NAC687B.083. Contract or certificate to condition payment of benefits on insured’s ability to perform daily activities and cognitive impairment.

     1. A long-term care insurance contract or certificate must condition the payment of benefits on a determination of the ability of the insured to perform activities of daily living and on the cognitive impairment of the insured. Eligibility for the payment of benefits must not be more restrictive than requiring a determination that the insured:

     (a) Is unable to perform more than three of the activities of daily living; or

     (b) Has a cognitive impairment.

     2. For the purpose of determining the ability of an insured to perform the activities of daily living pursuant to subsection 1, such activities include, without limitation:

     (a) Bathing;

     (b) Continence;

     (c) Dressing;

     (d) Eating;

     (e) Toileting;

     (f) Transferring; and

     (g) Any other activity of daily living defined in the long-term care insurance contract or certificate.

     3. For the purposes of this section, the determination of a deficiency in the ability of the insured to perform the activities of daily living must not be more restrictive than a determination that the insured:

     (a) Requires the hands-on assistance of another person to perform the prescribed activities of daily living; and

     (b) If the deficiency is due to a cognitive impairment, requires supervision or verbal cues by another person to protect the insured or other persons.

     4. Determinations regarding activities of daily living and cognitive impairment must be performed by a licensed health care practitioner.

     5. In addition to the criteria set forth in subsections 1 to 4, inclusive, an insurer may use any other criteria for determining when benefits are payable under a long-term care insurance contract or certificate that are not more restrictive than the criteria set forth in subsection 1.

     6. A long-term care insurance contract or certificate must include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.

     7. Except for certificates issued on or after October 1, 2008, under a group long-term care insurance contract issued to a group described in subsection 1 of NAC 687B.025 that was in force on October 1, 2008, the provisions of this section apply to any long-term care insurance contract or certificate issued in this State on or after October 1, 2008.

     8. As used in this section, “licensed health care practitioner” means a person licensed pursuant to chapters 630 to 633, inclusive, of NRS, a licensed social worker or other individual who meets the requirements prescribed by the Secretary of the Treasury pursuant to 26 U.S.C. § 7702B(c)(4).

     (Added to NAC by Comm’r of Insurance by R121-07, 9-18-2008, eff. 10-1-2008; A by R028-10, 12-16-2010, eff. 10-1-2011)