(a) A long-term care insurance policy shall condition the payment of benefits on a determination of the insured’s ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall not be more restrictive than requiring either a deficiency in the ability to perform not more than three of the activities of daily living or the presence of cognitive impairment.

Terms Used In Hawaii Revised Statutes 431:10H-234

  • Certificate: means , for the purposes of this article, any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this State. See Hawaii Revised Statutes 431:10H-104
  • Group long-term care insurance: means a long-term care insurance policy which is delivered or issued for delivery in this State and issued to:

    (1) One or more employers or labor organizations, or a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof, of the labor organizations; or

    (2) Any professional, trade, or occupational association for its members or former or retired members, or combination thereof, if the association:

    (A) Is composed of individuals all of whom are or were actively engaged in the same profession, trade, or occupation; and

    (B) Has been maintained in good faith for purposes other than obtaining insurance; or

    (3) An association or a trust or the trustees of a fund established, created, or maintained for the benefit of members of one or more associations. See Hawaii Revised Statutes 431:10H-104

  • Long-term care insurance: means any insurance policy or rider advertised, marketed, offered, or designed to provide coverage for not less than twelve consecutive months for each covered person on an expense incurred, indemnity, prepaid, or other basis, for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital. See Hawaii Revised Statutes 431:10H-104
  • Policy: means , for the purposes of this article, any policy, contract, subscriber agreement, rider, or endorsement delivered or issued for delivery in this State by an insurer; fraternal benefit society; nonprofit health, hospital, or medical service corporation; prepaid health plan; health maintenance organization; or any similar organization. See Hawaii Revised Statutes 431:10H-104
(b) Activities of daily living shall include at least the following as defined in § 431:10H-201 and the policy: bathing, continence, dressing, eating, toileting, and transferring. Insurers may use activities of daily living to trigger covered benefits in addition to those contained in the preceding sentence as long as they are defined in the policy.
(c) An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate, however the provisions shall not restrict and are not in lieu of the requirements under subsections (a) and (b).
(d) For purposes of this section the determination of a deficiency shall not be more restrictive than:

(1) Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or
(2) If the deficiency is due to the presence of a cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured or others.
(e) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses, or social workers.
(f) Long-term care insurance policies shall include a clear description of the process for appealing and resolving benefit determinations.
(g) The requirements set forth in this section shall be effective July 1, 2000, and shall apply as follows:

(1) Except as provided in paragraph (2), this section applies to a long-term care policy issued in this State after June 30, 2000;
(2) For certificates issued after June 30, 2000, under a group long-term care insurance policy as defined in paragraph (1) under the definition of “group long-term care insurance” in § 431:10H-104, which policy was in force on July 1, 2000, this section shall not apply.
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