Wisconsin Minimum Standards for Policies
The Wisconsin Office of the Commissioner of Insurance has set minimum standards for each of the three types of insurance policies covering long-term care expenses.
All long-term care, nursing home and home health care insurance policies must:
- Provide at least one year of benefits.
- Provide a minimum $60 a day benefit.
- Provide benefits based on the level of care only if the lowest limit of daily benefits is not less than 50% of the highest limit of daily benefits. For example, benefits provided for home health care would have to be at least 50% of those provided for nursing home care.
- Provide coverage whether or not care is medically necessary. The policy may require that the care be provided in accordance with a plan of care.
- Pay benefits without requiring you to be in a hospital before getting the covered service.
- Pay benefits if you are unable to perform three or more activities of daily living (ADLs) or if you have a cognitive impairment. The assessment of ADLs and cognitive impairment needs to be performed by licensed or certified professionals, such as physicians, nurses, or social workers.
- Pay benefits for "irreversible dementia" (such as Alzheimer's disease) provided you have met the waiting periods under the policy and need the type of care covered by the policy. This does not prevent an insurance company from refusing to accept an application from you if you have Alzheimer's or a similar disease.
- Offer an inflation protection option that increases the maximum daily benefit and lifetime benefit amounts in an amount at least equal to 5% compounded annually.
- Offer a nonforfeiture benefits option that provides paid-up insurance if your policy lapses.
- Describe the benefit appeal procedure. This procedure requires the insurance company to review the appeal and make a decision within 30 days.
Policies that include home health care benefits must pay for community-based (home health) care:
- Whether or not you have an acute medical problem.
- Even if the services are not provided by a Medicare-certified agency or provider.
- Even if you were not previously in a hospital or nursing home.
Note: Policies that cover only nursing home care or only home health care provide limited benefits for long-term care services and may not be adequate for your needs. If you want coverage for both nursing home and home health care, you are better off buying a comprehensive long-term care insurance policy. Even a comprehensive policy may not cover all the types of services that you may need or want.
Interstate Insurance Product Regulation Commission (IIPRC)
Wisconsin is a member of the Interstate Insurance Product Regulation Commission (IIPRC). The IIPRC was created through a multi-state agreement to streamline the process of filing and reviewing insurance products using uniform national standards that IIPRC members develop and adopt. The IIPRC has developed national standards for long-term care insurance products, rate filings, and advertisements. Wisconsin allows long-term care products that are filed with and approved by the IIPRC to be sold in Wisconsin. IIPRC long-term care policies meet the IIPRC uniform product standards rather than the Wisconsin standards. More information about the IIPRC is available at www.insurancecompact.org.