2641 ADDITIONAL STANDARDS FOR BENEFIT TRIGGERS

FOR QUALIFIED LONG-TERM CARE INSURANCE

CONTRACTS

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2641

2641.1 A qualified long-term care insurance contract shall pay only for qualified long-term care services received by a chronically ill individual provided pursuant to a plan of care prescribed by a licensed health care practitioner.

2641.2 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 ninety (90) days due to a loss of functional capacity or to severe cognitive impairment.

2641.3 Certifications regarding activities of daily living and cognitive impairment required pursuant to subsection 2641.2 shall be performed by the following licensed or certified practitioners: physicians, registered professional nurses, licensed social workers, or other individuals who meet requirements prescribed by the Secretary of the United States Department of the Treasury.

2641.4 Certifications required pursuant to subsection 2641.2 may be performed by a licensed health care practitioner at the direction of the carrier as is reasonably necessary with respect to a specific claim, except that when a licensed health care practitioner has certified that an insured is unable to perform activities of daily living for an expected period of at least ninety (90) days due to a loss of functional capacity and the insured is in claim status, the certification shall not be rescinded and additional certifications shall not be performed until after the expiration of the ninety (90) day period.

2641.5 Qualified long-term care insurance contracts shall include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.

2641.6 For the purposes of this section the following definitions shall apply:

(a) "Qualified long-term care services" has the meaning prescribed in section 7702B(c)(1) of the Internal Revenue Code of 1986, approved August 21, 1996 (110 Stat. 2055; 26 U.S.C. § 7702B(c)(1)). Under that provision, the term "qualified long-term care services" means necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation and rehabilitative services, and maintenance or personal care services that are required by a chronically ill individual and are provided pursuant to a plan of care prescribed by a licensed health care practitioner.

(b) (1) "Chronically ill individual" has the meaning prescribed in section 7702B(c)(2)

of the Internal Revenue Code of 1986, approved August 21, 1996 (110 Stat. 2055; 26 U.S.C. § 7702B(c)(2)). Under this provision, a chronically ill individual means an individual who has been certified by a licensed health care practitioner as:

(A) Being unable to perform (without substantial assistance from another individual) at least two (2) activities of daily living for a period of at least ninety (90) days due to a loss of functional capacity; or

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

(2) The term “chronically ill individual” shall not include an individual otherwise meeting the requirements of subparagraph (1) of this paragraph unless within the preceding twelve (12) month period a licensed health care practitioner has certified that the individual meets those requirements.

(c) “Licensed health care practitioner” means a physician, as defined in section 1861(r)(1) of the Social Security Act, approved July 30, 1965 (79 Stat. 321; 42 U.S.C. § 1395x(r)), a registered professional nurse, licensed social worker, or other individual who meets requirements prescribed by the Secretary of the United States Department of the Treasury under section 7702B(c)(4) of the Internal Revenue Code of 1986, approved August 21, 1996 (110 Stat. 2056; 26 U.S.C. § 7702B(c)(4)).

(d) “Maintenance or personal care services” means care the primary purpose of which is the provision of needed assistance with a disability as a result of which the individual is a chronically ill individual (including the protection from threats to health and safety due to severe cognitive impairment).

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