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)(d) Provide for an elimination period only if:
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)2.2. It is clearly disclosed;
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)(d)4.4. It does not exceed 365 days.
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.d.d. War or act of war, whether declared or undeclared.
Ins 3.46(4)(m)2.e.e. Participation in a felony, riot or insurrection.
Ins 3.46(4)(m)2.f.f. Service in the armed forces or its auxiliary units.
Ins 3.46(4)(m)2.g.g. Suicide, sane or insane, attempted suicide or intentionally self-inflicted injury.