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 of at least five of the activities of daily living or the
presence of cognitive impairment.
Insurers may use activities of daily
living, other than those listed in Section
, to trigger covered benefits as long
as they are defined in the policy.
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 Sections
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;
(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
F. Long-term care
insurance policies shall include a clear description of the process for
appealing and resolving benefit determinations.
The requirements set forth in this section
shall be effective April 1, 2005, and shall apply as follows:
Except as provided in Section
provisions of this section apply to a policy, certificate or rider delivered or
issued for delivery in this state on or after the effective date of this
(2) For certificates issued
on or after the effective date of this section, under employee groups as
§2804, labor union groups as defined in
§2805, or trustee groups as defined in
§2806, in force at the time this rule
became effective, the provisions of this section shall not apply if the group
policy was in force at the time this rule became effective.