North Carolina Administrative Code
Title 11 - INSURANCE
Chapter 12 - LIFE AND HEALTH DIVISION
Section .0500 - ACCIDENT AND HEALTH: GENERAL NATURE
Section 12 .0555 - LONG-TERM CARE POLICY REQUIREMENTS
Universal Citation: 11 NC Admin Code 12 .0555
Current through Register Vol. 38, No. 18, March 15, 2024
(a) Definitions:
(1) Long-Term Care Insurance is defined as any contract of insurance
offering institutional or noninstitutional support in order to restore deteriorating health and to maintain
functional independence. Such services for an acute or chronic physical or mental impairment, or short term
illness or injury, include but are not limited to assistance with daily living, medical or rehabilitative
care, and home health care.
(2) In regard to Skilled,
Intermediate, Custodial, or Home Health Care, when the insured receives definitive treatment for these
services regardless of the type of facility or setting the insured is confined in, benefits are payable for
the service receive based on the benefits of the contract for that service.
(b) The following provisions are required:
(1) Long-term care insurance policies must provide benefits for at least
three levels of care and provide the same duration for each level of care for a minimum of 12
months.
(2) Coordination or non-duplication of benefits is
permitted between true group long-term care policies only.
(3)
The loss ratio is required to be at least 60 percent for individual policies and at least 75 percent for
group policies.
(4) Custodial care that is administered for
assistance of the patient in performing the activities of daily living shall not be denied based on the type
of facility in which the care is received; but rather must be provided as long as the insured is confined as
an inpatient in any facility licensed by the State, regardless of whether or not that facility is commonly
understood to be or is defined as a long-term care facility.
(5)
No long-term care policy, contract, or certificate may use waivers to exclude, limit, or reduce benefits for
specifically named or described pre-existing diseases or physical conditions.
Authority
G.S.
58-2-40;
58-51-1;
58-51-95;
58-55-30;
Eff. April 1, 1989;
Amended
Eff. February 1, 1992;
Pursuant to
G.S.
150B-21.3A, rule is necessary without substantive public interest Eff. May
1, 2018.
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