(a) Whenever long-term care insurance provides coverage for the facilities, services, or physical or mental conditions listed below, unless otherwise defined in the policy and certificate, and approved by the Commissioner, such facilities, services, or conditions are defined as follows:
(1) "Adult care home" shall be defined in accordance with the terms of G.S. 131D-2.1(3).
(1a) "Adult day care program" shall be defined in accordance with the provisions of G.S. 131D-6(b).
(2) "Chore" services include the performance of tasks incidental to activities of daily living that do not require the services of a trained homemaker or other specialist. Such services are provided to enable individuals to remain in their own homes and may include such services as: assistance in meeting basic care needs such as meal preparation; shopping for food and other necessities; running necessary errands; providing transportation to essential service facilities; care and cleaning of the house, grounds, clothing, and linens.
(3) "Combination home" shall be defined in accordance with the terms of G.S. 131E-101(1a).
(4) Repealed by Session Laws 1995, c. 535, s. 3.
(5) "Family care home" shall be defined in accordance with the terms of G.S. 131D-2.1(9).
(6) Renumbered.
(7) Repealed by Session Laws 1995, c. 535, s. 3.
(8) "Home health services" shall be defined in accordance with the terms of G.S. 131E-136(3).
(9) "Homemaker services" means supportive services provided by qualified para-professionals who are trained, equipped, assigned, and supervised by professionals within the agency to help maintain, strengthen, and safeguard the care of the elderly in their own homes. These standards must, at a minimum, meet standards established by the North Carolina Division of Social Services and may include: Providing assistance in management of household budgets; planning nutritious meals; purchasing and preparing foods; housekeeping duties; consumer education; and basic personal and health care.
(10) "Hospice" shall be defined in accordance with the terms of G.S. 131E-176(13a).
(11) "Intermediate care facility for the mentally retarded" shall be defined in accordance with the terms of G.S. 131E-176(14a).
(12) "Nursing home" shall be defined in accordance with the terms of G.S. 131E-101(6).
(13) "Respite care, institutional" means provision of temporary support to the primary caregiver of the aged, disabled, or handicapped individual by taking over the tasks of that person for a limited period of time. The insured receives care for the respite period in an institutional setting, such as a nursing home, family care home, rest home, or other appropriate setting.
(14) "Respite care, non-institutional" means provision of temporary support to the primary caregiver of the aged, disabled, or handicapped individual by taking over the tasks of that person for a limited period of time in the home of the insured or other appropriate community location.
(15) "Skilled Nursing Facility" shall be defined in accordance with the terms of G.S. 135-40.1(18).
(16) "Supervised living facility for developmentally disabled adults" means a residential facility, as defined in G.S. 122C-3(14), which has two to nine developmentally disabled adult residents.
(b) Whenever long-term care insurance provides coverage for organic brain disorder syndrome, progressive dementing illness, or primary degenerative dementia, such phrases shall be interpreted to include Alzheimer's Disease. Clinical diagnosis of "organic brain disorder syndrome", "progressive dementing illness", and "primary degenerative dementia" must be accepted as evidence that such conditions exist in an insured when a pathological diagnosis cannot be made; provided that such medical evidence substantially documents the diagnosis of the condition and the insured received treatment for such condition.
(c) All long-term care insurance policies must be filed with and approved by the Commissioner before they can be used in this State and are subject to the provisions of Article 38 of this Chapter. (1987, c. 331, s. 1; 1989, c. 207, ss. 5, 6; 1991, c. 721, s. 85; 1995, c. 535, s. 3; 2001-209, s. 4; 2008-187, s. 38(a); 2009-462, s. 4(a).)
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Last modified: March 23, 2014