No long-term care insurance policy or certificate may be
approved, advertised, or solicited, in this state as a Partnership Long-Term
Care Insurance Policy or Certificate which does not meet the standards of
Article 3, and which has not been certified by the Department of Health
Services and approved by the Commissioner of the Department of Insurance as a
Partnership Long-Term Care Insurance Policy or Certificate. A Partnership
Long-Term Care Insurance Policy or Certificate shall contain the following
benefits and features:
(a) coverage
for either nursing facility and Residential Care Facility only, or
Comprehensive Benefits. Policies or Certificates covering only nursing facility
and Residential Care Facility benefits shall display prominently on page one
(1) of the Policy or Certificate:
"NURSING FACILITY AND RESIDENTIAL CARE FACILITY
ONLY" POLICY [CERTIFICATE]
Policies or Certificates covering Nursing Facility,
Residential Care Facility, and home and community-based benefits shall display
prominently on page one (1) of the Policy or Certificate:
"COMPREHENSIVE" POLICY
[CERTIFICATE]
(b) a
lifetime maximum benefit that is set in dollars and not in days or other units
of care;
(c) a lifetime maximum
benefit which at the time of purchase is equivalent in dollars to at least
three hundred sixty-five (365) times seventy percent (70%) of the Average Daily
Private Pay Rate for Nursing Facilities;
(d) if a Partnership Nursing Facility and
Residential Care Facility Only Policy or Certificate, it shall provide a
Residential Care Facility as well as a nursing facility benefit;
(e) if a Partnership Comprehensive Benefits
Policy or Certificate, it shall provide a Respite Care, a Residential Care
Facility, and a Nursing Facility Benefit as well as the following home and
community-based care benefits:
(1) Home
Health Care;
(2) Adult Day
Health/Social Care;
(3) Personal
Care Services;
(4) Homemaker
Services; and
(5) Hospice Care.
The definitions of these services must be identical to
those contained in Article 1, and must appear verbatim in any Partnership
Policy or Certificate.
(f) Care Management services by a Care
Management Provider Agency. Changes for the initial assessment and
individualized Plan of Care provided by a Care Management Provider Agency shall
not be considered as a claim cost. Charges for coordinating the provision of
care and monitoring services can be considered as a claim cost. Insurance
benefit payments can count toward the Medi-Cal Property Exemption to the extent
they are for Long-Term Care Services Countable Toward Medi-Cal Property
Exemption delivered to insured individuals and are part of an individualized
Plan of Care approved by the State-approved Care Management Provider Agency as
the result of a face-to-face assessment conducted by the Care Management
Provider Agency (or its Qualified Official Designee).
(g) the Benefit Eligibility definition
(appropriate for the type of Policy or Certificate), and the related
definitions for Activities of Daily Living, Severe Cognitive Impairment,
Hands-on Assistance, Standby Assistance, Substantial Supervision, Licensed
Health Care Practitioner, Plan of Care, and Qualified Long-Term Care Services
used to determine eligibility for benefits and when benefits begin counting
toward the Medi-Cal Property Exemption. These definitions must be identical to
those contained in Article 1, and must appear verbatim in any Partnership
Policy or Certificate, except that policies or certificates issued by Issuers
that are self-funded and not otherwise subject to compliance with the
California Insurance Code may use in a Partnership Policy or Certificate
different criteria for determining eligibility for policy benefits so long as
the Policy or Certificate complies with the requirements of Section
7702 B of the Internal Revenue
Code, and so long as the criteria used are approved by the Department of Health
Services.
(1) The Partnership will prescribe
or approve the precise instruments to be used to determine if a Policy or
Certificate holder has met the Benefit Eligibility definition. The Mental
Status Questionnaire (MSQ), and the Folstein Mini Mental State Examination will
be used to assess Severe Cognitive Impairment. Policy and Certificate holders
will be deemed to have met the Severe Cognitive Impairment criteria for the
Benefit Eligibility by:
(A) failing to answer
correctly at least seven of the ten questions on the MSQ test; or,
(B) exhibiting specific behavior problems
requiring daily supervision, including but not limited to wandering, abusive or
assaultive behavior, poor judgment or uncooperativeness which poses a danger to
self or others, and extreme or bizarre personal hygiene habits, and failing to
answer correctly at least four questions on the MSQ, or achieving a score of 23
or lower on the Folstein Mini Mental State Examination.
