Sec. 31.14.01.27. Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts

A. In this regulation, the following terms have the meanings indicated.

B. Terms Defined.

(1) Chronically Ill Individual.

(a) "Chronically ill individual" means any individual who has been certified by a licensed health care practitioner as:

(i) Being unable to perform, without substantial assistance from another individual, at least two activities of daily living for a period of at least 90 days due to a loss of functional capacity; or

(ii) Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment.

(b) "Chronically ill individual" does not include an individual otherwise meeting the requirements in §B(1)(a) of this regulation unless within the preceding 12-month period a licensed health care practitioner has certified that the individual meets the requirements of §B(1)(a) of this regulation.

(2) "Licensed health care practitioner" means a physician, as defined in §1861(r)(1) of the Social Security Act, a registered professional nurse, a licensed social worker, or other individual who meets requirements prescribed by the United States Secretary of the Treasury.

(3) Maintenance or Personal Care Services.

(a) "Maintenance or personal care services" means any care the primary purpose of which is the provision of needed assistance with any of the disabilities as a result of which the individual is a chronically ill individual.

(b) "Maintenance or personal care services" includes care that provides protection from threats to health and safety due to severe cognitive impairment.

(4) Qualified Long-Term Care Services.

(a) "Qualified long-term care services" means services that meet the requirements of §7702(c)(1) of the Internal Revenue Code of 1986, as amended.

(b) "Qualified long-term care services" includes the following necessary services that are required by a chronically ill individual, and are provided under a plan of care prescribed by a licensed health care practitioner:

(i) Diagnostic services;

(ii) Preventive services;

(iii) Therapeutic services,

(iv) Curative services;

(v) Treatment services;

(vi) Mitigation services;

(vii) Rehabilitative services; and

(viii) Maintenance or personal care services.

C. A qualified long-term care insurance contract shall pay only for qualified long-term care services received by a chronically ill individual provided under a plan of care prescribed by a licensed health care practitioner.

D. A qualified long-term care insurance contract shall condition the payment of benefits on a determination of the insured's inability to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity or to severe cognitive impairment.

E. Certifications regarding activities of daily living and cognitive impairment required under §D of this regulation shall be performed by the following licensed or certified professionals:

(1) Physicians;

(2) Registered professional nurses;

(3) Licensed social workers; or

(4) Other individuals who meet requirements prescribed by the United States Secretary of the Treasury.

F. Permissible Frequency of Certifications.

(1) Certifications required under §D of this regulation may be performed by a licensed health care professional at the direction of the carrier as is reasonably necessary with respect to a specific claim, except as described in §F(2) of this regulation.

(2) If a licensed health care practitioner has certified that the insured is unable to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity and if the insured is in claim status, an insurer may not rescind a certification or require that additional certifications be performed until the 90-day period under §F(1) of this regulation expires.

G. Qualified long-term care insurance contracts shall include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.