NAC687B.117. Restrictions on limitation or exclusion of benefits.

     1. A long-term care insurance contract or certificate that provides benefits for services related to home health care or community care must not limit or exclude benefits:

     (a) By requiring that the insured or claimant would need care in a skilled nursing facility if services related to home health care were not provided;

     (b) By requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services in a home, community or institutional setting before services related to home health care are covered;

     (c) By limiting eligible services provided by registered nurses or licensed practical nurses;

     (d) By requiring that a nurse or therapist provide services covered by the long-term care insurance contract that can be provided by a home health aide, or other licensed or certified person providing home health care acting within the scope of his or her licensure or certification;

     (e) By excluding coverage for services related to personal care provided by a home health aide;

     (f) By requiring that the provision of services related to home health care be at a level of certification or licensure greater than that required by the eligible service;

     (g) By requiring that the insured or claimant have an acute condition before services related to home health care are covered;

     (h) By limiting benefits to services provided by agencies or providers certified by Medicare; or

     (i) By excluding coverage for services related to adult day care.

     2. Except as otherwise provided in subsection 3, a long-term care insurance contract or certificate that provides for services related to home health care or community care must provide total coverage for home health care or community care in an amount equivalent in dollars to at least one-half of 1 year’s benefits for care received in a nursing home pursuant to the coverage available under the long-term care insurance contract or certificate at the time covered services related to home health care or community care are being received.

     3. The provisions of subsection 2 do not apply to a long-term care insurance contract or certificate issued to a resident of a retirement community which provides continuing care.

     4. For the purpose of determining the maximum coverage under the terms of the long-term care insurance contract or certificate, coverage for home health care may be applied to the benefits provided in the long-term care insurance contract or certificate for care other than home health care.

     (Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R028-10, 12-16-2010, eff. 10-1-2011)