Ga. Comp. R. & Regs. R. 120-2-16-.30 - Additional Standards for Benefit Triggers for Qualified Long - Term Care Insurance Contracts
(1) For purposes of this section, the
following definitions apply:
(a) "Qualified
long-term care services" means services that meet the requirements of Section
7702(c)(1) of the Internal Revenue Code of 1986, as amended, as follows:
necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation
and rehabilitative services, and maintenance or personal care services which
are required by a chronically ill individual, and are provided pursuant to a
plan of care prescribed by a licensed health care practitioner.
(b)
(i)
"Chronically ill individual" has the meaning prescribed for this term by
section 7702B(c)(2) of the Internal Revenue Code of 1986, as amended. Under
this provision, a chronically ill individual means any individual who has been
certified by a licensed health care practitioner as:
(A) Being unable to perform (without
substantial assistance from another individual) at least two activities of
daily living for a period of at least 90 days due to a loss of functional
capacity; or
(B) Requiring
substantial supervision to protect the individual from threats to health and
safety due to severe cognitive impairment.
(ii) The term "chronically ill individual"
shall not include an individual otherwise meeting these requirements unless
within the preceding twelve-month period a licensed health care practitioner
has certified that the individual meets these requirements.
(c) "Licensed health care
practitioner" means a physician, as defined in Section 1861(r)(1) of the Social
Security Act, a registered professional nurse, licensed social worker or other
individual who meets requirements prescribed by the Secretary of the
Treasury.
(d) "Maintenance or
personal care services" means any care the primary purpose of which is the
provision of needed assistance with any of the disabilities as a result of
which the individual is a chronically ill individual (including the protection
from threats to health and safety due to severe cognitive
impairment).
(2) A
qualified long term care insurance contract shall pay only for qualified long
term care services received by a chronically ill individual provided pursuant
to a plan of care prescribed by a licensed health care practitioner.
(3) A qualified long-term care insurance
contract shall condition the payment of benefits on a determination of the
insured's inability to perform activities of daily living for an expected
period of at least 90 days due to a loss of functional capacity or to severe
cognitive impairment.
(4)
Certifications regarding activities of daily living and cognitive impairment
required pursuant to subsection (3) shall be performed by the following
licensed or certified professionals: physicians, registered professional
nurses, licensed social workers, or other individuals who meet requirements
prescribed by the Secretary of the Treasury.
(5) Certifications required pursuant to
subsection (3) may be performed by a licensed health care professional at the
direction of the carrier as is reasonably necessary with respect to a specific
claim, except that when a licensed health care practitioner has certified that
an insured is unable to perform activities of daily living for an expected
period of at least 90 days due to a loss of functional capacity and the insure
is in claim status, the certification may not be rescinded and additional
certifications may not be performed until after the expiration of the 90-day
period.
(6) Qualified long-term
care insurance contracts shall include a clear description of the process for
appealing and resolving disputes with respect to benefit
determinations.
Notes
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