Ind. Admin. Code tit. 760, r. 2-20-36.3 – Minimum benefit standards and required policy and certificate provisions for qualified riders

Sec. 36.3. (a) No long term care insurance rider may be advertised, solicited, or issued for delivery in this state as a qualified rider which does not meet the minimum benefit standards and required provisions in this section, and which has not been approved by the commissioner of the department of insurance as a qualified rider.

(b) An issuer may only attach a qualified rider to a qualified long term care policy sold by the same issuer.

(c) A qualified rider, which provides home and community based services, must provide benefits, at a minimum, but not be limited to, the following:

(1) Home health nursing.
(2) Home health aide services.
(3) Attendant care.
(4) Respite care.
(5) Adult day care services.

(d) All home and community based services covered through the qualified rider shall include case management services delivered by a case management agency. The issuer may establish a limit on case management benefits. This limit shall not be less than thirteen (13) times the daily nursing home benefit per year. Case management benefits shall not count toward the policy or certificate's maximum benefit.

(e) At a minimum, upon the initial effective date of the qualified rider, which provides home and community based services, the qualified rider must provide the following:

(1) A daily home and community based benefit of at least fifty percent (50%) of the then current daily nursing facility benefit of the long term care facility policy or certificate. No policy or certificate shall pay benefits in excess of the actual charges.
(2) The daily home and community based benefit shall not exceed the then current daily nursing facility benefit of the long term care facility policy or certificate.
(3) If issued on an expense incurred basis, provide benefits which are equal to at least seventy-five percent (75%) of the per diem cost incurred by the insured.

(f) At a minimum, upon the initial effective date of the qualified rider, which provides home and community based services, the qualified rider must provide a maximum benefit amount for the home and community care that:

(1) is at least fifty percent (50%) of the then current maximum total benefit amount of the long term care facility policy or certificate; and
(2) does not exceed the then current maximum benefit amount of the long term care facility policy or certificate.

(Department of Insurance; 760 IAC 2-20-36.3; filed Jun 15, 1994, 10:00 a.m.: 17 IR 2652; filed Jul 28, 1997, 1:50 p.m.: 20 IR 3373; filed Feb 9, 1999, 5:02 p.m.: 22 IR 1996; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; readopted filed Nov 27, 2007, 4:01 p.m.: 20071226-IR-760070717RFA; readopted filed Nov 26, 2013, 3:43 p.m.: 20131225-IR-760130479RFA; readopted filed Nov 19, 2019, 9:18 a.m.: 20191218-IR-760190497RFA; readopted filed Nov 30, 2022, 11:39 a.m.: 20221228-IR-760220302RFA)