Standards For Benefit Triggers

01. Conditions of Benefits Payment. A long-term care insurance policy conditions 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 is not more restrictive than requiring either a deficiency in the ability to perform not more than three (3) of the activities of daily living or the presence of cognitive impairment. (3-31-22) 02. Activities of Daily Living. Insurers may use activities of daily living to trigger covered benefits in addition to those contained in Subsection 033.02 as long as they are defined in the policy. Activities of daily living includes at least the following as defined in Section 010 and in the policy. (3-31-22) a. Bathing; (3-31-22) b. Continence; (3-31-22) c. Dressing; (3-31-22) d. Eating; (3-31-22) IDAHO ADMINISTRATIVE CODE IDAPA 18.04.11 – Long-Term Care Department of Insurance Insurance Minimum Standards Section 034 Page 34 e. Toileting; and (3-31-22) f. Transferring. (3-31-22) 03. Additional Provisions. An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however the provisions cannot restrict, and are not in lieu of, the requirements contained in Subsections 033.01 and 033.02. (3-31-22) 04. Determinations of Deficiency. For purposes of Section 033 the determination of a deficiency cannot be more restrictive than: (3-31-22) a. Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or (3-31-22) b. If the deficiency is due to the presence of cognitive impairment, needing supervision or verbal cueing by another person to protect the insured or others. (7-1-26) 05. Assessments. Assessments of activities of daily living and cognitive impairment are performed by licensed or certified professionals, such as physicians, nurses or social workers. (3-31-22) 06. Appeals. Long-term care insurance policies include a clear description of the process for appealing and resolving benefit determinations. (3-31-22) 07. Effective Date. The requirements set forth in Section 033 are effective April 5, 2000 and apply to a long-term care policy issued in this state after to that date, other than for certificates issued under a group long-term care insurance policy as defined in Section 41-4603(4)(a), Idaho Code, which was in force prior to that date. (7-1-26) 034. ADDITIONAL STANDARDS FOR BENEFIT TRIGGERS FOR QUALIFIED LONG-TERM CARE INSURANCE CONTRACTS. 01. Definitions. For purposes of Section 034 the following definitions apply: (3-31-22) a. Qualified long-term care services means services that meet the requirements of Section 7702B(a)(1) of the Internal Revenue Code of 1986, as amended, as follows: necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation, and rehabilitative services and maintenance or personal care services which are prescribed by a chronically ill individual, and are provided pursuant to a plan of care prescribed by a licensed health care practitioner. (3-31-22) b. Chronically ill individual has the meaning prescribed for this term by 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: (3-31-22) 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 (3-31-22) ii. Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment. (3-31-22) c. The term chronically ill individual cannot include an individual meeting these requirements unless within the preceding twelve (12) month period a licensed health care practitioner has certified that the individual meets these requirements. (3-31-22) d. Licensed health care practitioner means a physician, as defined in Section 1861(r)(1) of the Social Security Act, and a registered professional nurse, licensed social worker, or other individual who meets requirements prescribed by the Secretary of the Treasury. (3-31-22) IDAHO ADMINISTRATIVE CODE IDAPA 18.04.11 – Long-Term Care Department of Insurance Insurance Minimum Standards Section 035 Page 35 e. Maintenance or personal care services means any care, the primary purpose of which is the provision of needed assistance with any of the disabilities, the existence of which leads to the conclusion that the individual is a chronically ill individual (including the protection from threats to health and safety due to severe cognitive impairment). (3-31-22) 02. The Chronically Ill. A qualified long-term care insurance contract pays 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. (3-31-22) 03. Payments and Conditions. A qualified long-term care insurance contract conditions 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 a loss of functional capacity; or to severe cognitive impairment. (3-31-22) 04. Certifications by Professionals. Certifications regarding activities of daily living and cognitive impairment prescribed pursuant to Subsection 034.03 are performed by licensed or certified professionals, such as physicians, registered professional nurses, licensed social workers, or other individuals who meet requirements prescribed by the Secretary of the Treasury. (3-31-22) 05. Certifications by Carrier. Certification prescribed pursuant to Subsection 034.03 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 ninety (90) days due to a loss of functional capacity and the insured is in claim status, the certification cannot be rescinded and additional certifications cannot be performed until after the expiration of the ninety (90) day period. (3-31-22) 06. Appeals. Qualified long-term care contracts include a clear description of the process for appealing and resolving benefit determinations. (3-31-22)