RELATES TO:
KRS
304.6-070,
304.6-130,
304.6-180,
304.12-010,
304.12-020,
304.14-650-304.14-675,
304.17-080
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
304.2-110(1) authorizes the
Commissioner of Insurance to promulgate administrative regulations necessary
for or as an aid to the effectuation of any provision of the Kentucky Insurance
Code as defined in
KRS
304.1-010.
KRS
304.14-660 requires the Commissioner of
Insurance to promulgate administrative regulations to establish the
requirements for short-term nursing home insurance policies. This
administrative regulation establishes the minimum standards for short-term
nursing home insurance policies.
Section
1. Definitions.
(1) "Applicant"
means:
(a) For an individual short-term
nursing home insurance policy, the person who seeks to contract for benefits;
and
(b) For a group short-term
nursing home insurance policy, the proposed certificate holder.
(2) "Association" means entities
eligible for group health insurance pursuant to
KRS
304.18-020.
(3) "Benefit trigger" means a contractual
provision in the insured's policy conditioning the payment of benefits on a
determination of the insured's ability to perform activities of daily living
and on cognitive impairment.
(4)
"Certificate" means any certificate issued under a group short-term nursing
home insurance policy, which has been delivered or issued for delivery in
Kentucky.
(5) "Claim" means a
request for payment of benefits under an in-force policy regardless of whether
the benefit claimed is covered under the policy or any terms or conditions of
the policy have been met.
(6)
"Commissioner" is defined by
KRS
304.1-050.
(7) "Compensation" means pecuniary or
nonpecuniary remuneration of any kind relating to the sale or renewal of
short-term nursing home insurance or certificates, including bonuses, gift,
prizes, awards, and finders fees.
(8) "Elimination period" means the time that
elapses before benefits commence under a short-term nursing home insurance
policy or certificate.
(9)
"Insurer" means an entity authorized to issue short-term nursing home insurance
in Kentucky.
(10) "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).
(11) "Policy" means
any policy, contract, subscriber agreement, enrollment agreement, rider, or
endorsement delivered or issued for delivery in Kentucky.
(12) "Qualified short-term nursing home
insurance contract" is defined by
26 U.S.C. ยง
7702B.
(13) "Short-term nursing home insurance
policies" is defined by
KRS
304.14-650.
Section 2. Policy Requirements. A short-term
nursing home insurance policy delivered or issued for delivery in Kentucky
shall not use the terms set forth below unless the terms are defined in the
policy as follows:
(1) "Activities of daily
living" means at least bathing, continence, dressing, eating, toileting, and
transferring.
(2) "Acute condition"
means that the individual is medically unstable. The individual requires
frequent monitoring by medical professionals, such as physicians and registered
nurses, in order to maintain health status.
(3) "Adult day care" means a program for four
(4) or more individuals, of social or health-related, or both, services
provided during the day in a community group setting for the purpose of
supporting frail, impaired elderly or other disabled adults who can benefit
from care in a group setting outside the home.
(4) "Bathing" means washing oneself by sponge
bath; or in either a tub or shower, including the task of getting into or out
of the tub or shower.
(5)
"Cognitive impairment" means a deficiency in a person's short or long-term
memory, orientation as to person, place, and time, deductive or abstract
reasoning, or judgement as it relates to safety awareness.
(6) "Continence" means the ability to
maintain control of bowel and bladder function; or, when unable to maintain
control of bowel or bladder function, the ability to perform associated
personal hygiene (including caring for catheter or colostomy bag).
(7) "Dressing" means putting on and taking
off all items of clothing and any necessary braces, fasteners, or artificial
limbs.
(8) "Eating" means feeding
oneself by getting food into the body from a receptacle (such as a plate, cup,
or table) or by a feeding tube or intravenously.
(9) "Hands-on assistance" means physical
assistance (minimal, moderate, or maximal) without which the individual would
not be able to perform the activity of daily living.
