Ariz. Admin. Code § R20-6-1020 - Standards for Benefit Triggers
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. Except as
otherwise provided in
R20-6-1021, 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 of
the activities of daily living or the presence of cognitive
impairment.
B. Activities of daily
living shall include at least the following as defined in
R20-6-1003(A)(1)
and in the policy:
1. Bathing,
2. Continence,
3. Dressing,
4. Eating,
5. Toileting, and
6. Transferring.
C. An insurer may use additional activities
of daily living to trigger covered benefits if the activities are defined in
the policy.
D. An insurer may use
additional provisions to determine when benefits are payable under a policy or
certificate; however the provisions shall not restrict, and are not in lieu of,
the requirements in subsections (A), (B) and (C).
E. For purposes of this Section the
determination of a deficiency shall not be more restrictive than:
1. Requiring the hands-on assistance of
another person to perform the prescribed activities of daily living;
or
2. If the deficiency is due to
the presence of a cognitive impairment, requiring supervision or verbal cueing
by another person to protect the insured or others.
F. Licensed or certified professionals, such
as physicians, nurses or social workers, shall perform assessments of
activities of daily living and cognitive impairment.
G. The requirements in this Section are
effective on and after November 10, 2005 and shall apply as follows:
1. Except as provided in subsection (G)(2),
the provisions of this Section apply to a long-term care policy issued in this
state on or after January 10, 2005.
2. The provisions of this Section do not
apply to certificates issued on or after January 10, 2005, under a long-term
care insurance policy issued to a group as defined in A.R.S. §
20-1691(5)(a),
which policy was in force on January 10, 2005.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.