Nebraska Administrative Code
Topic - INSURANCE, DEPARTMENT OF
Title 210 - NEBRASKA DEPARTMENT OF INSURANCE
Chapter 46 - LONG-TERM CARE INSURANCE
Section 210-46-024 - Standards for Benefit Triggers

Universal Citation: 210 NE Admin Rules and Regs ch 46 ยง 024

Current through September 17, 2024

024.01 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 (3) of the activities of daily living or the presence of cognitive impairment.

024.02 Activities of daily living

024.02(A) Activities of daily living shall include at least the following as defined in section 005 and in the policy:
024.02(A)(1) Bathing;

024.02(A)(2) Continence;

024.02(A)(3) Dressing;

024.02(A)(4) Eating;

024.02(A)(5) Toileting; and

024.02(A)(6) Transferring.

024.02(B) Insurers may use activities of daily living to trigger covered benefits in addition to those contained in subsection 024.02(A)as long as they are defined in the policy.

024.03 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 024.01 and 024.02.

024.04 For purposes of this section the determination of a deficiency shall not be more restrictive than:

024.04(A) Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

024.04(B) 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.

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

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

024.07 The requirements set forth in this section shall become effective twelve (12) months after adoption of this provisions and shall apply as follows:

024.07(A) Except as provided in subsection 024.07(B), the provisions of this section apply to a long-term care policy issued in this state on or after the effective date of the amended regulation.

024.07(B) For certificates issued on or after the effective date of this section, under a group long-term care insurance policy as defined in Neb.Rev.Stat. § 44-4508(1) that was in force at the time this amended regulation became effective, the provisions of this section shall not apply.

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