Ind. Admin. Code tit. 760, r. 2-16.1-2 – Standards for benefit triggers

Sec. 2. (a) 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.

(b) Insurers may use additional activities of daily living to trigger covered benefits as long as they are defined in the policy.

(c) 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 are not in lieu of, the requirements contained in subsections (a) and (b).

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

(1) The hands-on assistance of another person to perform the prescribed activities of daily living.
(2) If the deficiency is due to the presence of a cognitive impairment, supervision, or verbal cuing by another person 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) This section shall be effective July 1, 2005, and shall apply as follows:

(1) Except as provided in subdivision (2), this section applies to a long term care policy issued in this state on or after the effective date of this section.
(2) For certificates issued on or after the effective date of this section, under a group long term care insurance policy that was in force at the time this section became effective, this rule shall not apply.

(Department of Insurance; 760 IAC 2-16.1-2; filed Oct 7, 2004, 1:00 p.m.: 28 IR 578; readopted filed Nov 24, 2010, 9:17 a.m.: 20101222-IR-760100633RFA; readopted filed Nov 23, 2016, 9:47 a.m.: 20161221-IR-760160436RFA; readopted filed Nov 30, 2022, 11:39 a.m.: 20221228-IR-760220302RFA)