Section 760 IAC 2-20-36.1 - Minimum benefit standards and required policy and certificate provisions for integrated policiesAuthority: IC 27-8-12-7.1
Affected: IC 12-15-2; IC 12-15-39.6
Sec. 36.1.
No long term care insurance policy or certificate may be advertised, solicited, or issued for delivery in this state as a qualified integrated policy or certificate that does not meet the minimum benefit standards and required policy and certificate provisions in this section and that has not been approved by the commissioner of the department as a qualified long term care insurance policy or certificate. These minimum standards do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards. These standards are in addition to all other requirements of this article. In order to qualify for participation in the Indiana long term care program, an integrated policy or certificate must meet the following:
(1) Contain a maximum benefit amount equivalent to at least three hundred sixty-five (365) times the minimum daily nursing facility benefit defined in subdivision (3)(A).(2) Offer a maximum benefit amount option equivalent to three hundred sixty-five (365) times the minimum daily nursing facility benefit defined in subdivision (3)(A). Issuers may offer other benefit amount options in addition to this minimum benefit amount option.(3) At a minimum, upon the initial effective date, provide the following:(A) A daily nursing facility benefit of at least seventy-five percent (75%) of the average daily private pay rate in nursing facilities rounded to the next highest five dollar ($5) or ten dollar ($10) increment. No policy or certificate shall pay benefits in excess of the actual charges.(B) A daily home and community based benefit of at least fifty percent (50%) of the daily nursing facility benefit contained in the policy or certificate. No policy or certificate shall pay benefits in excess of the actual charges.(C) The daily home and community based benefit shall not exceed the daily nursing facility benefit.(4) If issued on an expense incurred basis, provide benefits that are equal to at least seventy-five percent (75%) of the per diem cost incurred by the insured.(5) Include a provision that policy or certificate benefits can be used to purchase nursing facility care or home and community-based care. Home and community-based care shall include, at a minimum, but not be limited to, the following: (B) Home health aide services.(E) Adult day care services.(6) All home and community-based services shall include case management services delivered by a case management agency. The issuer may establish a limit on case management benefits. This limit shall not be less than thirteen (13) times the daily nursing home benefit per year. Case management benefits shall not count toward the policy's or certificate's maximum benefit.(7) Issuers may include benefits for residential care facilities, as defined in section 31.1 of this rule, in an integrated policy or certificate. These policies must:(A) provide a daily residential care facility benefit of at least seventy-five percent (75%) and no more than the daily nursing facility benefit contained in the policy or certificate;(B) if issued on an expense incurred basis, provide a daily residential care facility benefit that does not exceed seventy-five percent (75%) of the per diem cost incurred by the insured; and(C) include a provision that policy or certificate benefits can be used to purchase care in a nursing facility or residential care facility.Department of Insurance; 760 IAC 2-20-36.1; filed Jun 15, 1994, 10:00 a.m.: 17 IR 2651; errata filed Sep 28, 1994, 3:30 p.m.: 18 IR 268; filed Feb 9, 1999, 5:02 p.m.: 22 IR 1994; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; filed Oct 7, 2004, 1:00 p.m.: 28 IR 589; readopted filed Nov 27, 2007, 4:01 p.m.: 20071226-IR-760070717RFA; readopted filed November 26, 2013, 3:43 p.m.: 20131225-IR-760130479RFAReadopted filed 11/19/2019, 9:18 a.m.: 20191218-IR-760190497RFAReadopted filed 11/30/2022, 11:39 a.m.: 20221228-IR-760220302RFA