Current through Register Vol. 24-06, March 15, 2024
(1)
(a)
Except as provided in (b) of this subsection, every long-term care insurance
contract or certificate issued on or after January 1, 1996, which provides
coverage to a resident of this state, shall require certification by the
insured's attending physician that the services are appropriate due to illness
or infirmity, or include provisions which condition the payment of benefits on
an assessment of the insured's ability to perform specific activities of daily
living or the insured's cognitive impairment.
(b) Certificates issued on or after January
1, 1996, under a group long-term care insurance contract that was in force on
December 31, 1995, need not meet the standards of this section.
(2) Activities of daily living and
cognitive impairment shall be used to measure an insured's need for long-term
care and shall be described in the contract or certificate in a separate
paragraph labeled "Eligibility for the Payment of Benefits." Any additional
benefit triggers shall be explained in that section. If a trigger differs for
different benefits, an explanation of the trigger shall accompany each benefit
description. If an attending physician or other specified person must certify a
certain level of functional dependency in order to be eligible for benefits,
the policy shall so specify.
(3)
Eligibility for the payment of benefits based on the inability of the insured
to perform certain activities shall not be more restrictive than requiring a
deficiency in the ability to perform not more than three of the following
activities of daily living.
(a) "Activities of
daily living" on which an insurer intends to rely as a measure of functional
incapacity shall be defined in the policy, and shall include at least all of
the following:
(i) Bathing: The ability of
the insured to wash himself or herself either in the tub or shower or by sponge
bath, including the task of getting into or out of a tub or shower.
(ii) Continence: The ability of the insured
to control bowel and bladder functions; or, in the event of incontinence, the
ability to perform associated personal hygiene (including caring for catheter
or colostomy bag).
(iii) Dressing:
The ability of the insured to put on and take off all items of clothing, and
necessary braces, fasteners, or artificial limbs.
(iv) Eating: The ability of the insured to
feed himself or herself by getting food and drink from a receptacle (such as a
plate, cup, or table) into the body including intravenously or by feeding
tube.
(v) Toileting: The ability of
the insured to get to and from the toilet, get on and off the toilet, and
perform associated personal hygiene.
(vi) Transferring: The ability of the insured
to move in and out of a chair, bed, or wheelchair.
(b) For purposes of this section, the
determination of a deficiency shall not be more restrictive than:
(i) Requiring the hands-on assistance of
another person to perform the prescribed activities of daily living;
or
(ii) If the deficiency is due to
the presence of a cognitive impairment, supervision or verbal cuing by another
person is needed in order to protect the insured or others.
(c) Upon prior approval of the
commissioner in writing, an insurer may use standards or definitions for
activities of daily living in addition to the standards set forth in (a) of
this subsection; however, in no case may an insurer require a deficiency in
more than three activities of daily living as a barrier to benefits. Any
additional activities of daily living approved by the commissioner, shall be
used in addition to those set forth in (a) of this subsection, and not in lieu
thereof. Assessments of activities of daily living and cognitive impairment
shall be performed by licensed or certified professionals, such as physicians,
nurses, or social workers. No contract or certificate may combine more than one
activity of daily living to create a compound impairment requirement.
(d) Each long-term care insurance contract or
certificate shall include a clear description of the process for appealing and
resolving benefit determinations.
(4) If an insurer proposes standards other
than those described in this section, the insurer shall describe to the
satisfaction of the commissioner how the proposed assessment will reasonably be
expected to produce reliable, valid, and clinically appropriate results and
shall demonstrate that the alternate assessment method is not less beneficial
to the insured than the standards described in this section.
(5) For purposes of this section the
following definitions apply:
(a) "Cognitive
impairment" means a deficiency in a person's short-term or long-term memory;
orientation as to person, place, and time; deductive or abstract reasoning; or
judgment as it relates to safety awareness.
(b) "Hands-on assistance" means any amount of
physical assistance (whether minimal, moderate, or maximal) without which the
insured would not be able to perform the activity.
Statutory Authority:
RCW
48.02.060,
48.84.030 and
48.84.050. 95-19-028 (Order R
95-5), §
284-54-040, filed 9/11/95,
effective 10/12/95.