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)(r)8.8. Excluding coverage for adult day care services.
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)(a)(a) This subsection and ss. Ins 3.13 (2) (j) and 3.39 (9) (a) and ss. 632.76 and 632.897, Stats., do not apply to life insurance-long-term care coverage.
Ins 3.46(5)(b)(b) A form for long-term care policy or certificate shall:
Ins 3.46(5)(b)1.1. Comply with the restrictions on preexisting condition provisions under s. 632.76, Stats.
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.
THIS POLICY COVERS CERTAIN TYPES OF NURSING HOME CARE. THIS POLICY DOES NOT COVER HOME HEALTH CARE. 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)5.5. If it is a policy or certificate which covers care in a community setting only, contain a caption as follows:
THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR HOME HEALTH CARE INSURANCE. THIS POLICY MEETS THOSE STANDARDS.