Section 26-A2623. STANDARDS FOR BENEFIT TRIGGERS

 

2623.1A long-term care insurance policy shall condition 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 shall not be 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.

 

2623.2Activities of daily living shall include at least the following as defined in Section 2601 and in the policy:

 

(a)Bathing;

 

(b)Continence;

 

(c)Dressing;

 

(d)Eating;

 

(e)Toileting; and

 

(7)Transferring.

 

2623.3Insurers may use activities of daily living to trigger covered benefits in addition to those contained in subsection 2623.2, as long as they are defined in the policy.

 

2623.4An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however the provisions shall not restrict, and are not in lieu of, the requirements in subsections 2623.1 and 2623.2.

 

2623.5For purposes of this section the determination of a deficiency shall not be more restrictive than the following:

 

(a)Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

 

(b)If the deficiency is due to the presence of a cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured or others.

 

2623.6Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.

 

2623.7Long term care insurance policies shall include a clear description of the process for appealing and resolving benefit determinations.

 

2623.8The requirements set forth in this section shall be effective 12 months after adoption of this provision and shall apply as follows:

 

(a)Except as provided in paragraph (b), the provisions of this section apply to a long-term care policy issued in the District of Columbia on or after the effective date of the amended regulation, and

 

(b)For certificates issued on or after the effective date of this section, under a group long-term care insurance policy as defined in D.C. Official Code § 31-3601(4) that was in force at the time this amended regulation became effective, the provisions of this section shall not apply.

 

source

Final Rulemaking published at 52 DCR 10902 (December 16, 2005).