Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 65.00 - Long-term Care Insurance
Section 65.05 - Minimum Standards for Individual Policies
Universal Citation: 211 MA Code of Regs 211.65
Current through Register 1531, September 27, 2024
(1) Benefit Eligibility Standards.
(a)
Benefit Triggers.
1.
Individual policies that are not intended to be federally qualified may not
include benefit eligibility standards that are more stringent than a
requirement that the insured be unable to perform at least two Activities of
Daily Living due to a loss of functional capacity or severe cognitive
impairment .
2. Individual policies
that are intended to be federally qualified are required to meet the standards
set forth in the federal Internal Revenue Code and related federal
regulations.
(b)
Prior Treatment Requirements. No individual policy may
condition long-term care benefits on the insured's prior hospitalization or
prior receipt of services from any long-term care provider.
(c)
Medicare
Eligibility. No individual policy may restrict or deny benefits
because the insured is not eligible for Medicare.
(d)
Improvement
Requirement. No individual policy may condition receipt of covered
benefits on a requirement that the insured be making a "steady improvement",
have "recuperative potential" or have "returned to pre-morbid condition" or
words of similar import.
(e)
Medical Necessity. No individual policy may condition
receipt of any services, except medical services provided by licensed medical
professionals, on any standard of medical necessity. Any carrier using a
medical necessity standard shall disclose that standard within the
policy.
(f)
Care
Management. A carrier may establish a care management system to
manage the benefits provided under the individual policy, and plan benefits may
be disallowed if specific care management standards and procedures are not met.
A carrier that intends to use a care management system must:
1. establish a needs assessment tool which
measures functional ability,
2.
file with the commissioner a description of its care management policy and
procedures, as well as the mechanism by which the insured may appeal a care
management decision, and file any and all updates to the management policy and
procedures with the commissioner prior to implementation
3. specify the care management procedures
within the policy, as well as the way to appeal whenever benefits are
disallowed for failure to meet care management standards, and notify the
insured about any changes to care management procedures included in the policy
prior to implementation, and
4.
disclose applicable care management standards to insureds upon
request.
(2) Benefit Requirements.
(a)
Elimination Periods and
Deductibles.
1. Individual
policies may not include elimination periods of greater than 365 days, whether
services are received within or away from the home.
2. At a minimum, carriers shall count each
day that the insured receives any service that would be applied against the
lifetime maximum benefit amount or maximum benefit period toward the
satisfaction of an individual policy's elimination period. Individual policies
may not require that elimination periods be satisfied within a specified period
of time or that days be consecutive.
3. Individual policies may not apply more
than one elimination period unless the insured has received no benefits for at
least 180 consecutive days.
4.
Individual policies may offer deductibles in lieu of elimination periods, but
not both.
(b)
Individual Policy Benefits.
1. Daily maximum benefit amounts for specific
services must be clearly defined within the policy provisions. The daily
maximum benefit may be limited by the carrier to the usual and customary cost
of the service. If the service costs more than the maximum daily benefit and
there is no law to the contrary, the insured is responsible for the amount over
and above the daily maximum benefit .
2. Lifetime maximum benefit periods may not
cover fewer than 730 days beyond the policy's elimination period.
3. Individual policies may include a life
time maximum benefit amount in lieu of the life time maximum benefit period,
provided that the lifetime maximum benefit amount may not be less than the
product of 730 multiplied by the highest daily maximum benefit amount covered
in the policy.
(c)
Home Health Care Benefits in Long-Term Care Insurance
Policies.
1. An individual
policy shall not, if it provides benefits for home healthcare services, limit
or exclude benefits:
a. by requiring that the
insured or claimant would need care in a skilled nursing facility if home
health care were not provided;
b.
by requiring that the insured or claimant first or simultaneously received
nursing or therapeutic services, or both, in a hospital or institutional
setting before home health care services are covered;
c. by limiting eligible services to services
provided by registered nurses or licensed practical nurses;
d. by requiring that the provisions of home
health care services be at a level of certification or licensure greater than
that required by the eligible services;
e. by requiring that the insured or claimant
have an acute condition before home health care services are covered;
or
f. by limiting benefits to
services provided by Medicare-certified agencies or providers.
