Ins 3.46(3)(m)1.1. A Medicare supplement policy, Medicare replacement policy, or an endorsement or rider to such a policy. Ins 3.46(3)(m)3.3. A rider designed specifically to meet the requirements for coverage of skilled nursing care under s. 632.895 (3), Stats. Ins 3.46(3)(n)(n) “Medicaid” means the federal and state entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources established by Title XIX, 42 U.S.C. 1396 to 1396r-3. The federal government provides matching funds to the state Medicaid programs. Ins 3.46(3)(p)(p) “Medicare eligible persons” means persons who qualify for Medicare. Ins 3.46(3)(q)(q) “Mental or nervous disorder” may not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder. Ins 3.46(3)(r)(r) “Noncancellable” means an individual policy in which the insured has the right to continue the insurance in force by the timely payment of premiums during which period the insurer has no right to unilaterally make any change in any provision of the insurance or in the premium rate. Ins 3.46(3)(s)(s) “Outline of coverage” means a document that gives a brief description of benefits in the format prescribed in Appendix 1 to this section and which complies with sub. (8). Ins 3.46(3)(t)(t) “Personal care” means the provision of hands-on services to assist an individual with activities of daily living. Ins 3.46(3)(u)(u) “Qualified long-term care services” means services that meet the requirements of section 7702(c)(1) of the Internal Revenue Code of 1986, as amended, including the following: Ins 3.46(3)(u)1.1. Necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation and rehabilitative services. Ins 3.46(3)(u)2.2. Maintenance or personal care services that are required by a chronically ill individual. Ins 3.46(3)(u)3.3. Services that are provided pursuant to a plan of care prescribed by a licensed health care practitioner. Ins 3.46(3)(v)(v) “Skilled nursing care,” “personal care,” “home care,” “specialized care,” “assisted living care,” and other services shall be defined in relation to the level of skill required, the nature of the care and the setting in which care shall be delivered. Ins 3.46(3)(x)(x) “Wisconsin Long-Term Care Insurance Partnership Program” or “state partnership program” means the program developed by the department to meet the requirements of s. 49.45 (31), Stats. Ins 3.46(4)(4) General form requirements for long-term care, nursing home and home health care policies and life insurance-long-term care coverage. Forms for a long-term care policy, life insurance-long-term care coverage and certificates shall: Ins 3.46(4)(a)(a) Provide coverage for each person insured for convalescent and custodial care and care for chronic conditions and terminal illness. Ins 3.46(4)(b)(b) Establish fixed daily benefit limits only if the highest limit is not less than $60 per day. This fixed daily benefit applies to the total long-term care insurance in force for any one insured. Ins 3.46(4)(c)(c) Establish a fixed daily benefit limit based on the level of the covered care only if the lowest limit of daily benefits provided for under the policy or coverage is not less than 50% of the highest limit of daily benefits and the following when applicable: Ins 3.46(4)(c)1.1. If the policy provides for home health or community care services, it shall provide total home health or community care coverage that is a dollar amount equivalent to at least one-half of one year’s coverage available for nursing home benefits under the policy or certificate, at the time covered home health or community care services are being received. This requirement may not apply to policies or certificates issued to residents of continuing care retirement communities. Ins 3.46(4)(c)2.2. Home health care coverage may be applied to the non-home health care benefits provided in the policy or certificate when determining maximum coverage under the terms of the policy or certificate. Ins 3.46(4)(d)1.1. It is expressed in a number of days per lifetime or per period of confinement; Ins 3.46(4)(d)3.3. Days for which Medicare provides coverage are counted for the purpose of determining expiration of the elimination period; and Ins 3.46(4)(e)(e) Provide for a lifetime maximum limit only if the limit provides not less than 365 days of coverage. Only days of coverage under the policy, coverage or certificate may be applied against a lifetime maximum limit. Coverage by Medicare may not be applied against a lifetime maximum limit. Ins 3.46(4)(f)(f) Clearly disclose that it does not cover duplicate payments by Medicare for nursing home care or home health care if it has either exclusion. Ins 3.46(4)(g)(g) Provide coverage regardless of whether care is medically necessary. Coverage shall be triggered in conformance with the provisions contained in subs. (17) and (18). Ins 3.46(4)(h)(h) Not limit or condition coverage or benefits by requiring prior hospitalization or prior receipt of care, or benefits for care, in an institutional setting. Ins 3.46(4)(i)(i) Cover irreversible dementia. Coverage may not be excluded or limited on the basis of irreversible dementia. Ins 3.46(4)(j)(j) Define terms used to describe covered services, including, but not limited to, “skilled nursing care,” extended care facility,” “convalescent nursing home,” “personal care,” or “home care” services, if those terms are