31 Pa. Code § 89a.124 - 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. Eligibility for the payment of benefits may 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) Insurers may use activities of daily living to trigger covered benefits in addition to those contained in paragraphs (1)-(6) as long as they are defined in the policy. Activities of daily living shall include at least the following as defined in § 89a.104 (relating to policy definitions) and in the policy:

(1) Bathing.

(2) Continence.

(3) Dressing.

(4) Eating.

(5) Toileting.

(6) Transferring.

(c) An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate. The provisions may not restrict, and are not in lieu of, the requirements in subsections (a) and (b).

(d) For purposes of this section, the determination of a deficiency may not be more restrictive than either of the following:

(1) Requiring the supervisory or 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 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 in this section become effective March 17, 2003, and apply as follows:

(1) Except as provided in paragraph (2), this section applies to a long-term care policy issued in this Commonwealth on or after March 16, 2002.

(2) For certificates issued on or after March 16, 2002, under a group long-term care insurance policy as defined in section 1103 of the act (40 P. S. § 991.1103) that was in force on March 16, 2002, this section does not apply.

Notes

31 Pa. Code § 89a.124