2640 STANDARDS FOR BENEFIT TRIGGERS

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2640.1 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. Eligibility for the payment of benefits shall not be more restrictive than requiring either a deficiency in the ability to perform not more than three (3) of the activities of daily living or the presence of cognitive impairment.

2640.2 Activities of daily living shall include at least the following:

(a) Bathing;

(b) Continence;

(c) Dressing;

(d) Eating;

(e) Toileting; and

(f) Transferring.

2640.3 Each activity of daily living shall be defined in the policy. The definition in the policy of an activity of daily living listed in subsection 2640.2 shall be the same as the definition of the activity set forth in section 2699.

2640.4 Insurers may use activities of daily living in addition to those contained in subsection 2640.2 to trigger covered benefits, if the activities are defined in the policy.

2640.5 An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however, the provisions shall not restrict, and shall not be in lieu of, the requirements in subsections 2640.1 and 2640.2.

2640.6 For the purposes of this section, the determination of a deficiency shall not be more restrictive than the following:

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

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

2640.7 Assessments of activities of daily living and cognitive impairment shall be

performed by licensed or certified professionals, such as physicians, nurses, or social workers.

2640.8 A long-term care insurance policy shall include a clear description of the process for appealing and resolving benefit determinations.

2640.9 The requirements set forth in this section shall be effective on December 16, 2006, and shall apply as follows:

(a) Except as provided in paragraph (b) of this subsection, the provisions of this section shall apply to a long-term care insurance policy issued in the District of Columbia on or after December 16, 2005; and

(b) For certificates issued on or after December 16, 2005, under a group long-term care insurance policy as defined in section 2(4)(A) of the Long-Term Care Insurance Act of 2000, effective May 23, 2000 (D.C. Law 13-121; D.C. Official Code § 31-3601(4)(A) (2001)), that were in force on December 16, 2005, the provisions of this section shall not apply.

SOURCE: Final Rulemaking published at 55 DCR 3759 (April 11, 2008).