used, in relation to the services and facilities required to be available and the licensure, certification, registration or degree status of those providing or supervising the services. When the definition requires that the provider be appropriately licensed, certified or registered, it shall also state what requirements a provider shall meet in lieu of licensure, certification or registration when the state in which the service is to be furnished does not require a provider of these services to be licensed, certified or registered, or when the state licenses, certifies or registers the providers of services under another name. Ins 3.46(4)(k)(k) All providers of services, including, but not limited to, “skilled nursing facility,” “extended care facility,” “convalescent nursing home,” “personal care facility,” “specialized care providers,” “assisted living,” and “home care agency,” shall be defined in relation to the services and facilities required to be available and the licensure, certification, registration or degree status of those providing or supervising the services in the state where the policy was issued. When the definition requires that a provider be appropriately licensed, certified or registered, it shall also state what requirements a provider shall meet in lieu of licensure, certification or registration when the state in which the service is to be furnished does not require a provider of such services to be licensed, certified or registered, or if the state licenses, certifies or registers the provider of services under another name. Ins 3.46(4)(m)(m) Not exclude or limit coverage by type of illness, treatment, medical condition or accident, except it may include exclusions or limits for any of the following: Ins 3.46(4)(m)1.1. Preexisting conditions or diseases. If a long-term care insurance policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy and shall be labeled as “Preexisting Condition Limitations.” Ins 3.46(4)(m)2.2. Illness, treatment or medical condition arising out of any one or more of the following: Ins 3.46(4)(m)2.a.a. Treatment provided in a government facility, unless otherwise required by law. Ins 3.46(4)(m)2.b.b. Services for which benefits are available under Medicare or other governmental programs, except Medicaid, or under a state or federal worker’s compensation, employer’s liability, occupational disease law, or any motor vehicle no-fault law. Ins 3.46(4)(m)2.c.c. Services provided by a member of the insured’s immediate family or for which no charge is normally made in the absence of insurance. Ins 3.46(4)(m)2.g.g. Suicide, sane or insane, attempted suicide or intentionally self-inflicted injury. Ins 3.46(4)(m)2.h.h. Aviation, however, this exclusion applies only to non-fare-paying passengers. Ins 3.46(4)(m)3.3. Mental or nervous disorders; however, this may not permit exclusion or limitation of benefits on the basis of Alzheimer’s Disease. Ins 3.46(4)(m)5.5. Expenses for services or items available or paid under another long-term care insurance or health insurance policy. Ins 3.46(4)(m)6.6. This paragraph is not intended to prohibit exclusions or limitation by type of provider. In this subdivision, “state of policy issue” means the state in which the individual policy or certificate was originally issued. However, no long-term care insurer may deny a claim because services are provided in a state other than the state of policy issue when either of the following conditions occurs: Ins 3.46(4)(m)6.a.a. When a state other than the state of policy issue does not have the provider licensing, certification, or registration required in the policy, but where the provider satisfies the policy requirements outlined for providers in lieu of licensure, certification or registration. Ins 3.46(4)(m)6.b.b. When a state other than the state of policy issue licenses, certifies or registers the provider under another name. Ins 3.46(4)(m)7.7. This paragraph is not intended to prohibit territorial limitations. Ins 3.46(4)(m)8.8. If payment of benefits is based on standards described as “usual and customary,” “reasonable and customary” or words of similar import shall include a definition of these terms and include an explanation of the terms in its accompanying outline of coverage and comply with s. Ins 3.60 (5). Ins 3.46(4)(m)9.9. In the case of a qualified long-term care insurance contract, expenses for services or items to the extent that the expenses are reimbursable under Medicare or would be so reimbursable but for the application of a deductible or coinsurance amount. Ins 3.46(4)(m)10.10. Subject to the policy provisions, any plan of care required under the policy shall be provided by a licensed health care practitioner and does not require insurer approval. The insurer may provide a predetermination of benefits payable pursuant to the plan of care. This does not prevent the insurer from having discussions with the licensed health care practitioner to amend the plan of care. The insurer may also retain the right to verify that the plan of care is appropriate and consistent with generally accepted standards. Ins 3.46(4)(m)11.11. A long-term care policy containing post-confinement, post-acute care, or recuperative benefits shall include in a separate policy provision entitled “Limitation or Conditions on Eligibility for Benefits,” the