CurrentConnecticut Insurance DepartmentPolicy 38a-475-1

Connecticut Partnership for Long-Term Care Precertification Requirements

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Governs precertification, benefit standards, documentation, reporting, and Medicaid asset-protection requirements for long-term care insurance policies and certificates submitted for partnership approval in Connecticut.

Policy Summary

PayerConnecticut Insurance Department

PolicyConnecticut Partnership for Long-Term Care Precertification Requirements

Policy CodePolicy 38a-475-1

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInsurers must submit and obtain approval of a documentation plan before partnership approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

38a-475-1–6Applicable provisions

30 daysReplacement reporting

3.0% annuallyInflation increase

30 daysFree-look period

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CurrentConnecticut Insurance DepartmentPolicy 38a-475-1

Connecticut Partnership for Long-Term Care Precertification Requirements

Customize your policy alerts

Sign up for Connecticut Insurance Department Policy 38a-475-1 alerts

Get alerted when Policy 38a-475-1 changes without checking for updates manually.

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Policy Summary

PayerConnecticut Insurance Department

PolicyConnecticut Partnership for Long-Term Care Precertification Requirements

Policy CodePolicy 38a-475-1

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInsurers must submit and obtain approval of a documentation plan before partnership approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

38a-475-1–6Applicable provisions

30 daysReplacement reporting

3.0% annuallyInflation increase

30 daysFree-look period

Asset-protection reports

Partnership Approval and Asset-Protection Standards

Minimum partnership-approval standards

A long-term care policy may be advertised, solicited, issued for delivery, or retained as partnership-approved only when ALL of the following standards are met:

ALL of the following

Home and community-based services
- Offer or include home and community-based services, in addition to nursing home care, with a minimum benefit of one year at issue.
- Include case management by an access agency, including individualized assessment and plan-of-care development, service coordination, and monitoring of service delivery.
ONE inflation-protection option
- Cover at least 70% of actual charges or at least 70% of the applicable Connecticut average private-pay rate, without premium increases, and increase lifetime benefit levels by at least 3.0% annually without related premium increases. The policy may allow policyholders and applicants age 65 or older the option not to inflate lifetime benefit levels.
- Automatically increase the per-diem dollar level by at least 3.0% annually without related premium increases and increase lifetime benefit levels by at least 3.0% annually without related premium increases. The policy may allow policyholders and applicants age 65 or older the option not to inflate lifetime benefit levels.
Benefit standards
- Provide at least the applicable minimum nursing-home daily benefit, including $265 per day for policies applied for in 2017, with each later year's minimum increased by 3.0% over the prior year's minimum and rounded down to the nearest dollar.
- Do not pay more than the actual charges for care.
- For policies with home and community-based services, provide a daily benefit of at least 50% of the applicable minimum daily nursing-home benefit.
- For policies paying a percentage of costs rather than a daily benefit, pay at least 70% of actual charges or at least 70% of the applicable Connecticut average private-pay rate for each service.
Consumer disclosures and authorization
- Provide the required Connecticut Partnership for Long-Term Care publication and outline of coverage before delivery.
- Use an application acknowledging delivery of the required consumer publications, toll-free assistance information, inflation comparisons, and mandatory inflation-protection notice.
- Obtain the applicant's authorization for release of information to the State of Connecticut for Partnership evaluation, Medicaid asset-protection documentation, and Medicaid-audit requirements.
Policy provisions and access protections
- Provide a 30-day period to cancel and return the policy or certificate for a full premium refund.
- Do not require prior hospitalization or a prior nursing-home stay as a condition of providing benefits.
- Include benefit maximums stated in dollars, a single pool of benefit dollars when home and community-based services are selected with nursing-home benefits, and the required definition of one period of confinement.
- Include eligible-provider, Medicaid asset-protection, Connecticut Partnership residency, and other required policy and outline-of-coverage provisions.
- When a policy is at risk of lapse, proactively offer the insured an option to reduce the lifetime maximum benefit, including at least 15 days to elect the lower benefit before lapse, subject to the regulation's exceptions.

