetime Nursing Home Benefits (Dollars) N 9 Indicates the total amount of nursing home benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for nursing home benefits is expressed in dollars. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime benefit expressed in days
20 Remaining Lifetime Home Health Care Benefits (Dollars) N 9 Indicates the total amount of home health care benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for home health care benefits is expressed in dollars. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime maximum expressed in days
888888888 = No second pool
21 Remaining Lifetime ALF/Other Facility Benefits (Dollars) N 9 Indicates the total amount of ALF/Other Facility Benefits benefits remaining in the policy as of the end of the reporting period, if the lifetime maximum for home health care benefits is expressed in dollars. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime maximum expressed in days
888888888 = No third pool
22 Remaining Lifetime Nursing Home Benefits (Days) N 5 Indicates the total amount of nursing home benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for nursing home benefits is expressed in days. Numeric value (in days).
00000 = Unlimited Lifetime Benefits
99999 = Pool maximum expressed in dollars
23 Remaining Lifetime Home Health Care Benefits (Days) N 5 Indicates the total amount of home health care benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for home health care benefits is expressed in days. Numeric value (in days).
00000 = Unlimited Lifetime Benefits
99999 = Pool maximum expressed in dollars
88888 = No second pool
24 Remaining Lifetime ALF/Other Facility Care Benefits (Days) N 5 Indicates the total amount of ALF/Other Facility benefits remaining in the policy as of the end of the reporting period, if the lifetime maximum for ALF/Other Facility benefits is expressed in days. Numeric value (in days).
00000 = Unlimited Lifetime Benefits
99999 = Pool maximum expressed in dollars
88888 = No third pool

Sheet 3: File 3

File 3 - Registry File




For Employer-Paid Core Only & Core & Buy-Up Plans










Field Number Field Name Field Type Field Length Field Definition Field Values
1 Company Code 5 Unique company identifier using NAIC company code. If the block of business was purchased from another carrier, the company code of the acquiring company should be provided. The HHS data repository will develop a unique code for self-funded and FLTCIP plans that do not have NAIC codes. 5 Digit NAIC Code or a uniquely assigned company code for self-funded plans and Federal Employees Long Term Care Insurance program (FLTCIP)
2 Report Date N 8 Date on which the report was submitted to HHS. Format: MMDDYYYY
3 Reporting Period N 16 Begin date and end date of reporting period. In general, the reporting period for File 3 will be a calendar year (e.g. January 1 through December 31) Format: MMDDYYYYMMDDYYYY
4 Employer Name A 60 Indicates name of employer. If employer offers more than one plan type (e.g. to different classifications of employees), different plan types will be indicated by Employer Name A, Employer Name B, etc. Name
5 Employer Type 2 Indicates the type of employer using standard industry codes Two digit industry code
6 Number of Persons Insured with Core Coverage N 6 Indicate number of insureds covered under the employers core plan Numeric value with no commas or decimals
7 Situs State A 2 Indicate the two-letter USPS code for state in which the group policy is sitused. If an individual policy form is being used, indicate N/A USPS state code
NA = An individual policy form is being used
8 Employer Street Address 1 AN 50 Indicate employer primary address, line 1. This address should be the primary address where the carrier corresponds with the employer regarding the group plan. Employer street address
9 Employer Street Address 2 AN 50 Indicate employer primary address, line 2. This address should be the primary address where the carrier corresponds with the employer regarding the group plan. Same as above Employer street address - additional address line
10 Employer City A 40 Employer address: City City Name
11 Employer State A 2 Employer address: State USPS state code
12 Employer ZIP Code N 9 Postal zip code of employer’s address 5-digit numeric code
9-digit numeric code optional (no hyphen for zip+4).
13 Core Coverage Policy Benefit Type A 2 Indicates the major type of benefits allowed under the policy. CP = Comprehensive
NH = Nursing Home Only
FC = Facility Care Only (includes NH and ALF)
HC = Home Health Care Only
OT = Other
14 Core Coverage Basis A 1 Indicates whether the policy is a group or an individual policy. For multi-life groups, the value selected should be based on how the policy was filed with the Department of Insurance. G = Group Policy
I = Individual Policy
15 Average Monthly Premium Amount N 9 Indicates average monthly premium amount paid by the employer for each insured covered under the core plan Numeric value (in dollars) rounded to the nearest dollar amount.