(2) To determine Benefit Eligibility based on
Activities of Daily Living,
(A) In a
Comprehensive Policy or Certificate 2 Activities of Daily Living shall be used
for home and community-based and Residential Care Facility benefits and either
2 or 3 Activities of Daily Living shall be used for the Nursing Facility
benefit.
(B) In a Nursing Facility
and Residential Care Facility Only Policy or Certificate, either 2 or 3
Activities of Daily Living shall be used.
(h) either the Elimination Period definition
contained in Section
58010(a) must
appear verbatim, or the definition specified in Section
58010(b) which
defines the number of days the insured must be disabled before the benefits are
covered by the Policy or Certificate, must be used in any Partnership Policy or
Certificate. The Elimination Period shall not be less than thirty days (30) for
Partnership Policies and Certificates with lifetime maximum benefits which at
time of purchase are equivalent in dollars to less than seven hundred and
thirty (730) times the Average Daily Private Pay Rate for Nursing Facilities.
An Elimination Period of not more than ninety days (90) shall be used in
Partnership Policies and Certificates with lifetime maximum benefits which at
time of purchase are equivalent in dollars to at least seven hundred and thirty
(730) times the Average Daily Private Pay Rate for Nursing
Facilities;
(i) upon the issue
date, if issued as an expense reimbursable Policy;
(1) a nursing facility per diem benefit of no
less than seventy percent (70%) of the Average Daily Private Pay Rate for
Nursing Facilities, rounded to the nearest multiple of ten dollars
($10);
(2) a Residential Care
Facility benefit that is not less than seventy percent (70%) and not more than
one hundred percent (100%) of the nursing facility per diem benefit contained
in the Partnership Policy or Certificate;
(3) a Respite Care Benefit in Policies or
Certificates with Comprehensive Benefits that is not subject to the Elimination
Period and not less than a total of 21 days in any calendar year for care in a
Nursing Facility, Residential Care Facility, or in a home or a community-based
program. The Respite Care benefit is payable at the daily and monthly maximum
benefit amounts applicable for the type of service being used to provide the
Respite Care; and
(4) monthly home
and community-based care benefits, for Partnership Policies or Certificates
with Comprehensive Benefits, of at least fifty percent (50%) and no more than
one hundred (100%) of the nursing facility per diem benefit provided in the
Partnership Policy or Certificate, multiplied by thirty. The home and
community-based care benefits shall be issued in increments of ten percent
(10%). Insurance products approved for residents in continuing care retirement
communities are exempt from this provision;
(j) upon the issue date, if issued on an
expense incurred basis, benefits that pay no less than seventy percent (70%)
and no more than one hundred (100%) of the cost incurred by the insured for all
covered services;
(k) an inflation
protection provision which satisfies one (1) of the following criteria:
(1) if the Partnership Policy or Certificate
is issued on an expense incurred basis, as specified in Section
58059(j), the
lifetime maximum benefit must automatically increase at five percent (5%) each
year over the previous year for each year that the contract is in force with
the following exception: the Partnership Policy or Certificate may be issued
with a lifetime maximum benefit that automatically increases each year by a
fixed amount equal to five percent (5%) of the original amount issued provided
that the applicant is seventy (70) years of age or over at the time the
application is taken, the applicant is first offered an inflation protection
provision that automatically increases by five percent (5%) each year over the
previous year for each year that the contract is in force, and the applicant is
given a graph which illustrates the difference in policy benefits payable
between the two inflation protection provisions and the cost of care;
or
(2) if the Partnership Policy or
Certificate is issued on an expense reimbursable basis, the nursing facility
per diem benefit, the lifetime maximum benefit, and the monthly home and
community-based care benefit if a Comprehensive Benefits Policy or Certificate,
must automatically increase at five percent (5%) each year over the previous
year for each year that the contract is in force, with the following exception:
the Partnership Policy or Certificate may be issued with a nursing facility per
diem benefit, a lifetime maximum benefit, and a monthly home and
community-based care benefit if a Comprehensive Benefits Policy or Certificate,
that automatically increases by five percent (5%) each year over the amount
initially issued provided that the applicant is seventy (70) years of age or
over at the time the application is taken, the applicant is first offered an
inflation protection provision that automatically increases by five percent
(5%) each year over the previous year for each year that the contract is in
force, and the applicant is given a graph which illustrates the difference in
policy benefits payable between the two inflation protection
provisions;
(l) a
Shortened Benefit Period Non-Forfeiture Benefit, or a provision that gives the
Policy or Certificate holder the option to elect, at the time the Partnership
Policy or Certificate is issued, to pay an extra premium for a rider providing
such a benefit. The Shortened Benefit Period Non-Forfeiture Benefit must have
the following features:
(1) eligibility begins
no later than after ten (10) years of premium payments;
(2) the lifetime maximum benefit is no less
than the dollar equivalent of three (3) months of care at the nursing facility
per diem benefit contained in the Partnership Policy or Certificate and, in the
case of an expense reimbursable Policy or Certificate, the nursing facility per
diem and monthly home and community-based care benefit, if a Comprehensive
Benefits Policy or Certificate, are no less than the benefits already contained
in the Policy or Certificate.