(10) "Home health care services" means
medical and nonmedical services, provided to ill, disabled or infirm persons in
their residences. The services may include homemaker services, assistance with
activities of daily living, and respite care services.
(11) "Medicare" means "The Health Insurance
for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then
Constituted or Later Amended", or "Title I, Part I of Pub.L.
89-97, as Enacted
by the Eighty-Ninth Congress of the United States of America and popularly
known as the Health Insurance for the Aged Act, as then constituted and any
later amendments or substitutes thereof", or words of similar import.
(12) "Mental or nervous disorder" means not
including more than neurosis, psychoneurosis, psychopathy, psychosis, or mental
or emotional disease or disorder.
(13) "Personal care" or maintenance means the
provision of hands-on services to assist an individual with activities of daily
living.
(14) "Skilled nursing
care", "intermediate care", "personal care", "home care", "specialized care",
"assisted living" and other services means being defined in relation to the
level of skill required, the nature of the care, and the setting in which care
is to be delivered.
(15)
"Toileting" means getting to and from the toilet, getting on and off the
toilet, and performing associated personal hygiene.
(16) "Transferring" means moving into or out
of bed, chair, or wheelchair.
Section
3. Policy Practices and Provisions.
(1) Renewability. The terms "guaranteed
renewable" and "noncancellable" shall not be used in any individual short-term
nursing home insurance policy without further explanatory language in
accordance with the disclosure requirements of Section 5 of this administrative
regulation.
(a) A short-term nursing home
insurance policy issued to an individual shall not contain renewal provisions
other than "guaranteed renewable" or "noncancellable".
(b) The term "guaranteed renewable" may be
used only if the insured has the right to continue the short-term nursing home
insurance in force by the timely payment of premiums and if the insurer has no
unilateral right to make any change in any provision of the policy or rider
while the insurance is in force, and cannot decline to renew, except that rates
may be revised by the insurer on a class basis.
(c) The term "noncancellable" may be used
only if the insured has the right to continue the short-term nursing home
insurance in force by the timely payment of premiums during which period the
insurer has no right to unilaterally make any change in any provision of the
insurance or in the scheduled premium rate.
(d) The term "level premium" may only be used
if the insurer does not have the right to change the premium.
(2)
(a) Limitations and exclusions. A policy
shall not be delivered or issued for delivery in Kentucky as a short-term
nursing home insurance if the policy limits or excludes coverage by type of
illness, treatment, medical condition, or accident, except as follows:
1. Preexisting conditions or diseases as
defined in Section 5(8) through (10) of this administrative
regulation;
2. Mental or nervous
disorders, but this shall not permit exclusion or limitation of benefits on the
basis of Alzheimer's disease;
3.
Alcoholism and drug addiction;
4.
Illness, treatment, or medical condition arising out of:
a. War or act of war (whether declared or
undeclared);
b. Participation in a
felony, riot, or insurrection;
c.
Service in the armed forces or auxiliary units;
d. Suicide (sane or insane), attempted
suicide, or intentionally self-inflicted injury; or
e. Aviation (this exclusion shall apply only
to nonfare-paying passengers);
5. Treatment provided in a government
facility (unless otherwise required by law), services for which benefits are
available under Medicare or other governmental program (except Medicaid), any
state or federal workers' compensation, employer's liability, or occupational
disease law, services provided by a member of the covered person's immediate
family, and services for which no charge is normally made in the absence of
insurance;
(b) This
subsection shall not prohibit exclusions and limitations by type of provider or
territorial limitations.
(3) Continuation or conversion.
(a) Group short-term nursing home insurance
issued in Kentucky on or after the effective date of this administrative
regulation shall provide:
1. A covered
individual with a basis for continuation or conversion of coverage without
underwriting upon termination of coverage; and
2. A converted policy or continued coverage
including benefits identical to or benefits determined by the Commissioner to
be substantially similar to or in excess of those provided under the group
policy from which conversion or continued coverage is made.
