Okla. Admin. Code § 365:10-5-48.7

Current through Vol. 42, No. 7, December 16, 2024

Section 365:10-5-48.7 - Standards for benefit triggers

(a) 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 (3) of the activities of daily living or the presence of cognitive impairment.

(b)Activities of daily living.

(1) Activities of daily living shall include at least the following as defined in Rule 365:10-5-42(a) and in the policy:

(A) Bathing;

(B) Continence;

(C) Dressing;

(D) Eating;

(E) Toileting; and

(F) Transferring;

(2) Insurers may use activities of daily living to trigger covered benefits in addition to those contained in Paragraph (1) as long as they are defined in the policy.

(c) 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 a and b.

(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; or

(2) 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 shall include a clear description of the process for appealing and resolving benefit determinations.

(g) The requirements set forth in this section shall be effective November 1, 1998, and shall apply as follows:

(1) Except as provided in Paragraph (2), the provisions of this section apply to a long-term care policy issued in this state on or after the effective date of this section.

(2) For certificates issued on or after the effective date of this section, under a group long-term care insurance policy as defined in 36 O.S. Section 4424(4)(a) of the Long-term Care Insurance Act that was in force at the time this section became effective, the provisions of this section shall not apply.

Okla. Admin. Code § 365:10-5-48.7

Added at 15 Ok Reg 3207, eff 7-13-98