core standards for individual long term care insurance policies

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Date: 7/13/10 Under review by the Product Standards Committee Higlighted changes are those added since the 7/6 draft. Drafting Note: Section 7702B of the Internal Revenue Code of 1986, as amended, includes a provision for triggering benefits that is different from that found in § 3F of these standards. The definitions used in the triggering of benefits in § 7702B (substantial assistance, loss of functional capacity, substantial supervision and severe cognitive impairment) have been defined in guidance promulgated by the Department of the Treasury. (3) A tax-qualified policy shall state that certifications regarding activities of daily living and cognitive impairment required pursuant to Item (2) shall be performed by the following licensed or certified professionals: physicians, registered professional nurses, licensed social workers, or other individuals who meet requirements prescribed by the Secretary of the Treasury. (4) A tax-qualified policy shall state that certifications required pursuant to Item (2) 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ninety (90) days due to a loss of functional capacity and the insured is in claim status, the certification may not be rescinded and additional certifications may not be performed until after the expiration of the ninety-day period. Drafting Note: Standard based on § 30, Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts, of the Model Regulation H. CONFORMITY WITH INTERSTATE INSURANCE PRODUCT REGULATION COMMISSION STANDARDS (1) The policy shall state that it was approved under the authority if the Interstate Insurance Product Regulation Commission and issued under the Commission standards. The policy shall also state that any provision of the policy that on the provision’s effective date is in conflict with Interstate Insurance Product Regulation Commission standards for this product type is hereby amended to conform to the Interstate Insurance Product Regulation Commission standards for this product type as of the provision’s effective date. I. DEFINITIONS AND CONCEPTS (1) The policy shall define certain terms or describe concepts that, as used in the policy, will have specific meanings. If the policy contains the terms or concepts set forth below, the respective definitions or descriptions shall be consistent with, or no less favorable to the insured than, the standards set forth below. The actual term or concept to be included in the policy, as well as the respective definition or description, may vary as long as the intent is consistent with the standards set forth below. The terms may be defined or concepts described in a definitions section of the policy or in a policy provision that is a logical place for such definitions or concept descriptions. (a) (b) (c) (d) “Activities of daily living” means at least bathing, continence, dressing, eating, toileting and transferring. “Acute condition” means that the individual is medically unstable. Such an individual requires frequent monitoring by medical professionals, such as physicians and registered nurses, in order to maintain his or her health status. “Adult day care” means a state licensed or certified program providing social or health-related or both types of services during the day in a community group setting for the purpose of supporting frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside the home. “Bathing” means washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower. Deleted: for Deleted: six Deleted: or more individuals of Deleted: and Deleted: provided © IIPRC 2010 10
Date: 7/13/10 Under review by the Product Standards Committee Higlighted changes are those added since the 7/6 draft. (e) (i) “Chronically ill individual” has the meaning prescribed for this term by § 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: (I) (II) 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 Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment. (ii) The term “chronically ill individual” shall not include an individual otherwise meeting these requirements unless within the preceding twelve-month period a licensed health care practitioner has certified that the individual meets these requirements. (f) (g) (h) (i) (j) (k) (l) (m) (n) (o) “Cognitive impairment” means a deficiency in an individual’s short or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness. “Continence” means the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag). “Dressing” means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs. “Eating” means feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously. “Hands-on assistance” means physical assistance (minimal, moderate or maximal) without which the individual would not be able to perform the activity of daily living. “Home health care services” means medical and non-medical services, provided to ill, disabled or infirm persons in their residences. Such services include homemaker services, assistance with activities of daily living and respite care services. “Licensed health care practitioner” means a physician, as defined in § 1861(r)(1) of the Social Security Act, a registered professional nurse, licensed social worker or other individual who meets requirements prescribed by the Secretary of the Treasury. “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). “Medicare” shall be defined as “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended,” or “Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof,” or words of similar import. “Nursing facility” means a home, residence, or institution, other than a hospital (except for a hospital or hospital unit licensed or certified to provide long-term care services), that is primarily engaged in providing nursing care and related services on an in-patient basis under a license issued by the Deleted: may © IIPRC 2010 11
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core standards for individual long term care insurance policies

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