[§431:10H-234]  Standards for benefittriggers.  (a)  A long-term care insurance policy shall condition thepayment of benefits on a determination of the insured's ability to performactivities of daily living and on cognitive impairment.  Eligibility for thepayment of benefits shall not be more restrictive than requiring either adeficiency in the ability to perform not more than three of the activities ofdaily living or the presence of cognitive impairment.

(b)  Activities of daily living shall includeat least the following as defined in section 431:10H-201 and the policy:bathing, continence, dressing, eating, toileting, and transferring.  Insurersmay use activities of daily living to trigger covered benefits in addition tothose contained in the preceding sentence as long as they are defined in thepolicy.

(c)  An insurer may use additional provisionsfor the determination of when benefits are payable under a policy orcertificate, however the provisions shall not restrict and are not in lieu ofthe requirements under subsections (a) and (b).

(d)  For purposes of this section thedetermination of a deficiency shall not be more restrictive than:

(1)  Requiring the hands-on assistance of anotherperson to perform the prescribed activities of daily living; or

(2)  If the deficiency is due to the presence of acognitive impairment, supervision or verbal cueing by another person is neededin order to protect the insured or others.

(e)  Assessments of activities of daily livingand cognitive impairment shall be performed by licensed or certifiedprofessionals, such as physicians, nurses, or social workers.

(f)  Long-term care insurance policies shallinclude a clear description of the process for appealing and resolving benefitdeterminations.

(g)  The requirements set forth in this sectionshall be effective July 1, 2000, and shall apply as follows:

(1)  Except as provided in paragraph (2), this sectionapplies to a long-term care policy issued in this State after June 30, 2000;

(2)  For certificates issued after June 30, 2000,under a group long-term care insurance policy as defined in paragraph (1) underthe definition of "group long-term care insurance" in section431:10H-104, which policy was in force on July 1, 2000, this section shall notapply. [L 1999, c 93, pt of §2]