[§431:10H-234.5]  Additional standards for

benefit triggers for qualified long-term care insurance contracts.  (a) 

For purposes of this section, the following definitions apply:

     "Chronically ill individual" has the

meaning prescribed for this term by section 7702B(c)(2)(A) of the Internal

Revenue Code of 1986, as amended.  Under this provision, a chronically ill

individual means any individual who has been certified by a licensed health

care practitioner as:

     (1)  Being unable to perform (without substantial

assistance from another individual) at least two activities of daily living for

a period of at least ninety days due to a loss of functional capacity; or

     (2)  Requiring substantial supervision to protect the

individual from threats to health and safety due to severe cognitive

impairment.

     "Chronically ill individual" shall

not include an individual otherwise meeting these requirements unless within

the preceding twelve-month period a licensed health care practitioner has

certified that the individual meets these requirements.

     "Licensed health care practitioner"

means a physician, as defined in section 1861(r)(1) of the Social Security Act,

and any registered professional nurse, licensed social worker, or other

individual who meets requirements prescribed by the Secretary of the Treasury.

     "Maintenance or personal care

services" means any care the primary purpose of which is the provision of

needed assistance with any of the disabilities as a result of which the

individual is a chronically ill individual (including the protection from

threats to health and safety due to severe cognitive impairment).

     "Qualified long-term care services"

means services that meet the requirements of section 7702B(c)(1) of the

Internal Revenue Code of 1986, as amended, as follows:  necessary diagnostic,

preventive, therapeutic, curative, treatment, mitigation and rehabilitative

services, and maintenance or personal care services which are required by a

chronically ill individual and are provided pursuant to a plan of care prescribed

by a licensed health care practitioner.

     (b)  A qualified long-term care insurance

contract shall pay only for qualified long-term care services received by a

chronically ill individual provided pursuant to a plan of care prescribed by a

licensed health care practitioner.

     (c)  A qualified long-term care insurance

contract shall condition the payment of benefits on a determination of the

insured's inability to perform activities of daily living for an expected

period of at least ninety days due to a loss of functional capacity or to

severe cognitive impairment.

     (d)  Certifications regarding activities of

daily living and cognitive impairment required pursuant to subsection (c) shall

be performed by a licensed health care practitioner.

     (e)  Certifications required pursuant to

subsection (d) may be performed by a licensed health care practitioner at the

direction of the carrier as is reasonably necessary with respect to a specific

claim, except that when a licensed health care practitioner has certified that

an insured is unable to perform activities of daily living for an expected

period of at least ninety days due to a loss of functional capacity and the

insured is claiming payment of benefits, the certification may not be rescinded

and additional certifications may not be performed until after the expiration

of the ninety-day period.

     (f)  Qualified long-term care insurance

contracts shall include a clear description of the process for appealing and

resolving disputes with respect to benefit determinations. [L 2007, c 233, pt

of §4]