(b) Written application for the
converted policy or continued coverage shall be made and the first premium due,
if any, shall be paid as directed by the insurer not later than thirty-one (31)
days following notice of continuation or conversion rights under the group
policy. The converted policy shall be issued effective on the day following the
termination of coverage under the group policy and shall be renewable
annually.
(4) Extension
of benefits. Termination of short-term nursing home insurance shall be without
prejudice to any benefits payable for institutionalization if the
institutionalization began while the short-term nursing home insurance was in
force and continues without interruption after termination. The extension of
benefits beyond the period the short-term nursing home insurance was in force
may be limited to the duration of the benefit period, if any, or to payment of
the maximum benefit and may be subject to any policy waiting period, and all
other applicable provisions of the policy.
(5) Discontinuance and replacement. If a
group short-term nursing home insurance policy is replaced by another group
short-term nursing home insurance policy issued to the same policyholder, the
succeeding insurer shall offer coverage to all persons covered under the
previous group policy on its date of termination. Coverage provided or offered
to individuals by the insurer and premiums charged to persons under the new
group policy shall not:
(a) Result in an
exclusion for preexisting conditions that would have been covered under the
group policy being replaced; and
(b) Vary or otherwise depend on the
individual's health or disability status, claim experience or use of short term
care services.
(6)
Premium changes. The premium charged to an insured for short-term nursing home
insurance shall not increase due to either:
(a) The increasing age of the insured at ages
beyond sixty-five (65); or
(b) The
duration the insured has been covered under the policy.
(7) Coverage of dependents. A short-term
nursing home policy may be issued that jointly covers the life of the
policyholder and his or her spouse.
Section 4. Unintentional Lapse. An insurer
offering short-term nursing home insurance shall, as a protection against
unintentional lapse, comply with the following:
(1) Notice before lapse or termination. An
individual short-term nursing home policy or certificate shall not be issued
until the insurer has received from the applicant either a written:
(a) Designation of at least one (1) person,
in addition to the applicant, who is to receive notice of lapse or termination
of the policy or certificate for nonpayment of premium; or
(b) Waiver, dated and signed by the
applicant, electing not to designate additional persons to receive
notice.
(2) Lapse or
termination for nonpayment of premium:
(a) An
individual short-term nursing home policy or certificate shall not lapse or be
terminated for nonpayment of premium unless the insurer, at least thirty (30)
days before the effective date of the lapse or termination, has given notice to
the insured and to those persons designated pursuant to subsection (1)(a) of
this section, at the address provided by the insured for purposes of receiving
notice of lapse or termination; and
(b) Notice shall:
1. Be given by first class United States
mail, postage prepaid;
2. Not be
given until thirty (30) days after a premium is due and unpaid; and
3. Be found to have been given as of five (5)
days after the date of mailing.
(3) Reinstatement. A short-term nursing home
policy shall contain a reinstatement provision as required in
KRS
304.17-080.
Section 5. Required Information and
Disclosure Provisions.
(1) Renewability.
(a) Individual short-term nursing home
insurance policies shall contain a renewability provision.
(b) The provision shall:
1. Be appropriately captioned;
2. Appear on the first page of the policy;
and
3. State clearly that:
a. The coverage is guaranteed renewable and
that premium rates are subject to change; or
b. the coverage is noncancellable.
(c) All short-term
nursing home policies or certificates issued in the commonwealth of Kentucky
shall state in (16) sixteen point bold type print on the front page of the
policy the following statement: This is a short-term nursing home product that
offers benefits for less than twelve (12) months. This is not a long-term care
policy.
(2) Riders and
endorsements.
(a) Except for riders or
endorsements by which the insurer effectuates a request made in writing by the
insured under an individual short-term nursing home insurance policy, riders or
endorsements added to an individual short-term nursing home insurance policy
after date of issue, reinstatement or renewal which reduce or eliminate
benefits or coverage in the policy shall require signed acceptance by the
individual insured.
