23 CAR § 84-129. Additional standards for benefit triggers for qualified long-term care insurance contracts

(a) For purposes of this section the following definitions apply: (1)(A) “Chronically ill individual” has the meaning prescribed for this term by I.R.C. § 7702B(c)(2), as amended. (B) Under this provision, a chronically ill individual means any individual who has been certified by a licensed healthcare practitioner as: (i) Being unable to perform (without substantial assistance from another individual) at least two (2) activities of daily living for a period of at least ninety (90) days due to a loss of functional capacity; or (ii) Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment. (C) The term “chronically ill individual” shall not include an individual otherwise meeting these requirements unless within the preceding twelve-month period a licensed healthcare practitioner has certified that the individual meets these requirements; (2) “Licensed healthcare practitioner” means: (A) A physician, as defined in Section 1861(r)(1) of the Social Security Act, codified at 42 U.S.C. § 1395x(r)(1); (B) A registered professional nurse; (C) A licensed social worker; or (D) Other individual who meets requirements prescribed by the United States Secretary of the Treasury; (3) “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); and (4) “Qualified long-term care services” means services that meet the requirements of I.R.C. § 7702B(c)(1), as amended, as follows: necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation, and rehabilitative services and maintenance or personal care services that are: (A) Required by a chronically ill individual; and (B) Provided pursuant to a plan of care prescribed by a licensed healthcare 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 pursuant to a plan of care prescribed by a licensed healthcare 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 ninety (90) days due to: (1) A loss of functional capacity; or (2) Severe cognitive impairment. (d) Certifications regarding activities of daily living and cognitive impairment required pursuant to subsection (c) of this section shall be performed by the following licensed or certified professionals: (1) Physicians; (2) Registered professional nurses; (3) Licensed social workers; or (4) Other individuals who meet requirements prescribed by the United States Secretary of the Treasury. (e) Certifications required pursuant to subsection (c) of this section may be performed by a licensed healthcare professional at the direction of the carrier as is reasonably necessary with respect to a specific claim, except that when a licensed healthcare practitioner has certified that an insured is unable to perform activities of daily living for an expected period of at least ninety (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 ninety-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.