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 (accessed May 26, 2025).

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

May 26, 2025

Rule 836-052-0586's source at or​.us