Asset-protection documentation and reporting

Benefits and services may qualify toward Medicaid asset protection only when ALL of the following requirements are met:

ALL of the following

ONE acceptable insured-event record
- Document the insured event through an assessment by access-agency staff as part of an initial assessment or reassessment.
- Document the insured event through an assessment conducted by the Connecticut Home Care Program for the Elderly of the Department of Social Services.
- Document the insured event through an assessment of a skilled nursing facility or intermediate care facility resident as required by federal law.
- Document the insured event through a substantially comparable assessment carried out by or under the supervision of a physician or registered nurse, based on direct observations, interviews, and medical-record review, with the required certification.

Insurer documentation and reporting requirements

For a policy to receive and retain Connecticut Partnership approval, the insurer must satisfy ALL of the following documentation and reporting requirements:

ALL of the following

Records and retention
- Maintain evidence of the insured event, initial and subsequent assessments, provider and service information, charges and invoices, benefits paid, and asset-protection determinations for policyholders who have received benefits.
- Update the required information at least quarterly and retain it for at least five years after coverage ceases when a policyholder who received benefits dies or the policy otherwise ends.
- Notify a policyholder at the end of coverage of the right to request service records and provide requested records to the policyholder or authorized agent within 60 days.
Submit a documentation plan to the Office of Policy and Management before partnership approval, and obtain approval of that plan before the policy is partnership-approved.

Auditing, corrective action, and client-protection consequences

The following audit, correction, and policyholder-protection requirements apply when insurer records or reporting are reviewed:

ALL of the following

Auditing
- The Department of Social Services must conduct a systems audit within one year after the first policyholder of a company's policy meets the insured-event criteria and as often thereafter as necessary.
- The Department of Social Services may periodically audit samples of Medicaid applications from persons who qualified for asset protection, with the Department determining the sample sizes and other audit methods.
- The insurer must advise the Department of Social Services when the one-year systems-audit period begins and is responsible for reasonable expenses of qualifying out-of-state audits.
Deficiency correction

Thresholds, Benefit Standards, and Reporting Timelines

ADL threshold for insured event

ADL thresholdSubstantial human assistance or supervision with two or more activities of daily living.

Activities includedDressing, bathing, eating, toileting, continence, and transferring.

PurposeQualifies as an insured event for asset-protection purposes when documented.

Mental Status Questionnaire threshold

TestMental Status Questionnaire (MSQ), a 10-question cognitive-status questionnaire.

Qualifying thresholdSeven or more incorrect responses.

Use

Insurer, Agent, and Access-Agency Responsibilities

Prior Authorization

Partnership Precertification Requires Regulatory Compliance

A long-term care policy may not be precertified as partnership-approved for the Connecticut Partnership for Long-Term Care unless it complies with all requirements of Regulations of Connecticut State Agencies §§ 38a-475-1 through 38a-475-6.

Documentation Required

Consumer Materials and Home-Care Option

Before offering partnership approval, the insurer must provide required consumer information and offer or include home and community-based services. Home-care coverage must provide at least one year of benefits at issue, in addition to nursing-home care, and must include access-agency case management.

Notify the Insurance Department in writing that the consumer will receive the Office of Policy and Management's Connecticut Partnership materials, including the toll-free number and outline of coverage.
Home-care plans must include an access agency's comprehensive individualized assessment and plan of care, service coordination as needed, and monitoring of service delivery.

Key Regulatory Terms

Connecticut Partnership for Long-Term Care

ProgramConnecticut Partnership for Long-Term Care.

AuthorizationA program authorized under section 17b-252 of the general statutes.

Regulatory contextThe term is used in sections 38a-475-1 through 38a-475-6.

Long-Term Care Insurance Policy

FormAn insurance policy or certificate whose form has been approved by the commissioner.

