Indiana Administrative Code › Title 760 - DEPARTMENT OF INSURANCE › Article 2 - LONG TERM CARE INSURANCE COVERAGE › Rule 20 - Indiana Long Term Care Program › Section 20-42 - Auditing and correcting deficiencies in issuer record keeping

Current through July 10, 2024
Authority: IC
				  27-8-12-7.1
Affected: IC
				  12-15-2; IC
				  12-15-39.6
Sec. 42.
(a) Within
				one (1) year of the first date that any policyholder or certificate holder of a
				particular issuer's policy or certificate has met the criteria for the insured
				event, and as often as the commissioner or OMPP deems necessary thereafter,
				OMPP as representative of the commissioner shall conduct a systems audit of
				that company's records. The issuer shall be responsible for advising OMPP and
				the department of insurance when this one (1) year period has begun. OMPP shall
				promptly inform each issuer of inaccuracies and other potential problems
				discovered in its systems audits and shall instruct the issuer of the methods
				necessary to correct any problems in the issuer's methods of operation. It is
				the responsibility of the issuer to make any necessary corrections.
(b) OMPP shall periodically reconcile a
				sample of individual applications to Medicaid of persons who have submitted
				documentation for qualification for asset protection with the reports submitted
				by issuers. OMPP shall have the final decision concerning sample sizes and
				other auditing methods. OMPP shall promptly advise issuers of any problems
				discovered and shall instruct the issuer of the methods necessary to correct
				any problems in the issuer's method of operation. OMPP shall also notify the
				issuer of any obligations described in this subsection to hold clients
				harmless.
(c) The assistant
				secretary of OMPP or other authorized individual may enter into voluntary
				arrangements with issuers of qualified long term care insurance policies and
				certificates under which the assistant secretary would issue binding
				determinations as to whether or not services qualify for asset protection.
				Policyholders or certificate holders may submit requests for information and
				advice through their issuer or case management agency. When the following
				procedures are followed in all material respects, the written determinations of
				the assistant secretary of OMPP or other authorized individual concerning
				whether services qualify for asset protection shall be binding upon OMPP in all
				subsequent actions, and OMPP shall not make any assertion contradicting these
				determinations in any action arising in this subsection:
(1) All requests for determinations as to
				whether or not services qualify for asset protection shall be submitted to the
				assistant secretary of OMPP or other authorized individual in writing. These
				requests may include, but are not limited to, requests for determinations in
				the following areas:
(A) Whether the insured
				event has occurred and has been adequately documented.
(B) Whether a care plan is
				required.
(C) Whether a revision of
				a care plan is required.
(D)
				Whether a service or services are in accord with the care plan.
(E) Whether a service is of such a nature as
				to qualify for asset protection.
(F) Whether the applicable amount is the
				amount paid by the issuer or the amount charged for the service.