Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 425 - LONG-TERM CARE INSURANCE
Section 031-425-27 - Standards for Benefit Triggers

Universal Citation: 02 ME Code Rules ยง 031-425-27

Current through 2024-13, March 27, 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 at least five of the activities of daily living or the presence of cognitive impairment.

B. Insurers may use activities of daily living, other than those listed in Section 5, to trigger covered benefits 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 Sections 27(A) and (B).

D. For purposes of this section 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 this section shall be effective April 1, 2005, and shall apply as follows:

(1) Except as provided in Section 27(G)(2), the provisions of this section apply to a policy, certificate or rider delivered or issued for delivery in this state on or after the effective date of this rule.

(2) For certificates issued on or after the effective date of this section, under employee groups as defined in 24-A M.R.S.A. §2804, labor union groups as defined in 24-A M.R.S.A. §2805, or trustee groups as defined in 24-A M.R.S.A. §2806, in force at the time this rule became effective, the provisions of this section shall not apply if the group policy was in force at the time this rule became effective.

H. A premium increase notice required by Section 9(D) of this rule shall include:

(1) An offer to reduce policy benefits provided by the current coverage consistent with the requirements of this section;

(2) A disclosure stating that all options available to the policyholder may not be of equal value; and

(3) In the case of a policy offered with the intent to meet the requirements of the Long-term Care Partnership Program, a disclosure that some benefit reduction options may result in a loss in Partnership status.

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