Approval statutesApproval is under section 38a-481 or 38a-513 of the general statutes.

Qualification requirements

Policy Summary

PayerConnecticut Insurance Department

PolicyConnecticut Partnership for Long-Term Care Precertification Requirements

Policy CodePolicy 38a-475-1

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInsurers must submit and obtain approval of a documentation plan before partnership approval.

SourceLink

On This Page

Maintain provider identifying information, service dates and descriptions, charges, invoices, benefits paid, and the portion of each service qualifying for asset protection.

Maintain access-agency information and copies of all applicable assessments and reassessments.

Home and community-based services

Provide services in accordance with a plan of care approved by an access agency.
Retain the original plan of care, plan-of-care reviews, and changes to the plan of care.
Document that plan-of-care changes are required by changes in the client's medical situation, cognitive abilities, behavioral abilities, or available social supports.
If new services begin before the plan-of-care revision, complete the revision within 10 business days of the commencement of the new services for those services to count toward asset protection.

Reporting

Send an asset-protection report at least quarterly to each policyholder who received benefits since the preceding report.
Include in the report prior qualified asset protection, total benefits paid during the quarter, the portion qualifying for asset protection, and cumulative qualifying benefits.
Send copies of asset-protection reports to the Office of Policy and Management on a quarterly basis.

Documentation plan contents

Identify the location where records will be kept, with required records available at one location accessible to the Department of Social Services and the Insurance Department.
Provide for Department of Social Services access to required information on an aggregate basis and for policyholders who have received benefits on an individual basis for audits and system evaluations.
Identify the responsible liaison and describe methods for determining when benefits qualify for asset protection, including insured-event, service, charge, payment, and plan-of-care documentation.
Describe the manual and electronic systems, information-retention procedures, standard forms and reporting procedures, computer-readable data specifications, required policy statements, participation agreement, and filed policy forms.

Reports and summaries

Submit quarterly asset-protection reports to the Office of Policy and Management and provide them to qualifying policyholders as required.
Prepare a service summary at the policyholder's request for a Medicaid application and when benefits are exhausted or coverage ends for a reason other than death.
Identify in each service summary the specific partnership-approved policy, total benefits paid to date, and the amount qualifying for asset protection, and submit copies to the Office of Policy and Management on a quarterly basis.

Correct inaccuracies, potential system problems, and recordkeeping deficiencies identified by the Department of Social Services within the reasonable deadline established by the Department.

Provide accurate supporting records for written asset-protection determinations, including assessments, plans of care, and invoices when requested.

Approval status and existing policyholders

Partnership approval may be removed for failure to comply with the applicable regulations.
Policyholders who purchased policies while they were partnership-approved retain their right to asset protection after approval is removed.
Persons who purchase policies after partnership-approval status is removed have no right to asset protection under that status.
Continue documentation and reporting for policies already issued when approval is removed or the insurer stops selling the partnership-approved policy, including through an assuming insurer when applicable.

Client-protection consequence

If errors in a service summary, asset-protection report, or service documentation cause a policyholder who received Medicaid services to become ineligible for Medicaid, the Department of Social Services may require the insurer to pay for services counting toward asset protection up to the amount of the insurer's errors.
If the condition of the insurer's records prevents the Department of Social Services from determining whether the policyholder qualifies for asset protection, the Department may require the insurer to pay for services counting toward asset protection up to the amount of the insurer's errors.

The threshold is one basis for establishing an insured event.

Behavioral and cognitive insured-event threshold

Behavioral requirementSpecific behavior problems requiring daily supervision, including wandering, abusive or assaultive behavior, dangerous poor judgment or uncooperativeness, or extreme or bizarre personal hygiene habits.

MSQ alternativeAt least four incorrect MSQ responses.

Folstein alternativeA Folstein Mini Mental State Examination score of 23 or lower.

