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
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certification may not be rescinded and additional certifications may not be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.
28 SDR 157, effective May 19, 2002.
Authority: SDCL 58-17B-4.
Implemented: SDCL 58-17B-4.
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