(b) After the
date of policy issue, a rider or endorsement which increases benefits or
coverage with a concomitant increase in premium during the policy term shall be
agreed to in writing signed by the insured, except if the increased benefits or
coverage are required by law.
(c)
If a separate additional premium is charged for benefits provided in connection
with riders or endorsements, the premium charge shall be set forth in the
policy, rider, or endorsement.
(3) Payment of benefits. A short-term nursing
home insurance policy or certificate shall clearly define how benefits will be
paid.
(4) Limitations. If a
short-term nursing home insurance policy or certificate contains any
limitations with respect to preexisting conditions, the limitations shall
appear as a separate paragraph of the policy or certificate and shall be
labeled as "Preexisting Condition Limitations".
(5) Other limitations or conditions on
eligibility for benefits. A short-term nursing home insurance policy or
certificate containing any limitations or conditions for eligibility including
any elimination period shall be clearly defined in the policy or certificate
and the paragraph shall be labeled "Limitations or Conditions on Eligibility
for Benefits".
(6) Benefit
triggers.
(a) Activities of daily living and
cognitive impairment shall be:
1. Used to
measure an insured's need for short-term nursing home care;
2. Described in the policy or certificate in
a separate paragraph; and
3.
Labeled "Eligibility for the payment of benefits."
(b) Any additional benefit triggers shall
also be explained in this section.
(c) If these triggers differ for different
benefits, explanation of the trigger shall accompany each benefit
description.
(d) If an attending
physician or other specified person shall certify a certain level of functional
dependency in order to be eligible for benefits, this shall be
specified.
(7) A
provider of service shall be defined in relation to the services and facilities
required to be available and the licensure or degree status of those providing
or supervising the services. The definition may require that the provider be
appropriately licensed or certified.
(8) Short-term nursing home policies or
certificates shall not use a definition of preexisting condition that is more
restrictive than the following: "Preexisting condition means a condition for
which medical services or treatment is recommended by, or received from, a
provider of health care services within six (6) months preceding the effective
date of coverage of an insured person."
(9) A short-term nursing home policy or
certificate shall not exclude coverage for a loss or confinement which is the
result of a preexisting condition unless that loss or confinement begins within
six (6) months following the effective date of coverage of the insured
person.
(10) A short term nursing
home policy or certificate shall not exclude or use waivers or riders of any
kind to exclude, limit, or reduce coverage or benefits for specifically named
or described preexisting conditions or physical conditions beyond the
preexisting condition periods described in subsections (8) and (9) of this
section.
(11) Insurers shall offer
an option to purchase inflation protection at a minimum of three (3) percent
compounded annually with any short-term nursing home policy or
certificate.
(12) Short-term
nursing home policies shall contain on the front page of the policy or
certificate the following statement: "Notice to buyer: This policy may not
cover all of the costs associated with nursing home care incurred by the buyer
during the period of coverage. The buyer is advised to review carefully all
policy limitations".
(13) An
elimination period shall be calculated based upon consecutive calendar days,
beginning the first day eligible services are received by the individual, and
ending the first day benefits are payable.
Section 6. Prohibition Against Post-claims
Underwriting.
(1)
(a) If an application for short-term nursing
home insurance contains a question that asks if the applicant has had
medication prescribed by a physician, it shall also ask the applicant to list
all medication that has been prescribed.
(b) If the medications listed in the
application are known by the insurer, or should have been known at the time of
application, to be directly related to a medical condition that coverage would
otherwise be denied, then the policy or certificate shall not be rescinded for
that condition.
