| 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 |
| 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 |
| 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 |
| 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 Type | application/vnd.ms-excel |
| Author | lorr |
| Last Modified By | DHHS |
| File Modified | 2008-08-12 |
| File Created | 2008-01-04 |