16 Core Lifetime Maximum Structure A 1 Indicates whether the Lifetime Maximum is expressed as a single benefit pool across all covered services (Integrated Lifetime Maximum) or whether there are separate Lifetime Maximums for two or more covered benefits. S = Single lifetime maximum for all covered services (although there may be inner limits on some benefits provided over and above the lifetime maximum)
M = Multiple lifetime maximums by covered service (one or more)
17 Core Lifetime Maximum Structure Detail A 2 Indicates whether the policy counts Dollars or Days of benefits used as the Lifetime Maximum. DL = Dollars (pool(s) of dollars design)
DY = Days and not pool of dollars design
18 Core Lifetime Policy Maximum for Nursing Home Coverage (Dollars) N 9 Indicates the whole dollar amount of the Core Policy Lifetime Maximum for Nursing Home Benefits, or indicates an “unlimited” Policy Lifetime Maximum. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
19 Core Lifetime Policy Maximum for Home Health Care (Dollars) N 9 If the policy has multiple pools and pays in dollars, this field indicates the current dollar amount of the Lifetime Policy Maximum for Home Health Care Benefits, or indicates an “unlimited” Lifetime Maximum. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
888888888 = Policy/certificate only has one pool
20 Core Lifetime Policy Maximum for ALF/Other Facility Care (Dollars) N 9 If the policy has multiple pools and pays in dollars, this field indicates the current dollar amount of the Lifetime Policy Maximum for ALF/Other Facility Benefits, or indicates an “unlimited” Lifetime Maximum. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
888888888 = Policy/certificate only has one or two pools
21 Core Lifetime Policy Maximum for Nursing Home Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the current Lifetime Policy Maximum for number of days of Nursing Home Coverage. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum expressed in dollars
22 Core Lifetime Policy Maximum for Home Health Care Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the current lifetime maximum number of Home Health Care days. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum is calculated in dollars
88888 = Policy/certificate only has one pool
23 Core Lifetime Policy Maximum for ALF/Other Facility Care Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the lifetime maximum number of ALF/Other Facility days covered. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum is calculated in dollars
88888 = Policy/certificate only has one or two pools
24 Core Nursing Home Benefit Amount N 4 The current daily benefit amount for nursing home coverage. If the benefit is paid as weekly or monthly, the daily amount should be derived. If the policy has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Core Nursing Home Benefit
25 Core Home Health Care Benefit Amount N 4 The current daily benefit amount for home health care provision on the policy. If the benefit is paid as weekly or monthly, the daily amount should be derived. If the policy has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Core Home Health Care Benefit
26 Core Assisted Living Facility (ALF) Benefit Amount N 4 The current daily benefit amount for Assisted Living Facility/Other Facility Care. If the benefit is paid as weekly or monthly, the daily amount should be derived. If the policyholder has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Core ALF Benefit
27 Core Automatic Inflation Protection Type A 3 Indicates the type of inflation protection provided in the policy. ABI = Automatic annual compound inflation protection, funded on level issue-age basis
ASI = Automatic annual simple inflation protection, funded on level issue-age basisfunded on level issue-age basis
GIP = Graded inflation protection; both benefits and premiums increase by specified amount each year
SIP = Step-rated design where nature of inflation protection changes over time or at certain attained ages
CPI = General consumer price index
LCI = Long Term Care specific consumer price index
OTI = Other price index value
CDI = Carrier determined index
OTH = Other (but not to include FPO/GPO/BIO, see below)
NIP = No inflation protection
28 Core Inflation Protection Increase Amount or Index Value N 5 (2.2) This field provides the annual increase percentage of inflation protection provided in the policy (e.g., 2%, 3%, 5%). If the annual increase is tied to an index, as indicated in field # 27, apply the current index value. If the annual increase is tied to an index, as indicated in field # 27, apply the current index value.
Percentage value with two decimal points (e.g. 02.50)
99.99 = No annual inflation amount
88.88 = If field 27 equals NIP
29 Core Inflation Protection Duration: Attained Age of Insured N 1 Indicates if automatic inflation protection stops at an attained age of the insured. 1=Yes, inflation protection stops at an attained age
0=No, inflation protection does not stop at an attained age
If field 27 = NIP or there is no limit on inflation protection, this field may be zero-filled.
30 Core Attained Age at Which Inflation Protection Ends N 3 Attained age of insured when automatic inflation protection ends. Numeric value in years
If field 27 = NIP or there is no limit on inflation protection, this field may be zero-filled.