(2) The
following language, or language substantially similar to the following, shall
be set out conspicuously on the short-term nursing home insurance policy or
certificate no later than when it is delivered: "Caution: The issuance of this
short-term nursing home insurance (policy or certificate) is based upon your
responses to the questions on your application. A copy of your (application or
enrollment form) is enclosed or was retained by you when you applied. If your
answers, to the best of your knowledge and belief, are incorrect or untrue, the
insurer may have the right to deny benefits or rescind your policy. The best
time to clear up any questions is now, before a claim arises! If, for any
reason, any of your answers are incorrect, contact the insurer at this address:
(insert address)."
(3) A copy of
the completed application or enrollment form, whichever is applicable, shall be
delivered to the insured no later than when the policy or certificate is
delivered unless it was retained by the applicant at the time of
application.
Section 7.
Reserve Standards.
(1)
(a) If short-term nursing home insurance
benefits are provided through the acceleration of benefits under group or
individual life policies or riders to these policies, policy reserves for these
benefits shall be determined in accordance with
KRS
304.6-130 to
304.6-180.
(b) Claim reserves shall also be established
if the policy or rider is in claim status.
(c) In the development and calculation of
reserves for policies and riders subject to the requirements of this
subsection, due regard shall be given to the applicable policy provisions,
marketing methods, administrative procedures, and all other considerations that
may have an impact on projected claim costs.
(d) Any applicable valuation morbidity table
shall be certified as appropriate as a statutory valuation table by a member of
the American Academy of Actuaries.
(2) If short-term nursing home benefits are
provided other than as described in subsection (1) of this section, reserves
shall be determined in accordance with
KRS
304.6-070.
Section 8. Loss Ratio.
(2) Initial premium rate schedules shall be
calculated so that the present value of future projected incurred claims,
without the inclusion of active life reserves, shall not be less than the
present value of future projected earned premiums times sixty (60)
percent.
(3) Premium rate schedule
increases shall be calculated so that the sum of the accumulated value of
incurred claims, without the inclusion of active life reserves, and the present
value of future projected incurred claims, excluding active life reserves,
shall not be less than the sum of the following:
(a) The accumulated value of the initial
earned premiums times sixty (60) percent;
(b) Eighty-five (85) percent of the
accumulated value of prior premium rate schedule increases on an earned
basis;
(c) The present value of
future projected initial earned premiums times sixty (60) percent;
and
(d) Eighty-five (85) percent of
the present value of future projected premiums not described in paragraph (c)
of this subsection on an earned basis.
(4) All present and accumulated values used
to determine rates shall use the maximum valuation interest rate for contract
reserves as specified in
806
KAR 6:080. The actuary shall disclose as part of the
actuarial memorandum required by
806 KAR
17:070, Section 3, the use of any appropriate
averages.
Section 9.
Minimum Standards for Home Health and Community Care Benefits in Short-term
nursing Insurance Policies.
(1) A short-term
nursing home insurance policy or certificate that provides benefits for home
health care or community care services shall not limit or exclude benefits by:
(a) Requiring that the insured or claimant
would need care in a skilled nursing facility if home health care services are
not provided;
(b) Requiring that
the insured or claimant first or simultaneously receive nursing or therapeutic
services, or both, in a home, community, or institutional setting before home
health care services are covered;
(c) Limiting eligible services to services
provided by registered nurses or licensed practical nurses;
(d) Requiring that a nurse or therapist
provide services covered by the policy that may be provided by a:
1. Home health aide; or
2. Other licensed or certified home care
worker acting within the worker's scope of licensure or
certification;
(e)
Excluding coverage for personal care services provided by a home health
aide;
(f) Requiring that the
provision of home health care services be at a level of certification or
licensure greater than that required by the eligible service;
(g) Requiring that the insured or claimant
have an acute condition before home health care services are covered;
(h) Limiting benefits to services provided by
Medicare-certified agencies or providers; or
(i) Excluding coverage for adult day care
services.
