Ill. Admin. Code tit. 50, § 2012.128 - Standards for Benefit Triggers
Current through Register Vol. 46, No. 15, April 8, 2022
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 3 of the activities of daily living or the presence of
cognitive impairment.
b) Insurers
may use activities of daily living to trigger covered benefits as long as they
are defined in the policy. Activities of daily living shall include but not be
limited to the following, as defined in Section
2012.40 of
this Part and in the policy:
1)
Bathing;
2) Continence;
3) Dressing;
4) Eating;
5) Toileting; and
6) Transferring.
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) of this
Section.
d) 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, supervision or verbal cueing by another
person is needed 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) The requirements set forth in this Section
shall apply as follows:
1) Except as provided
in subsection (g)(2) of this Section, the provisions of this Section apply to a
long-term care policy issued in this State.
2) For certificates issued under a group
long-term care insurance policy as defined in Section 351A-1(e)(1) of the Code,
the provisions of this Section shall not apply.
Notes
Amended at 32 Ill. Reg. 7600, effective May 5, 2008
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