(3)
the lifetime maximum benefit, and, in the case of an expense reimbursable
Policy or Certificate, the nursing facility per diem benefit, and the monthly
home and community care benefit if a Comprehensive Benefits Policy or
Certificate, increases each year in the same amount and is computed in the same
manner as the inflation protection provision issued with the Policy or
Certificate as specified in subsection (k) of this section;
(4) the lifetime maximum benefit may be
reduced by the amount of any claims already paid;
(5) Cash back, extended term, and reduced
paid-up forms of non-forfeiture benefits will not be allowed. Other
non-forfeiture benefits that meet the requirements of this Section may be
allowed if they are acceptable to the Department of Health Services and the
Department of Insurance.
(m) Self-funded Issuers not subject to
California Insurance Code are exempt from:
(1)
the requirement of Subsection (e) that the definition for Homemaker Services be
used verbatim in each Comprehensive Policy and Certificate as long as the
definition conforms to Section
58017; and
(2) the requirement of Subsection (i)(2) to
include a Residential Care Facility Benefit that is no less than seventy
percent (70%) of the nursing facility per diem benefit contained in the
Partnership Policy or Certificate, as long as a Residential Care Facility
Benefit is included at no less than fifty percent (50%) of the nursing facility
per diem benefit contained in the Partnership Policy or
Certificate.
Notes
Cal. Code Regs. Tit. 22, §
58059
1. New
article 3 and section filed 8-30-93 as an emergency; operative 8-30-93
(Register 93, No. 36). Submitted for printing only pursuant to section
22009,
Welfare and Institutions Code.
2. Certificate of Compliance as to
8-30-93 order, including amendment of subsections (c), (i)(3), (j)(1)-(j)(3),
(k)(2), and (l)(4), repealer of subsections (k)(2)(A)-(B), and new subsection
(l)(6) transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No.
4).
3. Amendment of subsection (l) filed 10-26-94 as an emergency;
operative 10-26-94 (Register 94, No. 43). Submitted for printing only pursuant
to section
22009,
Welfare and Institutions Code.
4. Certificate of Compliance as to
10-26-94 order transmitted to OAL 2-22-95 and filed 3-30-95 (Register 95, No.
13).
5. Amendment of subsections (c), (i)(1), (j), (k)(1)-(2) and
(l)(3) filed 9-6-95 as an emergency; operative 9-6-95. Submitted to OAL for
printing only pursuant to Welfare and Institutions Code section
22009(d)
(Register 95, No. 36). A Certificate of Compliance must be transmitted to OAL
by 1-4-96 or emergency language will be repealed by operation of law on the
following day.
6. Editorial correction of HISTORY 5 (Register 95,
No. 42).
7. Amendment of subsections (c), (i)(1), (j), (k)(1)-(2)
and (l)(3) refiled 1-2-96 as an emergency; operative 1-2-96 (Register 96, No.
1). A Certificate of Compliance must be transmitted to OAL by 5-1-96 or
emergency language will be repealed by operation of law on the following
day.
8. Certificate of Compliance as to 9-6-95 order, including
amendment of subsections (k)(1)-(2) and (l)(3), transmitted to OAL 4-3-96 and
filed 5-2-96 (Register 96, No. 18).
9. Amendment filed 1-23-97 as an
emergency; operative 1-23-97 (Register 97, No. 10). A Certificate of Compliance
must be transmitted to OAL by 5-23-97 or emergency language will be repealed by
operation of law on the following day.
10. Editorial correction of
HISTORY 9 (Register 97, No. 27).
11. Certificate of Compliance as to
1-23-97 order transmitted to OAL 5-21-97 and filed 7-1-97 (Register 97, No.