31 Core Inflation Protection Duration: Attained Age of Policy/Certificate N 1 Indicates if automatic inflation protections end at an attained age for the policy/certificate. 1=Yes, inflation protection stops at an attained age of the Policy/Certificate
0=No, inflation protection does not stop at an attained age of the Policy/Certificate
If field 27 = NIP or there is no limit on inflation protection, this field may be zero-filled.
32 Core Policy/Certificate Age at Which Inflation Protection Ends N 2 Attained age of policy/certificate when automatic inflation protection ends. Numeric value in years
If field 27 = NIP or there is no limit on inflation protection, this field may be zero-filled.
33 Core Inflation Protection Duration Type: Life of Policy/Certificate N 1 Indicates if automatic inflation projection continues for the entire duration of the policy/certificate. 1=Yes, inflation protection continues for entire duration of the policy/certificate
0=No, inflation protection does not continue for the entire duration of the policy/certificate
34 Core Inflation Protection Duration Type: When Benefit has Doubled N 1 Indicates if automatic inflation protection ends when the benefit has doubled. 1 = Yes, inflation protection ends when benefit has doubled
0 = No, inflation protection does not end when benefit has doubled
If field 27 = NIP or there is no limit on inflation protection, this field may be zero-filled.
35 Core Inflation Protection Duration Type: Other Trigger Type N 1 Indicates if automatic inflation protection ends by some trigger other than the triggers described in fields 29, 31, or 34. 1 = Yes, inflation protection ends by some other trigger
0 = No, inflation protection does not end by a trigger
If field 27 = NIP or there is no limit on inflation protection, this field may be zero-filled.
36 Partnership Status of Core Coverage A 2 Indicates if the core coverage provided by the employer-paid group policy is PQ in at least one or more states covered by the policy, or if the core coverage provided under the plan is not PQ in any state. PQ=Core Coverage is Partnership Qualified
NQ = Core Coverage Not Partnership Qualified
37 Buy-Up Option Available N 1 Indicates whether employees are eligible to purchase additional coverage on their own to supplement the employer-paid portion (core plan) 1 = Yes
0 = No
38 Number of Insureds with Buy-Up PQ Coverage N 6 Indicates the number of insureds who have elected to “buy-up” to coverage such that they have Partnership-qualified plans Numeric value with not commas or decimals
39 Group Policy Status at End of Reporting Period A 1 Indicates if group policy is still in force or if it has terminated since the prior reporting period. S=Still in Force
T=Terminated
40 Active Claim Status N 1 Indicates whether any claims are being or have been paid on behalf of insureds covered under the employer-paid core plan. If YES, insurer completes and submits File 4 for each insured for whom benefits have been paid. 1 = Yes
0 = No

Sheet 4: File 4

File 4 - Claimant File




For Employer-Paid Core Only & Core & Buy-Up Plans









Field Number Field Name Field Type Field Length Field Definition Field Values
1 Company Code 5 Unique company identifier using NAIC company code. If the block of business was purchased from another carrier, the company code of the acquiring company should be provided. The HHS data repository will develop a unique code for self-funded and FLTCIP plans that do not have NAIC codes. 5 Digit NAIC Code or a uniquely assigned company code for self-funded plans and Federal Employees Long Term Care Insurance program (FLTCIP)
2 Report Date N 8 Date on which the report was submitted to HHS. Format: MMDDYYYY
3 Reporting Period N 16 Begin date and end date of reporting period. In general, the reporting period for File 4 will be a calendar year quarter (e.g. January 1 to March 31) Format: MMDDYYYYMMDDYYYY
4 Claimant Social Security Number N 10 Social security number of insured claimant. 10 digit numeric code (no dashes)
999999999 if not available
5 Policy Number AN 30 The unique certificate or policy number assigned by the carrier. Any alphanumeric combination as determined by the carrier.
6 First Name A 30 First name of insured First Name
7 Middle Initial A 1 Middle initial in name of insured Middle Initial
8 Last Name A 40 Last name of insured Last name; include generational suffixes here i.e., JR SR
9 Date of Birth N 8 Birth date of insured Format: MMDDYYYY
10 Gender A 1 Gender of insured M = Male
F = Female
U = Unknown
11 Current Address Line 1 AN 50 Insured's current street address Street name and number
12 Current Address Line 2 AN 50 Insured's current street address line 2 Additional Address Line
13 Current City of Residence A 40 Insured’s current city of residence Insured’s city of residence during reporting period
14 Current State A 2 Insured’s current state of residence USPS state code.
15 Current ZIP Code N 9 Postal zip code of insured’s current residence 5-digit numeric code
9-digit numeric code optional (no hyphen for zip+4).