(2)
(a) A short term nursing insurance policy or
certificate that includes home health or community care services shall provide
the total home health or community care coverage that is a dollar amount
equivalent to at least one-half (1/2) of one (1) year of coverage available for
nursing home benefits under the policy or certificate, when covered home health
or community care services are received.
(b) The requirement identified in paragraph
(a) of this subsection shall not apply to a policy or certificate issued to a
resident of a continuing care retirement community.
(3) In determining maximum coverage under the
terms of a policy or certificate, home health care coverage may be applied to
the non-home health care benefits provided in the policy or
certificate.
Section 10.
Prohibition Against Preexisting Conditions and Probationary Periods in
Replacement Policies or Certificates. If a short-term nursing home insurance
policy or certificate replaces another short-term nursing home or long-term
care policy or certificate, the replacing insurer shall waive any time periods
applicable to preexisting conditions and probationary periods in the new
short-term nursing home insurance policy for similar benefits to the extent
that similar exclusions have been satisfied under the original
policy.
Section 11. Filing
Requirements for Advertising.
(1) An insurer
providing short term nursing home care insurance or benefits in Kentucky shall
provide a copy of any advertisement intended for use in Kentucky whether
through written, radio, or television medium to the commissioner for review in
accordance with this administrative regulation and
KRS
304.12-020,
304.14-120,
and
806 KAR 12:010,
806
KAR 14:005,
806 KAR
14:007, Section 5(2);
(2) An advertisement shall be retained by the
insurer for at least five (5) years from the date the advertisement was first
used.
(3) The commissioner may
exempt advertising from the requirements of this section pursuant to
KRS
304.14-120(4).
Section 12. Standards for
Marketing.
(1) An insurer marketing short term
nursing home insurance coverage in Kentucky, directly or through its agents,
shall:
(a) Establish marketing procedures and
agent training requirements to assure that:
1. Marketing activities, including policy
comparison, by its agent, shall be fair and accurate; and
2. Excessive insurance shall not be sold or
issued.
(b) Display
prominently by type, stamp, or other appropriate means, on the first page of
the outline of coverage and policy, the notice as established in
HIPMC-STN-1.
(2) An
insurer shall:
(a) Comply with the
requirements of KRS Chapter 304.12; and
(b) Not perform the following acts and
practices:
1. Twisting;
2. High pressure tactics;
3. Cold lead advertising; and
4. Misrepresentation.
(3)
(a) To comply with the requirements of this
subsection, an association may have the primary responsibility of educating
members concerning short-term nursing home issues in general:
1. If endorsing or selling short-term nursing
home insurance; and
2. To ensure
that its members make informed decisions.
(b) An association shall provide objective
information regarding short-term nursing home insurance policies or
certificates endorsed or sold by the association to ensure that members receive
a balanced and complete explanation of the features of the policy or
certificate that is endorsed or sold.
(c) An insurer shall file with the department
the following:
1. Insurance policies and, if
applicable, certificates;
2.
Outlines of coverage, which corresponds to the filed policy or certificate;
and
3. Advertisements as requested
by the department pursuant to Section 11(1) of this administrative
regulation.
(d) An
association shall disclose in a short-term nursing home insurance solicitation:
1. The specific nature and amount of the
compensation arrangements, including fees, commissions, administrative fees,
and other forms of financial support, which the association receives from
endorsement or sale of the policy or certificate to its members; and
2. A brief description of the process used to
select the policy and the insurer, which issued the policy.
(e) If an association and insurer
have interlocking directorates or trustee arrangements, the association shall
disclose that fact to the association members.
(f) The board of directors of an association
selling or endorsing a short-term nursing home insurance policy or certificate
shall review and approve the:
1. Insurance
policy; and
2. Compensation
arrangements made with the insurer.
(g) Except for a qualified short-term nursing
home insurance contract, an association shall:
1. Upon a decision to endorse a short-term
nursing home insurance contract, engage the services of a person with expertise
in short-term nursing home insurance not affiliated with the insurer to:
a. Conduct an examination of the policy,
including its benefits, features, and rates; and
b. Update the examination, if a material
change is made to the contract;
2. Actively monitor the marketing efforts of
the insurer and agents; and
3.
