For purposes of the financial eligibility exemption under
130
CMR 520.007(G)(8)(d),
concerning treatment of the former home as an asset, and the exemption under
130
CMR 515.011(B) and
515.012(C),
concerning repayment of assistance provided for nursing facility and other
long-term-care services (hereafter collectively referred to as "MassHealth
exemptions"), a long-term-care insurance policy must provide certain minimum
coverage requirements as determined by the Division of Insurance.
(A) Under Division of Insurance regulations
at 211 CMR
65.09(1)(e)(2), to qualify
for the MassHealth exemptions, an individual must be a covered person under an
individual, group, or employment-based group policy issued on or after March
15, 1999, that meets the individual policy minimum standards of
211
CMR
65.05:
Minimum Standards for
Individual Policies and all of the following requirements.
(1)
Scope of
Benefits. The policy must cover nursing and custodial care in a
nursing facility licensed by the Department of Public Health.
(2)
Daily Dollar
Benefits. The policy must have available benefits of at least $125
per coverage day in a nursing facility, except where the actual expense
incurred is less, regardless of whether accrued benefits are measured in terms
of days or dollar amount.
(3)
Nursing Facility Coverage Days: Lifetime Benefit
Period. The policy must have benefits available sufficient to
cover at least 730 days in a nursing facility.
(4)
Elimination
Period. No policy may have an elimination period (days on which
services are provided to an insured before the policy begins to pay benefits)
longer than 365 days in a nursing facility. The application of more than one
elimination period is not allowed, unless the insured has received no benefits
for a period of at least 180 consecutive days. In lieu of an
elimination period, the policy may have a deductible of no more than
$54,750.
(B) All policies
issued prior to March 15, 1999, need only comply with the minimum standards of
211
CMR
65.05:
Minimum Standards for
Individual Policies, and the limitations and exclusion provision of
211
CMR
65.06:
Mandatory Benefit Offers
for Individual Policies, which were effective from April 1, 1989,
through September 2, 1999.
(C)
Exception. No recovery for nursing facility or other
long-term-care services may be made under
130
CMR
515.012(B) if the
member
(1) was institutionalized;
(2) notified the MassHealth agency that he or
she had no intention of returning home; and
(3) on the date of admission to a
long-term-care institution, had long-term-care insurance that, when purchased,
or at any time thereafter, met the requirements of
130
CMR
515.014 and the Division of Insurance
regulations at
211
CMR
65.09(1)(e)2.
