Utah Admin. Code R590-148-9 - Benefit Trigger Standards for Qualified Long-Term Care Insurance Contracts
(1) 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.
(2) A qualified long-term care insurance
contract shall condition the payment of benefits on a determination of the
insured's inability to perform the activities of daily living for an expected
period of at least 90 days due to a loss of functional capacity or severe
cognitive impairment.
(3) A
certification regarding the activities of daily living or cognitive impairment
required under Subsection
R590-148-9(2)
shall be performed by a licensed or certified:
(a) physician;
(b) registered professional nurse;
(c) social worker; or
(d) another individual who meets the
requirements prescribed by the Secretary of the Treasury.
(4)
(a)
Except as provided in Subsection (4)(b), a certification required under
Subsection (2) may be performed by a licensed health care professional at the
direction of the insurer as reasonably necessary for a specific
claim.
(b) When a licensed health
care practitioner certifies that an insured is unable to perform the 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not be rescinded and an additional certification may not be performed until
after the expiration of the 90-day period.
(5) A qualified long-term care insurance
contract shall include a clear description of the process for appealing and
resolving a dispute with respect to a benefit determination.
Notes
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