2. A long-term care insurance
policy or certificate, if it provides for home health care services, shall
provide total home health coverage that is a dollar amount equivalent to at
least one-half of one year's coverage available for nursing home benefits under
the policy or certificate, at the time the covered home health services are
being received. This requirement shall not apply to policies or certificates
issued to residents of continuing care retirement communities.
3. Home health care coverage may be applied
to the non-home health care benefits provided in the policy or certificate when
determining maximum coverage under the terms of the policy or
certificate.
(d)
Minimum Benefits. Individual policies may not include
any policy benefits that are so limited in scope that they are not likely to be
of any substantial economic value to the insured.
(e)
Alternate Care
Benefits. Individual policies must include a provision that
enables the insured to use policy benefits after satisfying policy benefit
triggers, elimination periods and deductibles to cover long-term care
treatments or expenses not specifically identified in the policy's described
benefits. The alternate care benefits must be made available to the insured
subject to the agreement of the carrier, the insured and the insured's health
care practitioner.
(3) Limitations and Exclusions.
(a)
Pre-existing condition
limitations.
1. Pre-existing
condition limitations must be identified on the front of the policy and the
outline of coverage.
2.
Pre-existing condition limitations may not apply for more than a six-month
period from the effective date of the policy.
(b) No individual policy may exclude
otherwise eligible persons from policy benefits due to the presence or history
of mental or nervous conditions, Alzheimer's disease, alcoholism, or other
chemical dependency.
(c) No
individual policy may exclude otherwise eligible policy benefits because those
benefits are also payable by a non-Medicare government agency or because the
covered services are being received in a governmental facility.
(d)
Other
limitations. Individual policies may include other limitations or
conditions subject to the approval of the commissioner, provided that they are
clearly identified in a separate section of the policy. Such limitations may
include, but are not limited to, illnesses, treatments or conditions arising
out of the following circumstances:
1. war or
act of war (whether declared or undeclared);
2. participation in a felony, riot or
insurrection;
3. service in the
armed forces or units auxiliary thereto;
4. attempted suicide or intentionally self-
inflicted injury;
5. services
provided for alcohol or drug detoxification;
6. aviation (this exclusion applies only to
non-fare paying passengers);
7.
services for which benefits are payable under Medicare, any state or federal
workers' compensation program, employer's liability or occupational disease
law, or any motor vehicle no-fault law;
8. services provided by members of the
insured's immediate family; or
9.
services for which no amount is normally charged in the absence of
insurance.
(4) Continuation of Policy Benefits.
(a)
Renewal.
1. Carriers
may not refuse to renew any individual policy, except in cases when the carrier
is under receivership, rehabilitation or liquidation proceedings pursuant to
M.G.L. c. 175 or c. 176 § 33, administrative supervision pursuant to
M.G.L. c. 175J or comparable statutory requirements of another jurisdiction. A
carrier may discharge its obligation to renew existing individual policies only
upon a finding that the carrier has obtained coverage for all existing insureds
with equivalent benefits for value paid with another carrier.
2. All individual policies shall be
guaranteed renewable or noncancelable.
(b)
Extension of
Benefits.
1. If an individual
policy is terminated while an insured is confined to a nursing home, benefits
shall continue until the earliest of the following occurs:
a. the insured is discharged from the nursing
home,
b. the policy lifetime
maximum benefit period has expired, or
c. the insured has exhausted the lifetime
maximum benefit amount for nursing home services.
2. For the purposes of 211 CMR 65.05(4)(b),
the insured shall be considered to be continuously confined to a nursing home
while being transferred to another nursing home, receiving another level of
nursing care in any nursing home or being transferred back to a nursing home
from a temporary/acute hospitalization.
3.211 CMR 65.05(4)(b) does not apply if
coverage under the individual policy terminates because of failure of the
policyholder to pay the premium within the time set forth in the
policy.
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