Section 760IAC2-16.1-3. Standards for benefit triggers for federally tax-qualified long term care insurance contracts

   (a) For purposes of this section the following definitions apply:

(1) "Federally tax-qualified long term care services" means services that meet the requirements of Section 7702(c)(1) of the Internal Revenue Code of 1986, as amended, as necessary:

(A) diagnostic;

(B) preventive;

(C) therapeutic;

(D) curative;

(E) treatment;

(F) mitigation;

(G) rehabilitative; and

(H) maintenance or personal care;

services that are required by a chronically ill individual and are provided under a plan of care prescribed by a licensed health care practitioner.

(2) "Chronically ill individual" has the meaning set forth in Section 7702B(c)(2) of the Internal Revenue Code of 1986, as amended. Under this provision, the term 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 (2) activities of daily living for a period of at least ninety (90) 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.

The term shall not include an individual otherwise 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) "Licensed health care practitioner" means one (1) of the following:

(A) A physician, as defined in Section 1861(r)(1) of the Social Security Act.

(B) A registered professional nurse.

(C) A licensed social worker.

(D) An individual who meets requirements prescribed by the Secretary of the Treasury.

(4) "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).

  (b) A federally tax-qualified long term care insurance contract shall pay only for federally tax-qualified long term care services received by a chronically ill individual provided under a plan of care prescribed by a licensed health care practitioner.

  (c) A federally tax-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 a loss of functional capacity or to severe cognitive impairment.

  (d) Certifications regarding activities of daily living and cognitive impairment required under subsection (c) shall be performed by the following licensed or certified professionals:

(1) Physicians.

(2) Registered professional nurses.

(3) Licensed social workers.

(4) Other individuals who meet requirements prescribed by the Secretary of the Treasury.

  (e) Certifications required under subsection (c) 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 may not be rescinded, and additional certifications may not be performed until after the expiration of the ninety (90) day period.

  (f) Federally tax-qualified long term care insurance contracts shall include a clear description of the process for appealing and resolving disputes with respect to benefit determinations. (Department of Insurance; 760 IAC 2-16.1-3; filed Oct 7, 2004, 1:00 p.m.: 28 IR 579; readopted filed Nov 24, 2010, 9:17 a.m.: 20101222-IR-760100633RFA)