Ga. Comp. R. & Regs. R. 120-2-16-.29 - Standards for Benefit Triggers
(1) 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 of the activities of
daily living or the presence of cognitive impairment.
(2)
(a)
Activities of daily living shall include at least the following as defined in
Section 120-2-16-.05
and in the policy:
(i) Bathing;
(ii) Continence;
(iii) Dressing;
(iv) Eating;
(v) Toileting; and
(vi) Transferring.
(b) Insurers may use activities of daily
living to trigger covered benefits in addition to those contained in paragraph
(a) as long as they are defined in the policy.
(3) 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 (1) and (2).
(4) For purposes of this section the
determination of a deficiency shall not be more restrictive than:
(a) Requiring the hands-on assistance of
another person to perform the prescribed activities of daily living;
or
(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.
(5) Assessments of activities of
daily living and cognitive impairment shall be performed by licensed or
certified professionals, such as physicians, nurses or social
workers.
(6) Long term care
insurance policies shall include a clear description of the process for
appealing and resolving benefit determinations.
(7) The requirements set forth in this
section shall be effective April 1, 2008, and shall apply as follows:
(a) Except as provided in paragraph (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.
(b) For certificates issued on or after the
effective date of this section, under a group long-term care insurance policy
as defined in O.C.G.A. Section
33-42-4 that was in force at the
time this amended regulation became effective, the provisions of this section
shall not apply.
Notes
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