limitations or conditions applicable to these benefits, including any required number of days of confinement. Ins 3.46(4)(n)(n) Not exclude or limit any coverage of care provided in a community-based setting, including, but not limited to, coverage of home health care, by any of the following: Ins 3.46(4)(n)2.2. Requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services before community-based care is covered. Ins 3.46(4)(n)3.3. Limiting eligible services to services provided by registered nurses or licensed practical nurses. Ins 3.46(4)(n)4.4. Requiring that the insured have an acute condition before community-based care is covered. Ins 3.46(4)(n)5.5. Limiting benefits to services provided by Medicare certified agencies or providers. Ins 3.46(4)(o)(o) Provide substantial scope of coverage of facilities for any benefits it provides for care in an institutional setting. Ins 3.46(4)(p)(p) Provide substantial scope of coverage of facilities and programs for any benefits it provides for care in a community-based setting. Ins 3.46(4)(q)(q) Contain a description of the benefit appeal procedure and comply with s. 632.84, Stats. Ins 3.46(4)(r)(r) If coverage of care in a community-based setting is included, provide coverage of all types of care provided by state licensed or Medicare certified home health care agencies. A long-term care insurance policy may not, if it provides benefits for home health care or community care services limit or exclude benefits by any of the following acts: Ins 3.46(4)(r)1.1. Requiring that the insured or claimant would need care in a skilled nursing facility if home health care services were not provided. Ins 3.46(4)(r)2.2. Requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services, or both, in a home, community or institutional setting before home health care services is covered. Ins 3.46(4)(r)3.3. Requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide or other licensed or certified home care worker acting within the scope of his or her licensure or certification. Ins 3.46(4)(r)4.4. Excluding coverage for personal care services provided by a home health aide. Ins 3.46(4)(r)5.5. Requiring that the provision of home health care services be at a level of certification or licensure greater than that required by the eligible service. Ins 3.46(4)(r)6.6. Requiring that the insured or claimant have an acute condition before home health care services are covered. Ins 3.46(4)(r)7.7. Limiting benefits to services provided by Medicare-certified agencies or providers. Ins 3.46(4)(s)(s) If coverage of care in an institutional setting is provided, not condition eligibility for coverage of custodial or intermediate care on the concurrent or prior receipt of intermediate or skilled care. Ins 3.46(4)(t)(t) Include a provision which allows for reinstatement of coverage, in the event of lapse, if the insurer is provided proof of cognitive impairment or the loss of functional capacity and if the reinstatement of coverage is requested within 5 months after termination and provision is made for the collection of past due premiums, where appropriate. The standard of proof of cognitive impairment or loss of functional capacity to be used in evaluating an application for reinstatement may not be more stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional capacity, if any, contained in the policy and certificate. Ins 3.46(4)(u)(u) Require a signed acceptance by the individual insured for all riders or endorsements added to an individual long-term care insurance policy after the date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy, except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual long-term care insurance policy. After the date of issue, any rider or endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, except if the increased benefits or coverage are required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy, rider, or endorsement. Ins 3.46(5)(5) Form requirements for long-term care, nursing home and home health care policies only. Ins 3.46(5)(b)(b) A form for long-term care policy or certificate shall: Ins 3.46(5)(b)2.2. Include the unrestricted right to return the policy or certificate within 30 days of the date it is received by the policyholder and comply with s. 632.73 (2m), Stats. Ins 3.46(5)(b)3.3. If it is a policy or certificate which covers care in both institutional and community-based settings, contain a caption as follows: THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR LONG-TERM CARE INSURANCE.
THIS POLICY MEETS THOSE STANDARDS. THIS POLICY COVERS CERTAIN TYPES OF NURSING HOME AND HOME HEALTH CARE SERVICES. THERE MAY BE LIMITATIONS ON THE SERVICES COVERED. READ YOUR POLICY CAREFULLY.
FOR MORE INFORMATION ON LONG-TERM CARE SEE THE “GUIDE TO LONG-TERM CARE” GIVEN TO YOU WHEN YOU APPLIED FOR THIS POLICY. THIS POLICY’S BENEFITS ARE NOT RELATED TO MEDICARE.
Ins 3.46(5)(b)4.4. If it is a policy or certificate which covers care only in an institutional setting, contain a caption as follows: THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR NURSING HOME INSURANCE. THIS POLICY MEETS THOSE STANDARDS.
/code/admin_code/ins/3
true
administrativecode
/code/admin_code/ins/3/46/4/f
Office of the Commissioner of Insurance (Ins)
administrativecode/Ins 3.46(4)(f)
administrativecode/Ins 3.46(4)(f)
section
true
