N.J. Admin. Code § 11:4-34.25
Current through Register Vol. 56, No. 24, December 18, 2024
Section 11:4-34.25 - Standards for benefit triggers(a) A long-term care insurance policy or certificate 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.(b) Activities of daily living shall include at least bathing, continence, dressing, eating, toileting and transferring as defined in N.J.A.C. 11:4-34.3. 1. Carriers may use activities of daily living in addition to those listed above to trigger covered benefits as long as they are defined in the policy and certificate.(c) A carrier 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 (a) and (b) above.(d) For purposes of this section, the determination of a deficiency shall not be more restrictive than: 1. Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or2. 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.(e) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.(f) Long-term care insurance policies and certificates shall include a clear description of the process for appealing and resolving benefit determinations.(g) The provisions of this section shall not apply to certificates issued under group long-term care insurance policies that were in force on December 19, 2005.N.J. Admin. Code § 11:4-34.25