Minimum nursing-home benefit for 2017 applications

Application yearPolicies applied for in 2017.

Minimum daily benefitAt least $265.00 per day for nursing-home care.

Payment limitThe policy may not pay more than the actual charges.

Annual minimum nursing-home benefit increase

Annual increaseThe minimum daily nursing-home benefit must be 3.0% greater than the previous year's minimum.

Rounding ruleThe resulting amount is rounded down to the nearest dollar.

Effective periodThe rule applies for each year after 2017.

Minimum home and community-based benefit

Minimum percentageAt least 50% of the minimum daily nursing-home benefit in effect for the applicable year.

Covered settingHome and community-based services.

Payment limitThe policy may not pay more than the actual charges.

Percentage-of-cost benefit standard

Actual-charge standardAt least 70% of the actual charges incurred by the insured.

Connecticut-rate standardAlternatively, at least 70% of the applicable Connecticut average private-pay rate.

Applies toPolicies paying benefits as a percentage of costs rather than as a daily benefit amount.

Required inflation protection

Per-diem increaseAt least 3.0% each year over the previous year while the contract is in force.

Lifetime benefit increaseLifetime benefit levels must also increase at least 3.0% annually without a related premium increase.

Older applicantsAt the insurer's option, policyholders and applicants age 65 or older may be offered the option not to inflate lifetime benefit levels.

One period of confinement

Confinement periods combinedSuccessive periods due to the same or a related cause are treated as one period.

Separation exceptionPeriods are not combined when separated by at least 90 days.

Required absenceDuring the separation, the insured must not be confined for skilled nursing, custodial, intermediate, or home and community-based care.

Plan-of-care revision deadline

Revision deadlineWithin ten business days after new services commence.

When applicableThe deadline applies when services begin before the plan-of-care revision is made.

Asset-protection effectNew services count toward asset protection only if the revision is completed within the deadline.

Asset-protection report frequency

Minimum frequencyAt least quarterly.

RecipientsEach policyholder who received benefits since the last asset-protection report.

Additional submissionCopies must also be sent quarterly to the Office of Policy and Management.

Initial systems audit timing

Initial audit deadlineWithin one year after the first policyholder of a company's policy meets the insured-event criteria.

Later auditsAdditional systems audits occur as often as the Department of Social Services considers necessary.

Insurer responsibilityThe insurer must advise the Department of Social Services when the one-year period begins.

Documentation Required

Access-Agency Case Management

Each home-care plan must use access-agency case management. The access agency is responsible for assessing the individual, developing the individualized plan of care, coordinating appropriate services, and monitoring delivery of those services.

Home and community-based services must be provided under an access-agency-approved plan of care to qualify for asset protection.
The access agency must document required services and plan-of-care changes.

Documentation Required

Application Acknowledgments and Release

Applications must contain signed acknowledgments confirming delivery of the required consumer and inflation-protection materials, and a separately signed authorization permitting release of policy records to the State of Connecticut for Partnership evaluation, Medicaid asset-protection claims, and Medicaid audits.

Provide “Before You Buy,” the state consumer-assistance number (1-800-547-3443), a complete Partnership description, a graphic comparison of increasing versus fixed benefits and premiums, and the mandatory inflation-protection notice.
Provide a graphic comparison covering at least 20 years and explain that maintaining required daily benefits is necessary for partnership approval and asset protection.
Use a separate signature for the applicant's release of insurance records; records must be used only for the stated purposes and kept confidential.

Billing Rule

30-Day Free-Look Cancellation

The policy must provide a 30-day free-look period. The applicant may cancel by delivering or mailing the policy or certificate to the insurer or agent and must receive a full refund of premiums paid.

Print the cancellation right prominently on the first page of the policy or certificate or attach the notice to it.
The notice must state that the policyholder or certificate holder may return the coverage within 30 days of delivery if dissatisfied for any reason.

