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.