Section 3 AAC 28.584 - Additional standards for benefit triggers for qualified long-term, care insurance contracts(a) A qualified long-term care insurance contract may pay only for qualified long-term care services received by a chronically ill individual provided under a plan of care prescribed by a licensed health care practitioner.(b) A qualified long-term care insurance contract must 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.(c) Certifications regarding activities of daily living and cognitive impairment required under (b) of this section shall be performed by the following licensed or certified professionals: (1) Physicians within the meaning given in 42 U.S.C. 1395 x(r)(l) (see 1861 (r)(l), social security Act);(2) registered professional nurses;(3) licensed social workers; or(4) other individuals who meet requirements prescribed by the Secretary of the Treasury.(d) Certifications required under (b) of this section 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at least 90 days due to a loss of functional capacity and the insured is in claim status, the certification may not be rescinded and additional certifications may not be performed until after the expiration of the 90-day period.(e) Qualified long-term care insurance contracts must include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.(f) For purposes of this section, (1) "qualified long-term care services" means services that meet the requirements of 26 U.S.C. 7702B(c)(1) Internal Revenue Code, and that consist of diagnostic, preventive, therapeutic, curative, treatment, mitigation and rehabilitative services and maintenance or personal care services, that are required by a chronically ill individual, and are provided under a plan of care prescribed by a licensed health care practitioner;(2) "chronically ill individual" has the meaning given under 26 U.S.C. 7702B(c)(2) (Internal Revenue Code) under this provision, a chronically ill individual means an 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 dally living for a period of at least 90 days due to a loss of functional capacity;(B) requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment; or(C) an individual otherwise meeting these requirements that a licensed health care practitioner has certified that the individual meets these requirements in the preceding 12-month period;(3) "licensed health care practitioner" means a physician within the meaning given in 42 U.S.C. 1395x(r)(i) (sec.1861(r)(l) of the Social Security Act a registered professional nurse, a licensed social worker, or other individual who meets requirements prescribed by the Secretary of the Treasury;(4) "maintenance or personal care services" means care the primary purpose of which IS the provision of needed assistance with 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.Eff. 3/27/2022, Register 241, April 2022Authority:AS 21.06.090
AS 21.53.064
AS 21.53.090