Denial Risk

Access and Agent-Training Conditions

Do not condition benefits on a prior hospitalization or prior nursing-home stay. Insurers must also provide required denial materials and ensure that agents satisfy Connecticut Partnership training requirements before marketing or soliciting partnership-approved coverage.

Offer each person denied partnership-approved coverage the Office of Policy and Management survey, which the person may complete and return to OPM.
Obtain signed company assurances that agents have completed seven hours of long-term-care training, including Connecticut Partnership-specific training.
Training programs must receive prior OPM approval, and the company must submit its agent-training attestation to the Commissioner.

Documentation Required

Insurer Records and Documentation Plan

Maintain and update, at least quarterly, complete records for every policyholder who has ever received benefits. Retain the required information for at least five years after the policy ceases to be in force because of death or lapse, and notify former policyholders of their right to request records.

Document the insured event through an access-agency assessment or reassessment, Connecticut Home Care Program for the Elderly assessment, qualifying SNF/ICF assessment, or a substantially comparable physician- or registered-nurse-supervised assessment when other evidence is unavailable.
Record each provider's name, address, telephone number, license number when applicable, service date, amount, nature, qualifying category, insurer payments, provider charges, and invoices.
Identify the access agency and retain assessments and reassessments.
Retain the original plan of care, reviews, and changes for home-care benefits; retain records at least five years after coverage ends.
Provide the policyholder or authorized agent a complete copy of requested service records within 60 days, with notice that retaining them may help establish Medicaid eligibility.

Documentation Required

Document Plan-of-Care Changes

A plan-of-care change must be supported by documentation showing that the change is required by a change in the client's medical situation, cognitive or behavioral abilities, or available social supports. New services count toward asset protection only after the access agency adds the documented need and service description to the plan of care.

If services begin before the plan is revised, complete the revision within 10 business days after the new services begin.
Maintain initial assessments and subsequent reassessments as part of the insured-event documentation.

Prior Authorization

Submit the Insurer Documentation Plan

Before partnership approval, submit an insurer documentation plan to the Office of Policy and Management. No policy may be partnership-approved until OPM approves the plan in writing and any identified shortcomings are resolved.

Identify one readily accessible location for Partnership records and the person responsible for maintaining them and liaising with OPM and the Department of Social Services.
Describe methods for determining when benefits qualify for asset protection, including insured-event, service, charge, payment, and plan-of-care documentation.
Describe the manual and electronic systems used to maintain required information.
Agree to provide DSS aggregate data for all policyholders and individual data for all policyholders who have received benefits, including access for audits; the insurer bears reasonable costs of out-of-state audits.

Documentation Required

Issue Quarterly Asset-Protection Reports

Send an asset-protection report at least quarterly to each policyholder who received benefits since the prior report, and send copies to the Office of Policy and Management each quarter.

Report the amount of asset protection qualified before the covered quarter.
Report total insurer benefits paid for services during the quarter and the portion qualifying for asset protection.
Report the cumulative amount paid under the policy that qualifies for asset protection.
Use the format and wording specified in OPM's Plan of Action Requirements; reports remain subject to DSS audit.

Documentation Required

Prepare Service Summaries

Prepare a service summary when requested by a policyholder for a Medicaid application, and when benefits are exhausted or coverage ends for a reason other than death, whichever occurs first.

Identify the specific partnership-approved policy, total benefits paid for services to date, and the amount qualifying for asset protection.
Use the format and wording in OPM's Plan of Action Requirements.
Send copies of service summaries to OPM on a quarterly basis; the summary is in addition to the required service records.

Unsupported block type: info

Denial Risk

Correct Deficiencies and Hold Clients Harmless

Correct documentation deficiencies identified through DSS audits or reviews within the established reasonable deadline and continue all documentation and reporting duties even if partnership approval is removed or the policy is no longer sold. Policyholders who bought coverage while it was approved retain asset-protection rights.

