SECTION 3.3815. Standards for Home Health and Adult Day Care Benefits

(a) No long-term care insurance policy or certificate which provides benefits for home health care or adult day care services may exclude or limit benefits by requiring any of the following:

(1) that the insured would need care in a nursing facility if home health care services were not provided;

(2) that the insured first or simultaneously receive nursing and/or therapeutic services in a home, community, or institutional setting before home health care services are covered;

(3) that eligible services be provided by a registered nurse or nurses or licensed practical nurse or nurses;

(4) that a nurse or therapist provide services covered by the policy that can be provided by a home health aide, or other licensed or certified home care worker acting within the scope of his or her licensure or certification;

(5) that the provision of home health care services be at a level of certification or licensure greater than that which is required for the eligible service to be performed under the laws of this state;

(6) that the insured have an acute condition before home health care services are offered; or

(7) that benefits be limited to services provided by Medicare certified agencies or providers.

(b) If a long-term care policy or certificate provides coverage for home health care or adult day care services, it shall not exclude or limit benefits for:

(1) adult day care services; or

(2) maintenance or personal care services provided by a home health aide.

(c) If a long-term care insurance policy or certificate provides for home health or adult day care services, it shall provide total home health or adult day care services 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 covered home health or adult day care services are being received. This requirement shall not apply to policies or certificates issued to residents of continuing care retirement communities.

(d) Home health care coverage may be applied to the total health care benefits provided in the policy or certificate when determining the maximum coverage under the terms of the policy or certificate.

Source Note: The provisions of this §3.3815 adopted to be effective July 20, 1992, 17 TexReg 4769; amended to be effective May 8, 1997, 22 TexReg 3786