OAR 836-052-0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies


(1)

A long-term care insurance policy, certificate or rider that provides benefits for home care services or community care services may not limit or exclude those benefits:

(a)

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

(b)

By requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services, or either service or simultaneously receive both services, in a home, community, or institutional setting before home care services are covered;

(c)

By limiting eligible services to services provided by registered nurses or licensed practical nurses;

(d)

By requiring that a nurse or therapist provide services covered by the policy when the services can be provided by a home care aide or other licensed or certified home care worker acting within the scope of the licensure or certification;

(e)

By requiring that the insured or claimant have an acute condition before home care services are covered;

(f)

By excluding coverage for personal care services provided by a home care aide;

(g)

By requiring that the provision of home care services be at a level of certification or licensure greater than that required by the eligible service;

(h)

By limiting benefits to services provided by Medicare-certified agencies or providers; or

(i)

By excluding coverage for adult day care services.

(2)

A provision in a long-term care insurance policy, certificate or rider for home care or community care services shall provide total home care or community care coverage that is a dollar amount equivalent to at least one-half of one year’s coverage available for nursing home benefits under the policy, certificate or rider, at the time covered home care or community care services are being received. This requirement does not apply to policies, certificates or riders issued to residents of continuing care retirement communities.

(3)

Home care coverage may be applied to the nonhome care benefits provided in the policy, certificate or rider when determining maximum coverage under the terms of the policy, certificate or rider.

Source: Rule 836-052-0586 — Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0586.

836–052–0103
Purpose
836–052–0107
Authority
836–052–0114
Applicability and Scope
836–052–0119
Definitions
836–052–0124
Policy Definitions and Terms
836–052–0129
Policy Provisions
836–052–0132
Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010
836–052–0133
Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836–052–0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992
836–052–0136
Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836–052–0138
Open Enrollment
836–052–0139
Medicare Select Policies and Certificates
836–052–0140
Standards for Claims Payment
836–052–0141
Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010
836–052–0142
Guaranteed Issue for Eligible Persons
836–052–0143
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate
836–052–0144
Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020.
836–052–0145
Loss Ratio Standards and Refund or Credit of Premium
836–052–0151
Filing and Approval of Policies and Certificates and Premium Rates
836–052–0156
Permitted Compensation Arrangements
836–052–0160
Required Disclosure Provisions
836–052–0165
Requirements for Application Forms, Replacement Coverage
836–052–0170
Filing Requirements for Advertising
836–052–0175
Standards for Marketing
836–052–0180
Appropriateness of Recommended Purchase and Excessive Insurance
836–052–0185
Reporting of Multiple Policies
836–052–0190
Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates
836–052–0192
Prohibition Against Use of Genetic Information and Requests for Genetic Testing
836–052–0194
Separability
836–052–0225
Durational Limits for Health Maintenance Organizations
836–052–0230
Provider Services Limits for Insurers and Health Care Contractors
836–052–0500
Statutory Authority
836–052–0508
Definitions
836–052–0516
Policy Definitions
836–052–0526
Policy Practices and Provisions
836–052–0531
Long Term Care Insurance Partnership Program
836–052–0546
Required Policy Provisions
836–052–0556
Required Disclosure of Rating Practices to Consumers
836–052–0566
Initial Rate Filing Requirements
836–052–0576
Prohibition Against Post-Claims Underwriting, Applications
836–052–0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies
836–052–0596
Standards for Covered Services
836–052–0606
Use and Definition of “Home” or Similar Wording
836–052–0616
Requirement to Offer Inflation Protection
836–052–0626
Requirements for Application Forms and Replacement Coverage
836–052–0636
Reporting Requirements
836–052–0637
Annual Rate Certification Requirements
836–052–0639
Training for Insurance Producers
836–052–0646
Benefits Provided Through Advancement of Life Insurance Proceeds
836–052–0656
Reserve Standards
836–052–0666
Loss Ratio
836–052–0676
Premium Rate Schedule Increases
836–052–0680
Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings
836–052–0686
Filing Requirements for Out-of-State Group Policies
836–052–0696
Filing Requirements for Advertising
836–052–0706
Standards for Marketing
836–052–0716
Disclosure Statement
836–052–0726
Suitability
836–052–0736
Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates
836–052–0738
Availability of New Services or Providers
836–052–0740
Right to Reduce Coverage and Lower Premiums
836–052–0746
Nonforfeiture Benefit Requirement
836–052–0756
Standards for Benefit Triggers
836–052–0766
Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts
836–052–0768
Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met
836–052–0770
Prompt Payment of Clean Claims
836–052–0776
Standard Format Outline of Coverage
836–052–0786
Requirement to Deliver Shopper’s Guide
836–052–0790
Disclosure of Benefits Paid
836–052–0800
Purpose
836–052–0810
Replacement Upon Termination
836–052–0840
Termination of Coverage
836–052–0850
Multiple Employer Trusts
836–052–0860
Form of Notice to Group Policyholder
836–052–1000
Prosthetic and Orthotic Devices
Last Updated

Jun. 8, 2021

Rule 836-052-0586’s source at or​.us