OAR 836-052-0756
Standards for Benefit Triggers


(1)

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.

(2)

Intentionally left blank —Ed.

(a)

Activities of daily living shall include at least the following as defined in OAR 836-052-0516 (Policy Definitions) and in the policy:

(A)

Bathing;

(B)

Continence;

(C)

Dressing;

(D)

Eating;

(E)

Toileting; and

(F)

Transferring;

(b)

An insurer may use activities of daily living to trigger covered benefits in addition to those contained in subsection (a) of this section as long as they are defined in the policy.

(c)

For purposes of this rule, a cognitive impairment must be a result of a clinically diagnosed organic dementia, including but not limited to Alzheimer’s disease or a related progressive degenerative dementia of an organic origin such as the following, by way of example only:

(A)

Parkinson’s Disease;

(B)

Huntington’s Disease;

(C)

Creutzfeldt-Jakob Disease;

(D)

Picks Disease;

(E)

Multi-infarct dementia;

(F)

Normal pressure hydrocephalus;

(G)

Multiple sclerosis;

(H)

Inoperable tumors of the brain.

(3)

An insurer may use additional provisions for determining when benefits are payable under a policy, certificate or rider, but the provisions shall not restrict, and are not in lieu of, the requirements contained in sections (1) and (2) of this rule.

(4)

For purposes of this rule, the determination of a deficiency shall not be more restrictive than:

(a)

Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

(b)

Requiring that 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.

(5)

Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.

(6)

A long term care insurance policy shall include a clear description of the process for appealing and resolving benefit determinations.

(7)

If an insurer denies payment of benefits under a long term care policy, the insurer shall include in its denial letter information about how the insured may contact the Insurance Division of the Department of Consumer and Business Services for assistance either by contacting the Insurance Division Consumer Advocacy Unit at its toll free telephone number or visiting the Division’s website at the website address currently provided by the Division as may be updated from time to time on the Division website.

(8)

The requirements set forth in this rule are effective March 1, 2006, except for the following:

(a)

The requirements of this rule apply to a long-term care policy or rider issued in this state on or after March 1, 2005.

(b)

This rule does not apply to a certificate issued on or after March 1, 2006, under a group long-term care insurance policy as defined in ORS 743.652 (Definitions for ORS 743.650 to 743.665)(3)(a) that was in force on March 1, 2005.

Source: Rule 836-052-0756 — Standards for Benefit Triggers, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0756.

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 836-052-0756’s source at or​.us