Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.31 - Additional Standards for Benefit Triggers for Qualified Long-term Care Insurance Contracts

Current through Register Vol. 47, No. 3, July 24, 2024
(1) For
				purposes of this rule, the following definitions apply:
"Chronically ill individual"
has the meaning
				  prescribed for this term by Section 7702B(c)(2) of the Internal Revenue Code of
				  1986. Under this provision, a chronically ill individual means any individual
				  who has been certified by a licensed health care practitioner as:
1. Being imable 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
2. Requiring
				substantial supervision to protect the individual from threats to health and
				safety due to severe cognitive impairment.
The term "chronically ill individual" shall not include an
				  individual otherwise meeting these requirements unless within the preceding
				  12-month period a licensed health care practitioner has certified that the
				  individual meets these requirements.
"Licensed health care practitioner"
means a
				  physician, as defined in Section 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).
"Qualified long-term care services"
means
				  services that meet the requirements of Section 7702(c)(1) of the Internal
				  Revenue Code of 1986, as follows: necessary diagnostic, preventive,
				  therapeutic, curative, treatment, mitigation and rehabilitative services, and
				  maintenance or personal care services which are required by a chronically ill
				  individual, and are provided pursuant to a plan of care prescribed by a
				  licensed health care practitioner
(2)
				A qualified long-term care insurance contract shall pay only for qualified
				long-term care services received by a chronically ill individual provided
				pursuant to a plan of care prescribed by a licensed health care
				practitioner
(3) A qualified
				long-term care insurance contract shall condition the payment of benefits on a
				determination of the insured's inability to perform activities of daily living
				for an expected period of at least 90 days due to a loss of functional capacity
				or to severe cognitive impairment.
(4) Certifications regarding activities of
				daily living and cognitive impairment required pursuant to subrule 39.31(3)
				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.
(5) Certifications
				required pursuant to subrule 39.31(3) 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 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 90-day period.
(6) Qualified long-term care insurance
				contracts shall include a clear description of the process for appealing and
				resolving disputes with respect to benefit determinations.