Section 3 AAC 28.583 - Standards for benefit triggers(a) A long-term care insurance policy must 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 may 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) Insurers may use activities of daily living to trigger covered benefits in addition to those contained in this subsection if they are defined in the policy. Activities of daily living must include at least the following as defined in 3 AAC 28.551 and 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 may not restrict, and are not instead of, the requirements contained in (a) and (b) of this section.(d) For purposes of this section the determination of a deficiency may 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, the need for supervision or verbal cueing by another person to protect the insured or others.(e) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals including physicians, nurses, or social workers.(f) A long term care insurance policy must include a clear description of the process for appealing and resolving benefit determinations.(g) The requirements set out in this section apply an and after January 1, 2023, as follows; (1) except as provided in (2) of this subsection, the provisions of this section apply to a long-term care policy issued in this state on or after {effective date of 3 AAC 28.550-3 AAC 28.599};(2) for certificates issued on or after {effective date of this section} under a group long-term care insurance policy as defined in AS 21.53.200(3)(A) that was in force before {effective date of 3 AAC 28.550 - 3 AAC 28.599} the provisions of this section do not apply. Eff. 3/27/2022, Register 241, April 2022Authority:AS 21.06.090
AS 21.53.064
AS 21.53.090