[§431:10H-234.5]  Additional standards forbenefit triggers for qualified long-term care insurance contracts.  (a) For purposes of this section, the following definitions apply:

"Chronically ill individual" has themeaning prescribed for this term by section 7702B(c)(2)(A) of the InternalRevenue Code of 1986, as amended.  Under this provision, a chronically illindividual means any individual who has been certified by a licensed healthcare practitioner as:

(1)  Being unable to perform (without substantialassistance from another individual) at least two activities of daily living fora period of at least ninety days due to a loss of functional capacity; or

(2)  Requiring substantial supervision to protect theindividual from threats to health and safety due to severe cognitiveimpairment.

"Chronically ill individual" shallnot include an individual otherwise meeting these requirements unless withinthe preceding twelve-month period a licensed health care practitioner hascertified that the individual meets these requirements.

"Licensed health care practitioner"means a physician, as defined in section 1861(r)(1) of the Social Security Act,and any registered professional nurse, licensed social worker, or otherindividual who meets requirements prescribed by the Secretary of the Treasury.

"Maintenance or personal careservices" means any care the primary purpose of which is the provision ofneeded assistance with any of the disabilities as a result of which theindividual is a chronically ill individual (including the protection fromthreats to health and safety due to severe cognitive impairment).

"Qualified long-term care services"means services that meet the requirements of section 7702B(c)(1) of theInternal Revenue Code of 1986, as amended, as follows:  necessary diagnostic,preventive, therapeutic, curative, treatment, mitigation and rehabilitativeservices, and maintenance or personal care services which are required by achronically ill individual and are provided pursuant to a plan of care prescribedby a licensed health care practitioner.

(b)  A qualified long-term care insurancecontract shall pay only for qualified long-term care services received by achronically ill individual provided pursuant to a plan of care prescribed by alicensed health care practitioner.

(c)  A qualified long-term care insurancecontract shall condition the payment of benefits on a determination of theinsured's inability to perform activities of daily living for an expectedperiod of at least ninety days due to a loss of functional capacity or tosevere cognitive impairment.

(d)  Certifications regarding activities ofdaily living and cognitive impairment required pursuant to subsection (c) shallbe performed by a licensed health care practitioner.

(e)  Certifications required pursuant tosubsection (d) may be performed by a licensed health care practitioner at thedirection of the carrier as is reasonably necessary with respect to a specificclaim, except that when a licensed health care practitioner has certified thatan insured is unable to perform activities of daily living for an expectedperiod of at least ninety days due to a loss of functional capacity and theinsured is claiming payment of benefits, the certification may not be rescindedand additional certifications may not be performed until after the expirationof the ninety-day period.

(f)  Qualified long-term care insurancecontracts shall include a clear description of the process for appealing andresolving disputes with respect to benefit determinations. [L 2007, c 233, ptof §4]