Delaware Administrative Code
Title 18 - Insurance
1400 - Health Insurance Specific Provisions
1404 - Long-Term Care Insurance
Section 1404-26.0 - Standards for Benefit Triggers

Universal Citation: 18 DE Admin Code 1404-26.0

Current through Register Vol. 28, No. 3, September 1, 2024

26.1 A long-term care insurance policy shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall not be more restrictive than requiring either a deficiency in the ability to perform not more than 3 of the activities of daily living or the presence of cognitive impairment.

26.2 Activities of Daily Living

26.2.1 Activities of daily living shall include at least the following as defined in Section 5.0 of this regulation and in the policy:
26.2.1.1 Bathing;

26.2.1.2 Continence;

26.2.1.3 Dressing;

26.2.1.4 Eating;

26.2.1.5 Toileting; and

26.2.1.6 Transferring;

26.2.2 Insurers may use activities of daily living to trigger covered benefits in addition to those contained in subsection 26.2.1 of this regulation as long as they are defined in the policy.

26.3 An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however, the provisions shall not restrict, and are not in lieu of, the requirements contained in subsections 26.1 and 26.2 of this regulation.

26.4 For purposes of Section 26.0 of this regulation, the determination of a deficiency shall not be more restrictive than:

26.4.1 Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

26.4.2 If the deficiency is due to the presence of a cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured or others.

26.5 Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.

26.6 Long term care insurance policies shall include a clear description of the process for appealing and resolving benefit determinations.

26.7 The requirements set forth in Section 26.0 of this regulation shall be effective (12 months after adoption of this provision) and shall apply as follows:

26.7.1 Except as provided in subsection 26.7.2 of this regulation, the provisions of Section 26.0 of this regulation apply to a long-term care policy issued in this state on or after the effective date of the amended regulation.

26.7.2 For certificates issued on or after the effective date of this section, under a group long-term care insurance policy as defined in 18 Del.C. § 7103(4) a, the provisions of Section 26.0 of this regulation shall not apply.

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