02-031 C.M.R. ch. 425, § 27 - Standards for Benefit Triggers

Current through 2022-14, April 6, 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 three of at least five of the activities of daily living or the presence of cognitive impairment.

B. Insurers may use activities of daily living, other than those listed in Section 5, to trigger covered benefits as long as they are defined in the policy.

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 Sections 27(A) and (B).

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 be effective April 1, 2005, and shall apply as follows:

(1) Except as provided in Section 27(G)(2), the 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 rule.

(2) For certificates issued on or after the effective date of this section, under employee groups as defined in 24-A M.R.S.A. §2804, labor union groups as defined in 24-A M.R.S.A. §2805, or trustee groups as defined in 24-A M.R.S.A. §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.

Notes

02-031 C.M.R. ch. 425, § 27