Review and approve:
a. Marketing materials;
or
b. Insurance communications
other than marketing materials, including communications:
(i) Used to promote sales; or
(ii) Sent to members regarding the policy or
certificate.
(h) A group short-term nursing home insurance
policy or certificate shall not be issued to an association unless the insurer
files with the commissioner the information required in this
subsection.
(i) Unless an insurer
certifies annually that an association has complied with the requirements
established in this subsection, an insurer shall not:
1. Issue a short-term nursing home policy or
certificate to the association; or
2. Continue to market the policy or
certificate.
(j) Failure
to comply with the filing and certification requirements of this section shall
constitute an unfair trade practice in violation of
KRS
304.12-010.
Section 13. Standard Format and Content of an
Outline of Coverage.
(1) An outline of
coverage shall:
(a) Be a freestanding
document, that shall be printed in no less than ten (10) point type;
and
(b) Not contain material of an
advertising nature.
(2)
Text, shall be emphasized by using a method, that provides prominence
equivalent to the:
(a) Capitalization;
or
(b) Underscoring.
(3) Except as indicated, use of
the text and sequence of text shall be:
(a)
Mandatory; and
(b) Consistent with
the Outline of Coverage, HIPMC-STN-1.
(4) The format to be used for the outline of
coverage shall be consistent with the Outline of Coverage,
HIPMC-STN-1.
Section 14.
Standards for Benefit Triggers.
(1) A short
term nursing home insurance policy shall condition the payment of benefits
based upon a determination of the insured's:
(a) Ability to perform activities of daily
living; and
(b) Cognitive
impairment.
(2)
Eligibility for the payment of benefits shall not be more restrictive than
requiring:
(a) A deficiency in the ability to
perform no more than three (3) activities of daily living; or
(b) The presence of cognitive
impairment.
(3)
(a) Activities of daily living shall include
no less than the activities defined in Section 2(1) of this administrative
regulation and the policy; and
(b)
To trigger covered benefits, an insurer may use activities of daily living that
are:
1. Described in paragraph (a) of this
subsection; and
2. In addition to
activities identified in paragraph (a) if defined in the policy.
(4)
(a) An insurer may use a provision other than
activities of daily living as identified in subsection (3) of this section to
determine the date benefits are payable under a policy or certificate;
and
(b) If a provision, as
established in paragraph (a) of this subsection is used by the insurer, the
provision shall not:
1. Restrict the
requirements identified in subsections (1), (2), and (3) of this section;
and
2. Be used in lieu of the
requirements of subsections (1), (2), and (3) of this section.
(5) A determination of
a deficiency, as identified in this section, shall not be more restrictive
than:
(a) Requiring the hands on assistance of
another person to perform the prescribed activities of daily living as
identified in subsection (3) of this section; or
(b) If the deficiency is due to the presence
of a cognitive impairment, supervision, or verbal cueing by another person
shall be needed in order to protect the insured or others.
(6) An assessment of the insured's activities
of daily living and cognitive impairment shall be performed by a licensed or
certified professional, including a:
(a)
Physician;
(b) Nurse; or
(c) Social worker.
(7) A short-term nursing home insurance
policy shall include a clear description of the process for an appeal and
resolution of a benefit determination.
Section 15. Incorporation by Reference.
(1) "Outline of Coverage", HIPMC-STN-1,
03/2021 is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at The Kentucky Department of
Insurance, The Mayo-Underwood Building, 500 Mero Street, Frankfort, Kentucky
40601, Monday through Friday, 8 a.m. to 4:30 p.m. This material is also
available on the Department of Insurance Internet Web site at
https://insurance.ky.gov/ppc/CHAPTER.aspx.