627.94074 Standards for benefit triggers.
627.94074 Standards for benefit triggers.
(1)(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 of the activities of daily living or the presence of cognitive impairment; or
(b) If a policy is a qualified long-term care insurance policy, the policy shall condition the payment of benefits on a determination of the insured’s being chronically ill; having a level of disability similar, as provided by rule of the commission, to the insured’s ability to perform activities of daily living; or being cognitively impaired as described in paragraph (6)(b). Eligibility for the payment of benefits shall not be more restrictive than requiring a deficiency in the ability to perform not more than three of the activities of daily living.
(2) Activities of daily living shall include at least:
(a) “Bathing,” which means washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower.
(b) “Continence,” which means the ability to maintain control of bowel and bladder function, or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene, including caring for catheter or colostomy bag.
(c) “Dressing,” which means putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.
(d) “Eating,” which means feeding oneself by getting food into the body from a receptacle, such as a plate, cup, or table, or by a feeding tube or intravenously.
(e) “Toileting,” which means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
(f) “Transferring,” which means moving into or out of a bed, chair, or wheelchair.
(3) Insurers may use activities of daily living to trigger covered benefits in addition to those contained in subsection (2) as long as they are defined in the policy.
(4) An issuer of qualified long-term care contracts is limited to considering only the activities of daily living listed in subsection (2).
(5) An insurer may use additional provisions, for a policy described in paragraph (1)(a), 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 (1) and (2).
(6) For purposes of this section, the determination of a deficiency due to loss of functional capacity or cognitive impairment shall not be more restrictive than:
(a) Requiring the hands-on assistance of another person to perform the prescribed activities of daily living, meaning physical assistance, minimal, moderate, or maximal, without which the individual would not be able to perform the activity of daily living; or
(b) Due to the presence of a cognitive impairment, requiring supervision, including verbal cueing by another person in order to protect the insured or others.
(7) Assessment of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses, or social workers.
(8) Long-term care insurance policies shall include a clear description of the process for appealing and resolving the benefit determinations.
(9) The requirement set forth in this section shall be effective on July 1, 1997, and shall apply as follows:
(a) Except as provided in paragraph (b), the provisions of this section apply to a long-term care policy issued in this state on or after July 1, 1997.
(b) The provisions of this section do not apply to certificates under a group long-term care insurance policy in force on July 1, 1997.
History. s. 7, ch. 96-275; s. 21, ch. 97-179; s. 1242, ch. 2003-261.