Utah Admin. Code R590-148-8 - Standards for Benefit Triggers
(1) 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 3 of the activities of daily living or the presence of
cognitive impairment.
(2) Insurers
may use activities of daily living to trigger covered benefits in addition to
those contained in Subsection
R590-148-5(2)(a)
as long as they are defined in the policy.
(3) 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 Subsections R590-148-8(1) and (2).
(4) For purposes of this section the
determination of a deficiency shall not be more restrictive than:
(a) requiring the hands-on assistance of
another person to perform the prescribed activities of daily living;
or
(b) if the deficiency is due to
the presence of a cognitive impairment, supervision or verbal cuing by another
person is needed in order to protect the insured or others.
(5) Assessments of activities of
daily living and cognitive impairment shall be performed by licensed or
certified professionals, such as physicians, nurses or social
workers.
(6) Long-term care
insurance policies shall include a clear description of the process for
appealing and resolving benefit determinations.
(7) The requirements set forth in this
section shall be effective January 1, 2003 and shall apply as follows:
(a) Except as provided in Subsection
R590-148-8(7)(b), the provisions of this section apply to a long- term care
policy issued in this state on or after July 1, 2002.
(b) For certificates issued on or after July
1, 2002, under a group long-term care insurance policy that was in force at the
time this rule became effective, the provisions of this section shall not
apply.
Notes
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