Kansas Administrative Regulations › Agency 40 - INSURANCE DEPARTMENT › Article 4 - ACCIDENT AND HEALTH INSURANCE › Section 40-4-37d - Long-term care insurance; benefits; medical condition; activities of daily living; definitions; requirements

Current through Register Vol. 43, No. 28, July 11, 2024
(a) A long-term
			 care policy may require a recommendation by a physician that the services are
			 necessary due to illness, injury, or functional impairment but shall not
			 condition benefits on medical necessity.
(b)
(1) In
			 addition to or in lieu of a recommendation by a physician as described in
			 section (a) of this regulation, group long-term care insurance policies
			 covering employees, dependents and retirees of a single employer may include
			 provisions which condition the payment of benefits on an assessment of the
			 insured's ability to perform activities of daily living or cognitive
			 impairment.
(2) As used in this
			 section, activities of daily living consist of the following defined activities
			 and performance criteria:
(A) "Bathing" means
			 the ability to get into and out of the tub or shower, turn on the water, get
			 the soap or other cleansing product, and bathe the entire body including back
			 and feet. A person is dependent if the person cannot bathe in a bathtub or
			 shower without the assistance of another person or is able to participate only
			 minimally, such as washing face and hands only.
(B) "Dressing" means the ability to get
			 clothes from closets or drawers and put them on or take them off, including
			 undergarments and outer-garments, as well as fasteners and braces, if worn.
			 Dressing includes the ability to fasten one's shoes. A person is dependent if
			 the person can dress only with the assistance of another person or is able to
			 participate only minimally, such as putting on outer-garments only.
(C) "Eating" means the ability to bring food
			 to the mouth or hold a glass to the mouth, and chew and swallow food. A person
			 is dependent if the person is fed by hand, is being fed intravenously or
			 through a feeding tube, is unable to bring food to the mouth or is unable to
			 chew and swallow the food.
(D)
			 "Maintaining continence" means the ability to maintain control of urination or
			 bowel movement. A person is dependent if the person loses bladder control three
			 times per week or more, loses bowel control two times per week or more, or
			 needs assistance in maintaining a catheter or colostomy bag.
(E) "Toileting" means the ability to get to
			 and from the toilet, onto and off the toilet, clean oneself after elimination,
			 and adjust clothes after toileting. A person is dependent if the person needs
			 help with one or more of these tasks, maintaining balance, or caring for a
			 catheter or colostomy bag.
(F)
			 "Transferring from bed to chair" means the ability to get into or out of bed or
			 a chair. A person is dependent if the person is unable to get into or out of
			 bed or a chair without human assistance.
(G) "Mobility" means the ability to walk or
			 move from one place to another. A person is dependent if the person requires
			 assistance or supervision from another person to safely walk or if the person
			 needs to be wheeled from one place to another.
(3) "Cognitive impairment" means a deficiency
			 in the ability to think, perceive, reason, remember or otherwise routinely
			 display an ability to take care of oneself without the ongoing assistance of or
			 supervision by another person.
(4)
			 Any determination of impairment shall not be more restrictive than requiring
			 either a deficiency in the ability to perform three of the activities of daily
			 living or the presence of cognitive impairment.
(5) Only properly credentialed, experienced,
			 trained professionals, such as physicians, registered nurses or licensed
			 specialist social workers shall perform assessments of activities of daily
			 living and cognitive impairment.
(6) Group long-term care insurance policies
			 which condition the payment of benefits on an assessment of the insured's
			 ability to perform activities of daily living or cognitive impairment shall
			 include a clear and understandable description of the method for resolving
			 insured grievances.