<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal { font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s052788eb-2f38-42d9-aff8-43c4dbc472d0000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001 { text-align: center; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000002 { color: #0000FF; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003 { text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000005 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">DEPARTMENT OF LABOR AND REGULATION</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">DIVISION OF INSURANCE</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">PARTNERSHIP DISCLOSURE FORM</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Chapter 20:</span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">06:21</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">APPENDIX K</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">SEE: § </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:78"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000002">20:06:21:78</span></a></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000001"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">    </span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">Source:</span><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont"> 33 SDR 230, effective </span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">July 2, 2007.</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000005"><br />&#x200e;</span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">Partnership Program Notice</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Important Consumer Information Regarding the South Dakota Long-Term Care Insurance Partnership Program</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Some long-term care insurance policies [certificates] sold in South Dakota may qualify for the South Dakota Long-Term Care Insurance Partnership Program (the Partnership Program). The Partnership Program is a partnership between state government and private insurance companies to assist individuals in planning their long-term care needs. Insurance companies voluntarily agree to participate in the Partnership Program by offering long-term care insurance coverage that meets certain State and Federal requirements. Long-term care insurance policies [certificates] that qualify as Partnership Policies [Certificates] may protect the policyholder's [certificateholder's] assets through a feature known as "Asset Disregard" under South Dakota's Medicaid program.</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">Asset Disregard</span><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont"> means that an amount of the policyholder's [certificateholder's] assets equal to the amount of long-term care insurance benefits received under a qualified Partnership Policy [Certificate] will be disregarded for the purpose of determining the insured's eligibility for Medicaid. This generally allows a person to keep assets equal to the insurance benefits received under a qualified Partnership Policy [Certificate] without affecting the person's eligibility for Medicaid. All other Medicaid eligibility criteria will apply and special rules may apply to persons whose home equity exceeds $500,000. Asset Disregard is </span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">not</span><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont"> available under a long-term care insurance policy [certificate] that is not a Partnership Policy [Certificate]. Therefore, you should consider if Asset Disregard is important to you, and whether a Partnership Policy meets your needs. </span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">The purchase of a Partnership Policy does not automatically qualify you for Medicaid</span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">.</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">What are the Requirements for a Partnership Policy [Certificate]?</span><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont"> In order for a policy [certificate] to qualify as a Partnership Policy [Certificate], it must, among other requirements:</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Be issued to or exchanged by an individual after </span><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">July 1, 2007;</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Cover an individual who is a State of South Dakota resident when coverage first becomes effective under the policy;</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Be a tax-qualified policy under § 7702(B)(b) of the Internal Revenue Code of 1986;</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Meet stringent consumer protection standards; and</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">Meet the following inflation requirements:</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">    For ages 60 or younger -- provides compound annual inflation protection;</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">    For ages 61 to 75 -- provides some level of inflation protection;</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">    For ages 76 and older -- no purchase of inflation protection is required.</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont">If you apply and are approved for long-term care insurance coverage, [carrier name] will provide you with written documentation as to whether or not your policy [certificate] qualifies as a Partnership Policy [Certificate]. If it is a Partnership Policy it will be clearly labeled as such on the schedule page of your policy [Certificate].</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">What Could Disqualify a Policy [Certificate] as a Partnership Policy?</span><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont"> Certain types of changes to a Partnership Policy [Certificate] could affect whether or not such policy [certificate] continues to be a Partnership Policy [Certificate]. If you purchase a Partnership Policy [Certificate] and later decide to make any changes, you should first consult with [carrier name] to determine the effect of a proposed change. In addition, if you move to a state that does not maintain a Partnership Program or does not recognize your policy [certificate] as a Partnership Policy [Certificate], you would not receive beneficial treatment of your policy [certificate] under the Medicaid program of that state. The information contained in this disclosure is based on current South Dakota and Federal laws. These laws may be subject to change. Any change in law could reduce or eliminate the beneficial treatment of your policy [certificate] under South Dakota's Medicaid program.</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont-000004">Additional Information.</span><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0DefaultParagraphFont"> If you have questions regarding long-term care insurance policies [certificates] please contact [carrier name]. If you have questions regarding current laws governing Medicaid eligibility, you should contact the South Dakota Department of Social Services.</span></p><p dir="ltr" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0Normal-000003"><span xml:space="preserve" class="s052788eb-2f38-42d9-aff8-43c4dbc472d0000000"> </span></p></div></body></html>