(a) For
purposes of this section, the following definitions apply:
Chronically ill individual-Has the meaning
prescribed for this term by 7702B(c)(2) of the
Internal Revenue Code of 1986 (26 U.S.C.A. §
7702B(c)(2)).
(i) Under this provision, a chronically ill
individual means an individual who has been certified by a licensed health care
practitioner as either of the following:
(A)
Being unable to perform (without substantial assistance from another
individual) at least two activities of daily living for at least 90 days due to
a loss of functional capacity.
(B)
Requiring substantial supervision to protect the individual from threats to
health and safety due to severe cognitive impairment.
(ii) The term does not include an individual
otherwise meeting these requirements unless within the preceding 12-month
period a licensed health care practitioner has certified that the individual
meets these requirements.
Licensed health care practitioner-A
physician, as defined in section 1861(r)(1) of the Social Security Act
(42 U.S.C.A. §
1395x(r)(1)), a registered
professional nurse, licensed social worker or other individual who meets
requirements prescribed by the Secretary of the United States Treasury.
Maintenance or personal care services-Any
care the primary purpose of which is the provision of needed assistance with
any of the disabilities as a result of which the individual is a chronically
ill individual (including the protection from threats to health and safety due
to severe cognitive impairment).
Qualified long-term care services-Services
that meet the requirements of
7702(C)(1) of the Internal
Revenue Code of 1986 (26
U.S.C.A. §
7702(C)(1))
as follows: necessary diagnostic, preventive, therapeutic, curative, treatment,
mitigation and rehabilitative services, and maintenance or personal care
services which are required by a chronically ill individual, and are provided
under a plan of care prescribed by a licensed health care
practitioner.
(b) A
qualified long-term care insurance contract shall pay only for qualified
long-term care services received by a chronically ill individual provided under
a plan of care prescribed by a licensed health care practitioner.
(c) A qualified long-term care insurance
contract shall condition the payment of benefits on a determination of the
insured's inability to perform activities of daily living for an expected
period of at least 90 days due to a loss of functional capacity or to severe
cognitive impairment.
(d)
Certifications regarding activities of daily living and cognitive impairment
required under subsection (c) shall be performed by the following licensed or
certified professionals: physicians, registered professional nurses, licensed
social workers, or other individuals who meet requirements prescribed by the
Secretary of the United States Treasury.
(e) Certifications required under subsection
(c) may be performed by a licensed health care professional at the direction of
the carrier as is reasonably necessary with respect to a specific claim, except
that when a licensed health care practitioner has certified that an insured is
unable to perform activities of daily living for an expected period of at least
90 days due to a loss of functional capacity and the insured is in claim
status, the certification may not be rescinded and additional certifications
may not be performed until after the expiration of the 90-day period.
(f) Qualified long-term care insurance
contracts shall include a clear description of the process for appealing and
resolving disputes with respect to benefit determinations.
