Section 65.05 - Minimum Standards for Individual Policies(1)Benefit Eligibility Standards.(a)Benefit Triggers. 1. Individual policies that are not intended to be federally qualified may not include benefit eligibility standards that are more stringent than a requirement that the insured be unable to perform at least two Activities of Daily Living due to a loss of functional capacity or severe cognitive impairment .2. Individual policies that are intended to be federally qualified are required to meet the standards set forth in the federal Internal Revenue Code and related federal regulations.(b)Prior Treatment Requirements. No individual policy may condition long-term care benefits on the insured's prior hospitalization or prior receipt of services from any long-term care provider.(c)Medicare Eligibility. No individual policy may restrict or deny benefits because the insured is not eligible for Medicare.(d)Improvement Requirement. No individual policy may condition receipt of covered benefits on a requirement that the insured be making a "steady improvement", have "recuperative potential" or have "returned to pre-morbid condition" or words of similar import.(e)Medical Necessity. No individual policy may condition receipt of any services, except medical services provided by licensed medical professionals, on any standard of medical necessity. Any carrier using a medical necessity standard shall disclose that standard within the policy.(f)Care Management. A carrier may establish a care management system to manage the benefits provided under the individual policy, and plan benefits may be disallowed if specific care management standards and procedures are not met. A carrier that intends to use a care management system must: 1. establish a needs assessment tool which measures functional ability,2. file with the commissioner a description of its care management policy and procedures, as well as the mechanism by which the insured may appeal a care management decision, and file any and all updates to the management policy and procedures with the commissioner prior to implementation3. specify the care management procedures within the policy, as well as the way to appeal whenever benefits are disallowed for failure to meet care management standards, and notify the insured about any changes to care management procedures included in the policy prior to implementation, and4. disclose applicable care management standards to insureds upon request.(2)Benefit Requirements. (a)Elimination Periods and Deductibles. 1. Individual policies may not include elimination periods of greater than 365 days, whether services are received within or away from the home.2. At a minimum, carriers shall count each day that the insured receives any service that would be applied against the lifetime maximum benefit amount or maximum benefit period toward the satisfaction of an individual policy's elimination period. Individual policies may not require that elimination periods be satisfied within a specified period of time or that days be consecutive.3. Individual policies may not apply more than one elimination period unless the insured has received no benefits for at least 180 consecutive days.4. Individual policies may offer deductibles in lieu of elimination periods, but not both.(b)Individual Policy Benefits. 1. Daily maximum benefit amounts for specific services must be clearly defined within the policy provisions. The daily maximum benefit may be limited by the carrier to the usual and customary cost of the service. If the service costs more than the maximum daily benefit and there is no law to the contrary, the insured is responsible for the amount over and above the daily maximum benefit .2. Lifetime maximum benefit periods may not cover fewer than 730 days beyond the policy's elimination period.3. Individual policies may include a life time maximum benefit amount in lieu of the life time maximum benefit period, provided that the lifetime maximum benefit amount may not be less than the product of 730 multiplied by the highest daily maximum benefit amount covered in the policy.(c)Home Health Care Benefits in Long-Term Care Insurance Policies. 1. An individual policy shall not, if it provides benefits for home healthcare services, limit or exclude benefits: a. by requiring that the insured or claimant would need care in a skilled nursing facility if home health care were not provided;b. by requiring that the insured or claimant first or simultaneously received nursing or therapeutic services, or both, in a hospital or institutional setting before home health care services are covered;c. by limiting eligible services to services provided by registered nurses or licensed practical nurses;d. by requiring that the provisions of home health care services be at a level of certification or licensure greater than that required by the eligible services;e. by requiring that the insured or claimant have an acute condition before home health care services are covered; orf. by limiting benefits to services provided by Medicare-certified agencies or providers.2. A long-term care insurance policy or certificate, if it provides for home health care services, shall provide total home health 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 or certificate, at the time the covered home health services are being received. This requirement shall not apply to policies or certificates issued to residents of continuing care retirement communities.3. Home health care coverage may be applied to the non-home health care benefits provided in the policy or certificate when determining maximum coverage under the terms of the policy or certificate.(d)Minimum Benefits. Individual policies may not include any policy benefits that are so limited in scope that they are not likely to be of any substantial economic value to the insured.(e)Alternate Care Benefits. Individual policies must include a provision that enables the insured to use policy benefits after satisfying policy benefit triggers, elimination periods and deductibles to cover long-term care treatments or expenses not specifically identified in the policy's described benefits. The alternate care benefits must be made available to the insured subject to the agreement of the carrier, the insured and the insured's health care practitioner.(3)Limitations and Exclusions. (a)Pre-existing condition limitations. 1. Pre-existing condition limitations must be identified on the front of the policy and the outline of coverage.2. Pre-existing condition limitations may not apply for more than a six-month period from the effective date of the policy.(b) No individual policy may exclude otherwise eligible persons from policy benefits due to the presence or history of mental or nervous conditions, Alzheimer's disease, alcoholism, or other chemical dependency.(c) No individual policy may exclude otherwise eligible policy benefits because those benefits are also payable by a non-Medicare government agency or because the covered services are being received in a governmental facility.(d)Other limitations. Individual policies may include other limitations or conditions subject to the approval of the commissioner, provided that they are clearly identified in a separate section of the policy. Such limitations may include, but are not limited to, illnesses, treatments or conditions arising out of the following circumstances: 1. war or act of war (whether declared or undeclared);2. participation in a felony, riot or insurrection;3. service in the armed forces or units auxiliary thereto;4. attempted suicide or intentionally self- inflicted injury;5. services provided for alcohol or drug detoxification;6. aviation (this exclusion applies only to non-fare paying passengers);7. services for which benefits are payable under Medicare, any state or federal workers' compensation program, employer's liability or occupational disease law, or any motor vehicle no-fault law;8. services provided by members of the insured's immediate family; or9. services for which no amount is normally charged in the absence of insurance.(4)Continuation of Policy Benefits. (a)Renewal. 1. Carriers may not refuse to renew any individual policy, except in cases when the carrier is under receivership, rehabilitation or liquidation proceedings pursuant to M.G.L. c. 175 or c. 176 § 33, administrative supervision pursuant to M.G.L. c. 175J or comparable statutory requirements of another jurisdiction. A carrier may discharge its obligation to renew existing individual policies only upon a finding that the carrier has obtained coverage for all existing insureds with equivalent benefits for value paid with another carrier.2. All individual policies shall be guaranteed renewable or noncancelable.(b)Extension of Benefits. 1. If an individual policy is terminated while an insured is confined to a nursing home, benefits shall continue until the earliest of the following occurs: a. the insured is discharged from the nursing home,b. the policy lifetime maximum benefit period has expired, orc. the insured has exhausted the lifetime maximum benefit amount for nursing home services.2. For the purposes of 211 CMR 65.05(4)(b), the insured shall be considered to be continuously confined to a nursing home while being transferred to another nursing home, receiving another level of nursing care in any nursing home or being transferred back to a nursing home from a temporary/acute hospitalization.3.211 CMR 65.05(4)(b) does not apply if coverage under the individual policy terminates because of failure of the policyholder to pay the premium within the time set forth in the policy.