State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_135 > GS_135-46_1

§ 135‑46.1.  Long‑termcare benefits.

Long‑term care benefitsprovided by this Part are subject to elimination periods, coinsuranceprovisions, and other limitations separate and apart from those provided for inPart 3 of this Article. No limitation on out‑of‑pocket expenses areprovided for the benefits covered by this section. Long‑term carebenefits are as follows:

(1)        Nursing HomeBenefits. – The Plan will pay a fixed amount of the reasonable and customarydaily charges allowed for nursing facilities providing skilled nursing care andintermediate nursing care up to a maximum amount per day for each day after afixed number of consecutive days for each nursing home stay. Such daily chargesshall be inclusive of semiprivate room and board; skilled and semiskillednursing services; routine laboratory tests and examinations; physical,occupational, and speech therapy; respiratory and other gas therapy; and drugs,injections, biologicals, fluids, solutions, dietary aids and supplements, andother routine medical supplies and equipment. Readmission to a nursing homewithin 180 days, exclusive of hospital stays, for the same or related cause orcauses shall be considered a single nursing home stay for the purposes of thissection. Benefits payable under this subdivision are contingent upon compliancewith the following conditions and will, in no instance, be paid under thissection without compliance with each of the following conditions:

a.         Confinement to anursing home is medically appropriate due to an illness, disease, or injuryupon recommendation of an admitting physician other than a proprietor,employee, or agent of the nursing home;

b.         Confinement to anursing home is for any overnight stay for which a charge for a day's stay isdue and payable; and

c.         Prior toconfinement, the admitting physician secures approval certification from thePlan for confinement.

As used in this section, anursing home is a facility or a part of a facility which is (i) operated underState law and which is qualified as a skilled nursing or intermediate nursingfacility under Medicare; or is (ii) a facility meeting the requirements forlicensure under Chapter 131E of the General Statutes.

(2)        Custodial Benefits.– The Plan will pay a fixed percentage of the fixed amount of reasonable andcustomary daily charges allowed by the Plan in subdivision (1) of this sectionfor assisted living facilities, for adult day care facilities, and for homecare agencies up to a maximum amount per day for each day after a fixed numberof consecutive days that such custodial care is provided. Benefits payableunder this subdivision are contingent upon compliance with the followingconditions and will, in no instance, be paid under this subdivision withoutcompliance with each of the following conditions:

a.         Use of suchcustodial benefits is medically appropriate in a treatment plan established andcertified initially and at least once every six months by an attendingphysician or other allied health professionals other than a proprietor,employee, or agent of one or more of the aforementioned facilities andagencies;

b.         Confinement to anursing home would be medically appropriate without custodial care proposed tobe rendered by one or more of the aforementioned facilities or agencies; and

c.         Prior to use of suchcustodial benefits, an attending physician or other allied health professionalsecures approval from the Plan for the use of the benefits.

As used in this section, anassisted living facility is a facility which (i) is operated under State law toprovide residential care for the aged or disabled whose principal need is ahome which provides personal care appropriate to their age or disability; or(ii) meets the requirements for licensure under Chapter 131D of the GeneralStatutes. As used in this section, an adult care facility is a facility which(i) is operated under State law to provide group care for the aged and disabledin a setting away from their residence on a less than 24‑hour basis whensuch aged or disabled would otherwise be in need of full‑time personalcare away from their residence; or (ii) meets the requirements forcertification under Chapter 131D of the General Statutes. As used in thissection, a home care agency is a residential care agency which is (i) operatedunder State law and which is qualified as a home health care agency underMedicare; or (ii) an agency meeting the requirements for licensure as a homecare agency under Chapter 131E of the General Statutes.

(3)        Other Benefits. – Uponprior approval of the Plan, other care, services, supplies, and equipment maybe used as more cost‑effective alternatives to the benefits provided bythis section when directed by an attending physician.

(4)        The ExecutiveAdministrator and Board of Trustees of the Plan shall establish the paymentpercentages, maximum daily payment rates, benefit periods, elimination periods,and maximum lifetime benefits payable for each covered individual for thenursing home and custodial benefits provided by this section. The ExecutiveAdministrator and Board of Trustees shall provide for inflationary increases inthe maximum daily payment rates and the maximum lifetime benefits payable foreach covered individual.

(5)        The ExecutiveAdministrator and Board of Trustees of the Plan shall provide a bed reservationbenefit whenever Plan members are hospitalized during a stay in a nursing homeor an assisted living facility.

(6)        The ExecutiveAdministrator and Board of Trustees of the Plan shall provide for a waiver ofpremiums involving minimum lengths of stay in a nursing home or an assistedliving facility. In addition, the Executive Administrator and Board of Trusteesshall allow coverage to be reinstated upon failure to pay premiums, providedcertain grace periods are not exceeded and retroactive premium payments aremade.

(7)        Limitations andExclusions to Long‑Term Care Benefits. – The benefits provided by thissection are for the purpose of meeting the requirements for assistance from theloss of functional capacity associated with a chronic illness, disease, ordisabling injury for extended periods of time; and are, in no way, intended toduplicate the benefits provided for acute and other medical care provided byMedicare or Part 3 of this Article. A loss of functional capacity can occurfrom: (i) an illness, disease, or disabling injury resulting in a physicalincapacity to perform the activities of daily living; or (ii) an irreversibleorganic mental impairment resulting in a mental incapacity. Activities of dailyliving consist of routine functions involving personal care and mobility.  (1997‑468, s. 7; 2008‑168,ss. 1(a), 4(a), (d), (e).)