16 Policy Issue State A 2 State in which the individual or group policy was originally issued. USPS state code.
17 Certificate Issue State A 2 For group business, this is the original residence state. The state in which the certificateholder lived at the time of original purchase. USPS state code.
18 Current Annual Premium N 6 The current annualized premium for the policy/certificate. Numeric code without commas, decimals or dollar signs. The premium amount may be zero for policies in waiver of premium, in a paid up status or in nonforfeiture status.
19 Original Coverage Effective Date as Partnership Qualified (PQ) Policy N 8 Indicates date on which the insured’s coverage first became effective as a PQ policy under his or her individual policy or group certificate. Based on each state’s rules for exchanges, this could be a date prior to the date on which the exchange takes place. Format: MMDDYYYY
20 Policy Exchange to PQ N 1 Indicate whether the policy is PQ as a result of an exchange from a non-PQ policy, rather than as an original purchase. 1 = Yes
0 = No
21 Policy Benefit Type A 2 Indicates the major type of benefits covered under the policy. CP = Comprehensive
NH = Nursing Home Only
FC = Facility Care Only (includes NH and ALF)
HC = Home Health Care Only
OT = Other
22 Coverage Basis A 1 Indicates whether the policy is a group or an individual policy. For multi-life groups, the value selected should be based on how the policy was filed with the Department of Insurance. G = Group policy
I = Individual policy
23 Lifetime Maximum Structure A 1 Indicates whether the Lifetime Maximum is expressed as a single benefit pool across all covered services (Integrated Lifetime Maximum) or whether there are separate Lifetime Maximums for two or more covered benefits. S = Single lifetime maximum for all covered services (although there may be inner limits on some benefits provided over and above the lifetime maximum)
M = Multiple lifetime maximums by covered service (one or more)
24 Lifetime Maximum Structure Detail A 2 Indicates whether the policy counts Dollars or Days of benefits used as the Lifetime Maximum. DL = Dollars (pool(s) of dollars design)
DY = Days and not pool of dollars design
25 Lifetime Policy Maximum for Nursing Home Coverage (Dollars) N 9 Indicates the whole dollar amount of the Policy Lifetime Maximum for Nursing Home Benefits, or indicates an “unlimited” Policy Lifetime Maximum. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
26 Lifetime Policy Maximum for Home Health Care (Dollars) N 9 If policy has multiple pools and pays in dollars, this field indicates the current dollar amount of the Lifetime Policy Maximum for Home Health Care Benefits, or indicates an “unlimited” Lifetime Maximum. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
888888888 = Policy/certificate only has one pool
27 Lifetime Policy Maximum for ALF/Other Facility Care (Dollars) N 9 If policy has multiple pools and pays in dollars, this field indicates the current dollar amount of the Lifetime Policy Maximum for ALF/Other Facility Benefits, or indicates an “unlimited” Lifetime Maximum. Numeric value without commas, decimals or dollar signs.
000000000 = Lifetime/Unlimited
999999999 = Pool maximum expressed in days
888888888 = Policy/certificate only has one or two pools
28 Lifetime Policy Maximum for Nursing Home Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the current Lifetime Policy Maximum for number of days of Nursing Home Coverage. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum expressed in dollars
29 Lifetime Policy Maximum for Home Health Care Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the current lifetime maximum number of Home Health Care days. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum expressed in dollars
88888 = Policy/certificate only has one pool
30 Lifetime Policy Maximum for ALF/Other Facility Care Benefits (Days) N 5 If the policy has multiple pools, with day limits on individual pools, this field indicates the lifetime maximum number of ALF/Other Facility days covered. Numeric value without commas or decimals.
00000 = Unlimited
99999 = Pool maximum expressed in dollars
88888 = Policy/certificate only has one or two pools
31 Nursing Home Benefit Amount N 4 The current daily benefit amount for nursing home coverage. If the benefit is paid as weekly or monthly, the daily amount can be derived. If the policyholder has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Core Nursing Home Benefit
32 Home Health Care Benefit Amount N 4 The current daily benefit amount for home health care provision on the policy. If the benefit is paid as weekly or monthly, the daily amount should be derived. If the policyholder has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Core Home Health Care Benefit
33 Assisted Living Facility (ALF) Benefit Amount N 4 The current daily benefit amount for Assisted Living Facility/Other Facility Care. If the benefit is paid as weekly or monthly, the daily amount should be derived. If the policyholder has inflation protection, this field should reflect the current daily benefit amount, as inflated. Numeric value without commas, decimals or dollar signs.