If approval is removed or sales stop, continue compliance for policies already issued; an assuming insurer must undertake these obligations in an assumption agreement.
If insurer errors in a service summary, asset-protection report, or service documentation cause a Medicaid-eligible policyholder to lose eligibility, the insurer may be required to pay qualifying services until it has paid an amount equal to the errors.
If records are so deficient that DSS cannot determine eligibility for asset protection, the insurer may likewise be required to pay qualifying services; compliance is required to retain partnership approval.

The policy or certificate must meet the applicable long-term-care insurance requirements in sections 38a-501 or 38a-528 and related regulations.

Partnership-Approved Policy

Resident requirementA qualified long-term-care policy issued for delivery to a Connecticut resident.

Benefit requirementProvides necessary care or treatment for injury, illness, or loss of cognitive or functional capacity, outside an acute-care hospital, for at least one year after a reasonable elimination period.

Approval requirementThe policy form is precertified by the Insurance Department.

Activities of Daily Living

Listed activitiesDressing, bathing, eating, toileting, continence, and transferring.

Deficiency standardA deficiency is based on the need for substantial human assistance or supervision in performing the activity.

Insured-event minimumThe insured event requires documented substantial assistance or supervision with two or more listed activities.

Asset Protection

Right protectedThe right to retain assets equal to qualifying insurance payments made on the person's behalf.

Eligibility contextThe retained amount is considered when determining eligibility for Medicaid.

Who receives itThe right extends to persons purchasing partnership-approved long-term-care insurance policies.

Insured Event

ADL basisDocumented substantial human assistance or supervision with two or more specified activities of daily living.

Cognitive basisSeven or more incorrect MSQ responses.

Behavioral basisSpecified behavior problems requiring daily supervision, together with at least four incorrect MSQ responses or a Folstein score of 23 or lower.

Access Agency

OrganizationAn organization approved by the Office of Policy and Management and the Department of Social Services.

Assessment functionsProvides assessments and reassessments and develops care plans.

Service functionsCoordinates and monitors home and community-based services.

Plan of Care

FormA written individualized plan of home and community services.

Required contentsSpecifies the type and frequency of all services, service providers, and service costs.

PurposeDescribes services required to maintain the individual at home or in the community, whether or not an actual charge exists.

Home and Community-Based Services

Skilled servicesSkilled nursing care and physical, occupational, respiratory, and speech therapy in the home or community.

Home health servicesHome health aide services.

Support servicesHomemaker, adult day health care, and respite care services.

Service Summary

Policy identificationIdentifies the specific partnership-approved policy.

Benefits paidStates the total benefits paid for services rendered to date.

Asset-protection amountStates the amount qualifying for asset protection.

Plan of care

Required servicesDocuments the client's required services under the plan of care.

Change documentationDocuments changes required by the client's medical situation, cognitive abilities, behavioral abilities, or available social supports.

New-service conditionNew services count toward asset protection only after the access agency adds the documented need and description to the plan.

Asset-protection report

Prior protectionShows the asset protection for which the policyholder qualified before the reporting quarter.

Quarterly benefitsShows total benefits paid during the quarter and the portion qualifying for asset protection.

Cumulative amountShows the total amount paid to date that qualifies for asset protection.

Service summary

Policy identificationIdentifies the specific partnership-approved policy.

Total benefitsStates total benefits paid for services rendered to date.

Qualifying amountStates the amount qualifying for asset protection.

Documentation plan

TimingMust be submitted before partnership approval and approved before a policy can receive partnership approval.

Required subjectsCovers record location, audit access, responsible personnel, eligibility methods, service and payment documentation, and manual or electronic systems.

Operational purposeExplains how required information will be maintained, retained, reported, and made available.

Asset-protection determination

Written scopeA determination may address whether an insured event occurred and was adequately documented.

Care and service questionsMay address whether a plan or revision is required, whether services follow the plan, and whether services qualify for asset protection.

Payment and provider questionsMay address the applicable payment amount and whether a provider is a family member.