Current through Register Vol. 51, No. 19, September 20, 2024
A. Optional Home Health Care Benefit.
(1) An insurer issuing a long-term care insurance policy shall offer the applicant for the policy the option to purchase a policy that provides for home health care benefits in addition to the benefits provided for nursing home care.
(2) The benefits required to be offered for home health care under this section are as follows:
(a) If the benefit for nursing home care is on a scheduled or indemnity-type basis, the daily limit for home health care benefits shall be at least 50 percent of the daily benefit for nursing home care;
(b) The period of eligibility for home health care benefits shall be at least equal to the period of eligibility for benefits for nursing home care; and
(c) If the policy provides for an overall lifetime limit, the benefits for home health care shall be at least equal to 50 percent of the overall lifetime limit.
(3) The minimum benefits required in §A(2) of this regulation do not apply to policies or certificates issued to residents of continuing care retirement communities.
B. If the offer required by §A of this regulation is rejected in writing by the applicant, then the insurer may offer a home health care rider providing benefits for a longer or shorter duration or for differing benefit levels.
C. A long-term care insurance policy or certificate may not limit benefits for home health care by:
(1) Requiring that the insured would need skilled nursing care or care in a hospital and skilled nursing facility if home health care services were not provided;
(2) Requiring that the insured first receive nursing care or therapeutic services, or both, in a community setting before home health care services are covered;
(3) Requiring that eligibility for services be limited to services provided by registered nurses or licensed practical nurses;
(4) Requiring that a nurse or licensed therapist provide services covered by the policy if the services can be provided by a home health aide or other home health care worker, unless required by applicable licensing regulations;
(5) Requiring that the insured have an acute condition before home health care services are covered;
(6) Limiting benefits to services provided by Medicare-certified agencies or providers;
(7) Excluding coverage for personal care services provided by a home health aide; or
(8) Requiring that the provision of home health care services be at a level of certification or licensure greater than that required by the eligible service.
D. Home health care coverage may be applied to the nonhome health care benefits provided in the policy or certificate to determine maximum coverage under the terms of the policy or certificate.
E. An insurer soliciting the sale of a long-term care insurance policy shall offer the applicant the option of including the policy home health care benefits in accordance with the provision in §§A-D of this regulation.
F. A qualified long-term care insurance policy that provides benefits for home health care or community care services may not exclude coverage for adult day care services.