0000 = Unlimited daily benefit amount
8888 = No Core ALF Benefit
34 Automatic Inflation Protection Type A 3 Indicates the type of inflation protection provided in the policy. ABI = Automatic annual compound inflation protection, funded on level issue-age basis
ASI = Automatic annual simple inflation protection, funded on level issue-age basis
GIP = Graded inflation protection; both benefits and premiums increase by specified amount each year
SIP = Step-rated design where nature of inflation protection changes over time or at certain attained ages
CPI = General consumer price index
LCI = Long Term Care specific consumer price index
OTI = Other price index value
CDI = Carrier determined index
OTH = Other (but not to include FPO/GPO/BIO, see below)
NIP = No inflation protection
35 Inflation Protection Increase Amount or Index Value N 5 This field provides the annual increase percentage of inflation protection provided in the policy (e.g., 2%, 3%, 5%). If the annual increase is tied to an index, as indicated in field #34, apply the current index value. If the annual increase is tied to an index, as indicated in field # 34, apply the current index value.
Percentage value with two decimal points (e.g. 02.50)
99.99 = No annual inflation amount
88.88 = If field 34 equals NIP
36 Inflation Protection Duration: Attained Age of Insured N 1 Indicates if automatic inflation protection stops at an attained age of the insured. 1=Yes, inflation protection stops at an attained age
0=No, inflation protection does not stop at an attained age
If field 34 = NIP or there is no limit on inflation protection, this field may be zero-filled
37 Attained Age at Which Inflation Protection Ends N 3 Attained age of insured when automatic inflation protection ends. Numeric value in years
If field 34 = NIP or there is no limit on inflation protection, this field may be zero-filled.
38 Inflation Protection Duration: Attained Age of Policy/Certificate N 1 Indicates if automatic inflation protections end at an attained age for the policy/certificate. 1=Yes, inflation protection stops at an attained age of the Policy/Certificate
0=No, inflation protection does not stop at an attained age of the Policy/Certificate
If field 34 = NIP or there is no limit on inflation protection, this field may be zero-filled.
39 Policy/Certificate Age at Which Inflation Protection Ends N 2 Attained age of policy/certificate when automatic inflation protection ends. Numeric value in years
If field 34 = NIP or there is no limit on inflation protection, this field may be zero-filled.
40 Inflation Protection Duration Type: Life of Policy/Certificate N 1 Indicates if automatic inflation projection continues for the entire duration of the policy/certificate. 1=Yes, inflation protection continues for entire duration of the policy/certificate
0=No, inflation protection does not continue for the entire duration of the policy/certificate
41 Inflation Protection Duration Type: When Benefit has Doubled N 1 Indicates if automatic inflation protection ends when the benefit has doubled. 1 = Yes
0 = No
If field 34 = NIP or there is no limit on inflation protection, this field may be zero-filled.
42 Inflation Protection Duration Type: Other Trigger Type N 1 Indicates if automatic inflation protection ends by some trigger other than the triggers described in fields 36, 38, or 41. 1 = Yes, inflation protection ends by some other trigger
0 = No, inflation protection does not end by a trigger
If field 34 = NIP or there is no limit on inflation protection, this field may be zero-filled.
