Ind. Admin. Code tit. 760, r. 2-20-38 – Maintaining auditing information

Sec. 38. (a) Each issuer shall maintain information as stipulated in subsection (f) on all policyholders or certificateholders who have ever received any benefit under the policy or certificate. Such information shall be updated at least quarterly. This requirement for updating shall not require the conduct of any assessment, reassessment, or other evaluation of the policyholder's or certificateholder's condition which is not otherwise required by federal or state statute or regulation.

(b) When a policyholder or certificateholder who has received any benefits dies or when a policyholder or certificateholder who has received any benefits lapses his or her policy or certificate for any reason, the issuer must retain the stipulated information for a period of at least five (5) years after the time the policy or certificate ceases to be in force or after the documented death of the policyholder or certificateholder. Unless notified by the department of insurance to the contrary during this period, after the five (5) years, the service summary provided by the issuer will be deemed to comply with all asset protection reporting, record keeping, and auditing requirements of this rule. The issuer may use microfiche, microfilm, optical storage media, or any other cost effective method of record storage as alternatives to storage of paper copies of stipulated information.

(c) At the time the policy or certificate ceases to be in force, the issuer shall notify the policyholder or certificateholder of his or her right to request his or her service records as stipulated in subsection (f).

(d) The issuer shall also, upon request in writing, provide such policyholder or certificateholder or the policyholder's or certificateholder's authorized designee, if any, with a copy of the issuer's service records as required in subsection (f) which are necessary to establish the asset disregard. These records shall be provided to the policyholder or certificateholder or the policyholder's or certificateholder's authorized designee, if requested, within sixty (60) days of the request. The issuer may charge a reasonable fee to cover the costs of providing each set of requested service record copies.

(e) The issuer shall enclose with the records a statement advising the former policyholder or certificateholder that it is in his or her interest to retain the records if he or she may ever wish to establish eligibility for Medicaid.

(f) The information to be maintained includes the following:

(1) Evidence that the insured event has taken place. The occurrence of the insured event may be documented in any of the following ways:
1. (A) By case management agency staff, as part of the initial assessment of the client or as part of a subsequent reassessment.
2. (B) By an assessment conducted as part of the preadmission screening program of DDARS.
3. (C) By an assessment of a resident of a nursing facility as required by Section 1919(b)(3) of the Social Security Act.
4. (D) For persons for whom clauses (A) through (C) are not available or do not provide the required information, by an assessment, carried out by or under the supervision of a physician or a registered nurse, which is substantially comparable to any of the methods in clauses (A) through (C). These assessments must be based on direct observations and interviews in conjunction with a medical record review. The physician or registered nurse carrying out or supervising the assessment must sign and certify the completion of the assessment. Each individual who completes a portion of such assessment shall sign and certify as to the accuracy of that portion of the assessment.
(2) Description of services provided under the policy or certificate, including the following:
1. (A) Name, address, phone number, and license number, if applicable, of provider.
2. (B) Amount, date, and type of services provided, and whether the services qualify for asset protection.
3. (C) Dollar amounts paid by the issuer, whether on an indemnity, expense incurred, or other basis.
4. (D) The charges of the service providers, including copies of invoices for all services counting towards asset protection.
5. (E) Identification of the case management agency, if applicable, and copies of all assessments and reassessments.
(3) In order for home and community based services to qualify for asset protection, these services must be in accord with a plan of care developed by a case management agency. If the policyholder or certificateholder has received any benefits delivered as part of a plan of care, the issuer must retain the following:
1. (A) A copy of the original plan of care.
2. (B) A copy of the plan of care required by DDARS.
3. (C) A copy of any changes made in the plan of care. The plan of care must document that the changes are required by changes in the client's medical situation, cognitive abilities, behavioral abilities, or the availability of social supports. Such services shall count towards asset protection after the case management agency adds the documented need for and description of the new services to the plan of care. In cases when the service must begin before the revisions to the plan of care are made, the new services will only count towards asset protection if the revisions to the plan of care are made within ten (10) business days of the commencement of the new services. Issuers must maintain initial assessments and subsequent reassessments as part of insured event documentation.

(Department of Insurance; 760 IAC 2-20-38; filed Nov 20, 1992, 9:00 a.m.: 16 IR 1155; filed Jun 15, 1994, 10:00 a.m.: 17 IR 2653; filed Feb 9, 1999, 5:02 p.m.: 22 IR 1997; 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)