Wash. Admin. Code § 284-83-140 - Qualified long-term care insurance policies - Additional standards for benefit triggers
(1) For purposes
of this section the following definitions apply:
(a) "Qualified long-term care services" means
services that meet the requirements of Section 7702B(c)(1) of the Internal
Revenue Code of 1986, as amended, including: 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 pursuant to a plan of care prescribed by a
licensed health care practitioner.
(b)
(i)
"Chronically ill individual" has the meaning of Section 7702B(c)(2) of the
Internal Revenue Code of 1986, as amended. Under this provision, a chronically
ill individual means any individual who has been certified by a licensed health
care practitioner as:
(A) Being unable to
perform (without substantial assistance from another individual) at least two
activities of daily living for a period of at least ninety days due to a loss
of functional capacity; or
(B)
Requiring substantial supervision to protect the individual from threats to
health and safety due to severe cognitive impairment.
(ii) The term "chronically ill individual"
does not include an individual otherwise meeting these requirements unless
within the preceding twelve-month period a licensed health care practitioner
certified that the individual meets these requirements.
(c) "Licensed health care practitioner" means
a physician, as defined in Section 1861(r)(1) of the Social Security Act, a
registered professional nurse, licensed social worker or other individual who
meets requirements prescribed by the federal Secretary of the
Treasury.
(d) "Maintenance or
personal care services" means 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).
(2) A
qualified long-term care insurance policy must pay only for qualified long-term
care services received by a chronically ill individual provided pursuant to a
plan of care prescribed by a licensed health care practitioner.
(3) A qualified long-term care insurance
policy must condition the payment of benefits on a determination that the
insured is a chronically ill individual as defined in subsection (1)(b)(i) of
this section.
(4) Certifications
regarding activities of daily living and cognitive impairment required pursuant
to subsection (3) of this section must be performed by a licensed or certified
physician, registered professional nurse, licensed social worker, or other
individual who meet requirements prescribed by the federal Secretary of the
Treasury.
(5) Certifications
required pursuant to subsection (3) of this section may be performed by a
licensed health care professional at the direction of the issuer as is
reasonably necessary with respect to a specific claim; except that when a
licensed health care practitioner has certified that the insured is unable to
perform activities of daily living for an expected period of at least ninety
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 ninety-day period.
(6) Qualified long-term care insurance
policies must include a clear description of the process for appealing and
resolving disputes with respect to benefit determinations.
Notes
Statutory Authority: RCW 48.02.060 and 48.85.030. 11-22-068 (Matter No. R 2011-08), § 284-83-140, filed 10/31/11, effective 12/1/11. Statutory Authority: RCW 48.02.060, 48.83.070, 48.83.110, 48.83.120, 48.83.130(1), and 48.83.140(4)(a). 08-24-019 (Matter No. R 2008-09), § 284-83-140, filed 11/24/08, effective 12/25/08.
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