43 Future Purchase Option A 2 Indicates if the insured has elected or automatically has a Future Purchase Option (FPO) as a provision of their policy or certificate and the type of FPO structure. YA = Annual FPO
YV = FPO, but not Annual
NO = No FPO
44 Frequency of Future Purchase Option N 3 Indicates the frequency (in years) with which the FPO offer is made to the insured. 1 = Annual FPO
Other numeric value for non-annual FPO offers
(e.g. 2 for every 2 years)
0 = No FPO
45 Termination of FPO Option AN 2 Indicates circumstances, if any, under which Future Purchase Option ends LT = Offers continue for the life of the policy
D1 = 1 decline triggers termination of offers
D2 = 2 declines trigger termination of offers
C2 = Offers end with 2 consecutive declines
AG = Offers end at specified age
CL = Insured goes into claim
OT = Other means of ending the offers
NO = No FPO
46 Policy Status at End of Reporting Period A 1 Indicate the status of the PQ policy at the end date of the current reporting period. Note that values E, V, R, D and O would only be reported if that status was obtained at some point during the current reporting period. I = Inforce
N = Active in non-forfeiture
E = Exhausted benefits
V = Voluntary Lapse
R = Recission
D = Death
T = Not Taken Out (NTO)
O = Other
47 Partnership Status A 2 Indicates if the policy remains Partnership Qualified at the end of the reporting period. NQ should only be reported once, since persons without PQ policies would be dropped from File 4 in subsequent reporting periods. PQ = Partnership Qualified
NQ = No longer qualified for Partnership
48 Qualifying Condition A 1 Indicates whether claimant became eligible for benefits based on ADL deficits, Cognitive Impairment, Both ADL and Cognitive Impairments, or some other benefit trigger. A = ADL Dependency
C = Cognitive Impairment
B = ADL and Cognitive Impairment
O = Other Benefit Eligibility Trigger(s)
49 Benefit Start Date of the Current Claim Period N 8 Indicates date on which benefit payments begin for the current claim period. This date should occur after any elimination period has been satisfied. Format: MMDDYYYY
50 Nursing Home Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits for nursing home services paid during the current reporting period. Numeric value (in dollars) rounded to the nearest dollar amount.
51 Home Health Care Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits paid during the reporting period for home health care and related home health care services. Numeric value (in dollars) rounded to the nearest dollar amount.
52 Assisted Living/Other Facility Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits paid during the reporting period for assisted living or other non-nursing home facility care. Numeric value (in dollars) rounded to the nearest dollar amount.
53 Total Cash Benefits Paid During Reporting Period N 9 Indicates the total amount of benefits paid during the reporting period for cash benefits. Numeric value (in dollars) rounded to the nearest dollar amount.
54 Other Benefit Amounts Paid During Reporting Period N 9 Indicate the total amount of benefits paid during the reporting period for all benefits paid other than nursing home, home and community care, assisted living/other facility care, or cash benefits. Numeric value (in dollars) rounded to the nearest dollar amount.
55 Total Lifetime Benefits Paid to Date N 9 Indicates the total amount of benefits paid under the certificate to date as of the end of the reporting period. Numeric value (in dollars) rounded to the nearest dollar amount.
56 Remaining Lifetime Benefits N 9 Indicates the total amount of benefits remaining under the lifetime maximum as of the end of the reporting period. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime benefit expressed in days
57 Remaining Lifetime Nursing Home Benefits (Dollars) N 9 Indicates the total amount of nursing home benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for nursing home benefits is expressed in dollars. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime benefit expressed in days
58 Remaining Lifetime Home Health Care Benefits (Dollars) N 9 Indicates the total amount of home health care benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for home health care benefits is expressed in dollars. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime maximum expressed in days
888888888 = No second pool
59 Remaining Lifetime ALF/Other Facility Benefits (Dollars) N 9 Indicates the total amount of ALF/Other Facility Benefits benefits remaining in the policy as of the end of the reporting period, if the lifetime maximum for home health care benefits is expressed in dollars. Numeric value (in dollars) rounded to the nearest dollar amount.
000000000 = Unlimited Lifetime Benefits
999999999 = Lifetime maximum expressed in days
888888888 = No third pool
60 Remaining Lifetime Nursing Home Benefits (Days) N 5 Indicates the total amount of nursing home benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for nursing home benefits is expressed in days. Numeric value (in days).
00000 = Unlimited Lifetime Benefits
99999 = Pool maximum expressed in dollars
61 Remaining Lifetime Home Health Care Benefits (Days) N 5 Indicates the total amount of home health care benefits remaining for the policy as of the end of the reporting period, if the lifetime maximum for home health care benefits is expressed in days. Numeric value (in days).
00000 = Unlimited Lifetime Benefits
99999 = Pool maximum expressed in dollars
88888 = No second pool
62 Remaining Lifetime ALF/Other Facility Care Benefits (Days) N 5 Indicates the total amount of ALF/Other Facility benefits remaining in the policy as of the end of the reporting period, if the lifetime maximum for ALF/Other Facility benefits is expressed in days. Numeric value (in days).
00000 = Unlimited Lifetime Benefits
99999 = Pool maximum expressed in dollars
88888 = No third pool
File Typeapplication/vnd.ms-excel
Authorlorr
Last Modified ByDHHS
File Modified2008-08-12
File Created2008-01-04

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