Ins 3.46(17)(17) Standards for benefit triggers; long-term care, nursing home and home health care policies. Ins 3.46(17)(a)1.1. “Activities of daily living” includes at least bathing, continence, dressing, eating, toileting, and transferring. Ins 3.46(17)(a)2.2. “Bathing” 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. Ins 3.46(17)(a)3.3. “Cognitive impairment” means a deficiency in a person’s short- or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness. Ins 3.46(17)(a)4.4. “Continence” 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. Ins 3.46(17)(a)5.5. “Dressing” means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs. Ins 3.46(17)(a)6.6. “Eating” 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. Ins 3.46(17)(a)7.7. “Hands-on assistance” means physical assistance, either minimal, moderate or maximal, without which the individual would not be able to perform the activity of daily living. Ins 3.46(17)(a)8.8. “Toileting” means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene. Ins 3.46(17)(a)9.9. “Transferring” means moving into or out of a bed, chair or wheelchair. Ins 3.46(17)(b)(b) A long-term care, nursing home only and home health care only policy or certificate 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 may not be more restrictive than requiring either a deficiency in the ability to perform not more than 3 of the activities of daily living or the presence of cognitive impairment. Ins 3.46(17)(c)1.1. Activities of daily living shall include at least those contained in the definition in par. (a). Ins 3.46(17)(c)2.2. Insurers may use deficiencies to perform activities of daily living to determine when covered benefits are payable in addition to those contained in par. (a) as long as they are defined in the policy. Ins 3.46(17)(d)(d) 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 in lieu of, the requirements contained in pars. (b) and (c). Ins 3.46(17)(e)(e) For purposes of this section, the determination of a deficiency may not be more restrictive than any of the following: Ins 3.46(17)(e)1.1. Requiring hands-on assistance of another person to perform the prescribed activities of daily living. Ins 3.46(17)(e)2.2. If the deficiency is due to the presence of cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured and others. Ins 3.46(17)(f)(f) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers. Ins 3.46(17)(g)(g) Long-term care, nursing home only and home health care only policies shall include a clear description of the process for appealing and resolving benefit determinations. Ins 3.46 NoteNote: The rule revision effective August 1, 1996 applies to any policy solicited, delivered or issued after September 1, 1996. After August 1, 1996 but before September 1, 1996, the insurer may market policies under either the current rule or the revised rule, if a policy form conforming to this section has been approved.
Ins 3.46(18)(18) Tax qualified long term care, nursing home and home health care policies. This subsection applies to long term care, nursing home or home health care policies which are intended to be tax qualified under and comply with the requirements of section 7702B of the Internal Revenue Code of 1986, as amended, and any regulations and administrative pronouncements issued under the Code. Ins 3.46(18)(a)(a) In order to qualify for certain tax treatment, long term care, nursing home only and home health care only policy provisions may contain the following conditions as defined in section 7702B of the Internal Revenue Code of 1986 as amended and any regulations and administrative pronouncements issued thereunder notwithstanding sub. (17): Ins 3.46(18)(a)1.1. The terms “severe cognitive impairment” and “substantial supervision” may be used in lieu of the term “cognitive impairment” and its accompanying supervision requirement may be used as a benefit trigger in sub. (17) (a) 3. and (e) 2. Ins 3.46(18)(a)3.3. The requirement that the claimant obtain a certification from a licensed health care practitioner, as defined in section 7702B of the Internal Revenue Code of 1986, as amended, and any regulations and administrative pronouncements issued under the Code, as a condition for claim payment that the functional incapacity or inability to perform at least 2 activities of daily living triggering benefits under the policy is expected to last at least 90 days, may be imposed by the insurer. Ins 3.46(18)(b)(b) The policy shall contain a clear disclosure that the policy is intended to be a tax qualified long term care policy.