§ 58-55-35. Facilities, services, and conditions defined.

643 words·~3 min read·/nc/chapter-58/58-55-35

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(a)Whenever long-term care insurance provides coverage for the facilities, services, or physical or mental conditions listed below, unless otherwise defined in the policy and certificate, and approved by the Commissioner, the facilities, services, or conditions have the following definitions:

(1)Adult care home. - As defined in G.S. 131D-2.1(3).

(1a)Adult day care program. - As defined in G.S. 131D-6(b).

(2)Chore services. - Include the performance of tasks incidental to activities of daily living that do not require the services of a trained homemaker or other specialist. The services are provided to enable individuals to remain in their own homes and may include such services as: assistance in meeting basic care needs such as meal preparation; shopping for food and other necessities; running necessary errands; providing transportation to essential service facilities; care and cleaning of the house, grounds, clothing, and linens.

(3)Combination home. - As defined in G.S. 131E-101(1a).

(4)Repealed by Session Laws 1995, c. 535, s. 3.

(5)Family care home. - As defined in G.S. 131D-2.1(9).

(6)Renumbered.

(7)Repealed by Session Laws 1995, c. 535, s. 3.

(8)Home care services. - As defined in G.S. 131E-136(3).

(9)Homemaker services. - Supportive services provided by qualified para-professionals who are trained, equipped, assigned, and supervised by professionals within the agency to help maintain, strengthen, and safeguard the care of the elderly in their own homes. These standards must, at a minimum, meet standards established by the North Carolina Division of Social Services and may include: providing assistance in management of household budgets; planning nutritious meals; purchasing and preparing foods; housekeeping duties; consumer education; and basic personal and health care.

(10)Hospice. - As defined in G.S. 131E-176(13a).

(11)Intermediate care facility for individuals with intellectual disabilities. - As defined in G.S. 131E-176(14a).

(12)Nursing home. - As defined in G.S. 131E-101(6).

(13)Respite care, institutional. - Provision of temporary support to the primary caregiver of the aged individual or individual with a disability by taking over the tasks of that person for a limited period of time. The insured receives care for the respite period in an institutional setting, such as a nursing home, family care home, rest home, or other appropriate setting.

(14)Respite care, non-institutional. - Provision of temporary support to the primary caregiver of the aged individual or individual with a disability by taking over the tasks of that person for a limited period of time in the home of the insured or other appropriate community location.

(15)Skilled nursing facility. - An institution licensed under applicable State laws and primarily engaged in providing to inpatients, under the supervision of a doctor and a registered professional nurse, skilled nursing care and related services on a 24-hour basis, and rehabilitative services.

(16)Supervised living facility for adults with developmental disabilities. - A residential facility, as defined in G.S. 122C-3(14), that has two to nine adult residents with developmental disabilities.

(b)Whenever long-term care insurance provides coverage for organic brain disorder syndrome, progressive dementing illness, or primary degenerative dementia, such phrases shall be interpreted to include Alzheimer's Disease. A clinical diagnosis of "organic brain disorder syndrome," "progressive dementing illness," or "primary degenerative dementia" must be accepted as evidence that such a condition exists in an insured if a pathological diagnosis cannot be made, the medical evidence substantially documents the diagnosis of the condition, and the insured received treatment for the condition.

(c)All long-term care insurance policies must be filed with and approved by the Commissioner before they can be used in this State and are subject to the provisions of Article 38 of this Chapter. (1987, c. 331, s. 1; 1989, c. 207, ss. 5, 6; 1991, c. 721, s. 85; 1995, c. 535, s. 3; 2001-209, s. 4; 2008-187, s. 38(a); 2009-462, s. 4(a); 2019-76, s. 13(a).)