Sec. 31.14.01.26. Standards for Benefit Triggers

A. Conditions for Payment of Benefits.

(1) A long-term care insurance policy shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment.

(2) An insurer may not establish the eligibility criteria for the payment of benefits on a more restrictive basis than:

(a) A deficiency in the ability to perform not more than three of the activities of daily living; or

(b) The presence of cognitive impairment.

B. Activities of Daily Living.

(1) Activities of daily living shall include at least the following as defined in Regulation .02 of this chapter and in the policy:

(a) Bathing;

(b) Continence;

(c) Dressing;

(d) Eating;

(e) Toileting; and

(f) Transferring.

(2) Insurers may use activities of daily living in addition to those contained in §B(1) of this regulation to trigger covered benefits as long as they are defined in the policy.

C. Additional Provisions for Benefit Determination.

(1) An insurer may use provisions in addition to those described in §§A and B of this regulation for the determination of when benefits are payable under a policy or certificate.

(2) The provisions permitted by §C(1) of this regulation may not restrict, and are not in place of, the requirements contained in §§A and B of this regulation.

D. For purposes of this regulation, the determination of a deficiency may not be more restrictive than:

(1) Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

(2) If the deficiency is due to the presence of a cognitive impairment, supervision or verbal cuing by another person is needed in order to protect the insured or others.

E. Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses, or social workers.

F. Long-term care insurance policies shall include a clear description of the process for appealing and resolving benefit determinations.

G. The requirements set forth in this regulation are effective April 1, 2003, and apply as follows:

(1) Except as provided in §G(2) of this regulation, the provisions of this regulation apply to a long-term care policy issued in Maryland on or after April 1, 2003; and

(2) The provisions of this regulation do not apply to certificates issued on or after April 1, 2003, if the certificates are issued under an employer group long-term care insurance policy that was in force before April 1, 2003.