Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 19 - Regulation 46-Long-Term Care Insurance
Section XIII-1957 - Standards for Benefit Triggers (Formerly section 1951)

Universal Citation: LA Admin Code XIII-1957

Current through Register Vol. 50, No. 9, September 20, 2024

A. 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 three of the activities of daily living or the presence of cognitive impairment.

B.

1. Activities of daily living shall include at least the following as defined in §1907 and in the policy:
a. bathing;

b. continence;

c. dressing;

d. eating;

e. toileting; and

f. transferring.

2. Insurers may use activities of daily living to trigger covered benefits in addition to those contained in §1957. B 1, as long as they are defined in the policy.

C. 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 §1957 A-B.

D. For purposes of §1957, the determination of a deficiency shall not be more restrictive than:

1. requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

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.

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

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

G. The requirements set forth in §1957 shall be effective January 1, 1999 and shall apply as follows.

1. Except as provided in §1957. G 2, the provisions of §1957 apply to a long-term care policy issued in this state on or after the effective date of the amended regulation.

2. For certificates issued on or after the effective date of §1957, under a group long-term care insurance policy, as defined in R.S. 22:1184(4)(a) that was in force at the time this amended regulation became effective, the provisions of §1957 shall not apply.

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:1186(A), 22:1186(E), 22:1188(C), 22:1189, and 22:1190.

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