Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY
Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE
Section 3.3818 - Standards for Eligibility for Benefits
Universal Citation: 28 TX Admin Code § 3.3818
Current through Reg. 50, No. 13; March 28, 2025
(a) A long-term care insurance policy or certificate shall contain provisions conditioning eligibility for benefits or services upon the occurrence of the following events:
(1) the inability to
perform, without assistance, any two activities of daily living, as set forth
by the insurer; provided, however, that such activities of daily living shall
include at a minimum those which are set forth and defined in §
3.3804 of this title (relating to
Definitions); or
(2) the impairment
of cognitive ability. For purposes of this subchapter, the term "impairment of
cognitive ability" shall not be defined more restrictively than the
deterioration or loss in intellectual capacity requiring substantial
supervision for protection of self or others, as established by the clinical
diagnosis of any licensed practitioner in this state authorized to make such a
diagnosis. Such diagnosis shall include the patient's history and physical,
neurological, psychological and/or psychiatric evaluations, and laboratory
findings.
(b) Any insurer or other entity that offers a long-term care insurance policy or certificate that complies with subsection (a) of this section may also offer a long-term care policy or certificate that provides coverage based on the inability to perform without assistance any three activities of daily living, provided:
(1) the policy or certificate meets
the requirements of subparagraphs (A) through (D) of this paragraph:
(A) the policy and certificate shall provide
coverage based on meeting the eligibility requirements of subsection (a)(1) of
this section,
(B) the coverage
based on the inability to perform, without assistance, any three activities of
daily living shall:
(i) be identical to the
coverage provided under subparagraph (A) of this paragraph;
(ii) provide a level of benefits for facility
coverage that is higher than the level of benefits payable for facility
coverage under subparagraph (A) of this paragraph;
(iii) provide a level of benefits for
non-facility coverage that is not less than the level of benefits payable for
non-facility coverage under subparagraph (A) of this paragraph; however, in
complying with §
3.3815(c) of
this title (relating to Standards for Home Health and Adult Day Care Benefits),
home health or adult day care services coverage must be a dollar amount
equivalent to at least one-half of one year's coverage available for the
nursing home benefit associated with the corresponding number of activities of
daily living.
(C) the
activities of daily living shall include those set forth and defined in §
3.3804 of this title for coverage
provided under subparagraphs (A) and (B) of this paragraph;
(D) coverage provided based on meeting the
eligibility requirements of subsection (a)(2) of this section for impairment of
cognitive ability shall be identical to the coverage provided under
subparagraph (A) of this paragraph and the benefit level shall not be less than
the applicable benefit level payable under subparagraph (B)(ii) or (B)(iii) of
this paragraph; and
(2)
the insurer or other entity shall offer the prospective insured, or where the
policy is offered to a group, the offer required by provisions of this
paragraph shall be made to the group policyholder; except that in the instance
where the group policy will not be issued to an employer, labor union, or
continuing care retirement center, the offering shall be made to each
prospective covered individual, the option to purchase a policy or certificate
that provides benefits set out in subsection (a) of this section and obtain
either: a written rejection of such offer or written acknowledgement of such
offer. Written rejection or acknowledgment of offer may be by a rejection or
acknowledgment receipt, attached to or made part of the application, or by a
certificate of rejection or offer signed by the prospective insured or group
policyholder if the group policyholder will be an employer, labor union, or
continuing care retirement center.
(c) For purposes of only subsection (b)(1)(B) of this section, the term "facility," to the extent coverage for care at any of the following is provided in the policy or certificate, means an assisted living facility, skilled nursing facility, extended care facility, intermediate care facility, convalescent nursing home, or maintenance or personal care facility.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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