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Rule 20:06:21:56 Additional standards for benefit triggers for qualified long-term care insurance contracts.

          20:06:21:56.  Additional standards for benefit triggers for qualified long-term care insurance contracts. A qualified long-term care insurance contract shall pay only for qualified long-term care services received a chronically ill individual provided pursuant to a plan of care prescribed by a licensed health care practitioner. 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.

          Certification regarding activities of daily living and cognitive impairment required pursuant to this section shall be performed by the following licensed or certified professionals: physicians, registered professional nurses, licensed social workers, or other individuals who meet requirements prescribed by the Secretary of the Treasury, if approved by the director. Certifications required pursuant to this section may be performed by any licensed health care professional, or, at the insured's option, 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at least 90 days due to a loss of functional capacity and the insured is in claim status, the certification may not be rescinded and additional certifications may not be performed until after the expiration of the 90-day period.

          Qualified long-term care insurance contracts must include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.

          Source: 28 SDR 157, effective May 19, 2002.

          General Authority: SDCL 58-17B-4.

          Law Implemented: SDCL 58-17B-4.


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