Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-150 - Minimum standards - General

Current through Register Vol. 24-14, July 15, 2024
No contract may be advertised, solicited, or issued for
				delivery in this state as a long-term care contract which does not meet the
				following standards. These are minimum standards and do not preclude the
				inclusion of other provisions or benefits which are not inconsistent with these
				standards.
(1) No contract shall limit
			 benefits to an unreasonable period of time or an unreasonable dollar amount.
			 For example, a provision that a particular condition will be covered only for
			 one year without regard to the actual amount of the benefits paid or provided,
			 is not acceptable. Policies or contracts may, however, limit in-patient
			 institutional care benefits to a reasonable period of time. Benefits may also
			 be limited to a reasonable maximum dollar amount, and, as for example in the
			 case of home health care visits, to a reasonable number of visits over a stated
			 period of time.
(2) If a
			 fixed-dollar indemnity, fee for services rendered or similar long-term care
			 contract contains a maximum benefit period stated in terms of days for which
			 benefits are paid or services are received by the insured, the days which are
			 counted toward the benefit period must be days for which the insured has
			 actually received one or more contract benefits or services. If benefits or
			 services are not received on a given day, that day may not be counted. Waiver
			 of premium shall not be considered a contract benefit for purposes of accrual
			 of days under this section, and long-term care total disability shall not
			 operate to reduce the benefit.
(3)
			 If a contract of a managed health care plan contains a maximum benefit period
			 it must be stated in terms of the days the insured is in the managed care
			 delivery system. The days which are counted toward the benefit period may
			 include days that the insured is under a care plan established by the case
			 manager, or days in which the insured actually receives one or more benefits or
			 services.
(4) A long-term care
			 contract must cover skilled, intermediate, and custodial or personal care,
			 whether benefits are for institutional or community based care.
(5) No contract may restrict or deny benefits
			 because the insured has failed to meet medicare beneficiary eligibility
			 criteria.
(6) No insurer may offer
			 a contract form which requires prior skilled or intermediate care as a
			 condition of coverage for institutional or community based care.
(7) No insurer may offer a contract form
			 which requires prior hospitalization as a condition of covering institutional
			 or community based care.
(8) No
			 long-term care contract may restrict benefit payments to a requirement that the
			 patient is making a "steady improvement" or limit benefits to "recuperation" of
			 health.
(9) All long-term care
			 contracts shall be issued as individual or family contracts only, unless
			 coverage is provided pursuant to a group contract, issued to a bona fide group,
			 which contract provides continuity of coverage equivalent to that which would
			 be provided under a guaranteed renewable individual contract, and otherwise
			 satisfies the commissioner that it is not contrary to the best interests of the
			 public.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030,
				  48.01.030. 94-14-100 (Order R
				  94-10), §
										284-54-150, filed 7/6/94,
				  effective 8/6/94. Statutory Authority:
				  RCW
				   48.02.060(3), 48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-150, filed
				  7/9/87.