33-22-1126. Additional standards for qualified long-term care contracts -- definitions.
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33-22-1126 . Additional standards for qualified long-term care contracts -- definitions.
(1)For the purposes of this section, the following definitions apply:
(i)"Chronically ill individual" has the meaning provided by section 7702B(c)(2) of the Internal Revenue Code, 26 U.S.C. 7702B(c)(2), and 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 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.
(ii)The term may not include an individual otherwise meeting the requirements of subsection (1)(a)(i)(A) or (1)(a)(i)(B) unless within the preceding 12-month period a licensed health care practitioner has certified that the individual meets the requirements of subsection (1)(a)(i)(A) or (1)(a)(i)(B).
(b)"Licensed health care practitioner" means a physician, as defined in section 1861(r)(1) of the Social Security Act, 42 U.S.C. 1395x(r)(1), a registered professional nurse, licensed social worker, or other individual who meets the requirements prescribed by the secretary of the treasury.
(c)"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.
(d)"Qualified long-term care services" means services that meet the requirements of section 7702(c)(1) of the Internal Revenue Code, 26 U.S.C. 7702(c)(1), and that:
(i)provide necessary diagnostic, preventative, therapeutic, curative, treatment, mitigation, and rehabilitative services;
(ii)provide maintenance or personal care services that are required by a chronically ill individual; and
(iii)are provided pursuant to a plan of care prescribed by a licensed health care practitioner.
(2)A qualified long-term care insurance contract must condition the payment of benefits on a certification of the insured's inability to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity or to severe cognitive impairment.
(3)Certifications regarding activities of daily living and cognitive impairment required pursuant to subsection
(2)must be performed by the following licensed or certified professionals:
(a)physicians or registered professional nurses;
(b)licensed social workers; or
(c)other individuals who meet the requirements prescribed by the secretary of the treasury.
(4)Certifications required pursuant to subsection
(2)may be performed by a licensed health care professional at the direction of the insurer 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 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 90-day period.
(5)Qualified long-term care insurance contracts must include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.