27).
12. Amendment of article heading, section heading and section
filed 10-1-98 as an emergency; operative 10-1-98. Submitted to OAL for printing
only pursuant to Welfare and Institutions Code section
22009(d)
(Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL
by 1-29-99 or emergency language will be repealed by operation of law on the
following day.
13. Certificate of Compliance as to 10-1-98 order
transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No.
12).
14. Amendment of subsections (h), (i)(2) and (m), new
subsections (m)(1)-(2) and amendment of NOTE filed 5-30-2001 as an emergency;
operative 5-30-2001. A Certificate of Compliance must be transmitted to OAL by
9-27-2001 or emergency language will be repealed by operation of law on the
following day. Submitted to OAL for printing only pursuant to Welfare and
Institutions Code section
22009(d)
(Register 2001, No. 22).
15. Certificate of Compliance as to
5-30-2001 order transmitted to OAL 9-24-2001 and filed 10-31-2001 (Register
2001, No. 44).
Note: Authority cited: Section
22009(a),
Welfare and Institutions Code. Reference: Section
22005.1,
Welfare and Institutions Code.
1. New article 3
and section filed 8-30-93 as an emergency; operative 8-30-93 (Register 93, No.
36). Submitted for printing only pursuant to section
22009,
Welfare and Institutions Code.
2. Certificate of Compliance as to
8-30-93 order, including amendment of subsections (c), (i)(3), (j)(1)-(j)(3),
(k)(2), and ( l)(4), repealer of subsections (k)(2)(A)-(B), and new subsection
( l)(6) transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No.
4).
3. Amendment of subsection ( l) filed 10-26-94 as an emergency;
operative 10-26-94 (Register 94, No. 43). Submitted for printing only pursuant
to section
22009,
Welfare and Institutions Code.
4. Certificate of Compliance as to
10-26-94 order transmitted to OAL 2-22-95 and filed 3-30-95 (Register 95, No.
13).
5. Amendment of subsections (c), (i)(1), (j), (k)(1)-(2) and (
l)(3) filed 9-6-95 as an emergency; operative 9-6-95. Submitted to OAL for
printing only pursuant to Welfare and Institutions Code section
22009(d)
(Register 95, No. 36). A Certificate of Compliance must be transmitted to OAL
by 1-4-96 or emergency language will be repealed by operation of law on the
following day.
6. Editorial correction of H istory 5 (Register 95,
No. 42).
7. Amendment of subsections (c), (i)(1), (j), (k)(1)-(2)
and ( l)(3) refiled 1-2-96 as an emergency; operative 1-2-96 (Register 96, No.
1). A Certificate of Compliance must be transmitted to OAL by 5-1-96 or
emergency language will be repealed by operation of law on the following
day.
8. Certificate of Compliance as to 9-6-95 order, including
amendment of subsections (k)(1)-(2) and ( l)(3), transmitted to OAL 4-3-96 and
filed 5-2-96 (Register 96, No. 18).
9. Amendment filed 1-23-97 as
an emergency; operative 1-23-97 (Register 97, No. 10). A Certificate of
Compliance must be transmitted to OAL by 5-23-97 or emergency language will be
repealed by operation of law on the following day.
10. Editorial
correction of H istory 9 (Register 97, No. 27).
11. Certificate of
Compliance as to 1-23-97 order transmitted to OAL 5-21-97 and filed 7-1-97
(Register 97, No. 27).
12. Amendment of article heading, section
heading and section filed 10-1-98 as an emergency; operative 10-1-98. Submitted
to OAL for printing only pursuant to Welfare and Institutions Code section
22009(d)
(Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL
by 1-29-99 or emergency language will be repealed by operation of law on the
following day.
13. Certificate of Compliance as to 10-1-98 order
transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No. 12).
14. Amendment of subsections (h), (i)(2) and (m), new subsections (m)(1)-(2)
and amendment of Note filed 5-30-2001 as an emergency; operative 5-30-2001. A
Certificate of Compliance must be transmitted to OAL by 9-27-2001 or emergency
language will be repealed by operation of law on the following day. Submitted
to OAL for printing only pursuant to Welfare and Institutions Code section
22009(d)
(Register 2001, No. 22).
15. Certificate of Compliance as to
5-30-2001 order transmitted to OAL 9-24-2001 and filed 10-31-2001 (Register
2001, No. 44).