Sec.38a-475-5. Insurer documentation and reporting

Unless otherwise noted, the requirements of subsections (a) to (f), inclusive, of this section refer to insurer documentation and reporting requirements for partnership-approved policies.

(a) Each insurer in fulfilling its reporting requirements shall adhere to the most recent specifications set forth in the Partnership For Long-Term Care Long-Term Care Insurance Uniform Data Set (UDS) and Connecticut state-specific requirements as noted in the Connecticut Partnership for Long-Term Care section of the state specific appendices of the UDS documentation. All reports are due to the Office of Policy and Management no later than thirty (30) days after the close of the reporting periods specified for the respective reports.

(b) Maintaining Auditing Information. Each insurer shall maintain information as stipulated in subdivisions (1), (2) and (3) of this subsection, on all policyholders who have ever received any benefit under the policy. Such information shall be updated at least quarterly; but this requirement for updating shall not require the conduct of any assessment, reassessment, or other evaluation of the policyholder's condition which is not otherwise required by federal or state statute or regulation. When a policyholder who has received any benefit dies or lapses his policy for any other reason the insurer shall retain the stipulated information for at least five years after the time when the policy ceases to be in force. At the time the policy ceases to be in force, the insurer shall notify the policyholder of their right to request their service records as stipulated in subdivisions (1), (2) and (3) of this subsection. The insurer shall also, upon request, provide such policyholder and the policyholder's authorized agent, if any, with a complete copy of the insurer's service records as stipulated in subdivisions (1), (2) and (3) of this subsection. These records shall be provided to the policyholder and policyholder's authorized agent, if any, within sixty days of the request. The insurer shall enclose with the records a statement advising the former policyholder that it is in his or her interests to retain the records if he or she may ever wish to establish eligibility for Medicaid.

The information includes:

(1) Evidence that the Insured Event has taken place. The occurrence of the Insured Event may be documented in any of the following ways:

(A) By access agency staff, as part of the initial assessment of the client or as part of a subsequent reassessment.

(B) By an assessment conducted by the Connecticut Home Care Program for the Elderly of the Department of Social Services;

(C) By an assessment of a resident of a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) as required by section 1919 (b)(3) of the Social Security Act;

(D) By an assessment, carried out by or under the supervision of a physician or a registered nurse, which is substantially comparable to any of the methods in subparagraphs (a), (b) and (c) of this subdivision. Assessments described in this subparagraph are valid only for persons for whom evidence was not available or not provided in a manner described in subparagraphs (a), (b) or (c) of this subdivision. These assessments shall be based on direct observations and interviews in conjunction with a medical record review. The physician or registered nurse carrying out or supervising the assessment shall sign and certify the completion of the assessment. Each individual who completes a portion of such assessment shall sign and certify as to the accuracy of that portion of the assessment.

(2) Description of services provided under the policy:

(A) Name, address, phone number and license number (if applicable) of provider(s);

(B) Amount, date and nature of services provided indicating under which category, if any, the service qualifies for asset protection;

(C) Dollar amounts paid by the insurers, whether on an indemnity, expense incurred, or other basis;

(D) The charges of the service providers, including copies of invoices for all services counting towards asset protection;

(E) Identification of the access agency (if applicable) and copies of all assessments and reassessments.

(3) In order for home and community-based services to qualify for asset protection, they shall be in accord with a plan of care approved by an access agency. If the policyholder has received any benefits delivered as part of a plan of care, the insurer shall retain the following:

(A) A copy of the original plan of care;

(B) Copies of any reviews of the plan of care;

(C) Copies of any changes made in the plan of care. The plan of care shall document that the changes are required by changes in the client's medical situation, cognitive abilities, behavioral abilities, or the availability of social supports. Such services shall count towards asset protection after the access agency adds the documented need for and description of the new services to the plan of care. In cases when the service begins before the revisions to the plan of care are made, the new services will only count towards asset protection if the revisions to the plan of care are made within ten business days of the commencement of the new services. Insurers shall maintain initial assessments and subsequent reassessments as part of insured event documentation.

(c) Reporting on Asset Protection. Each insurer shall send an asset protection report at least quarterly to each policyholder who has received any benefits since the last asset protection report sent to the policyholder. Each asset protection report shall include the following information:

(1) The amount of asset protection for which the policyholder had qualified prior to the quarter covered by the report.

(2) The total benefits paid by the insurer for services rendered during the quarter.

(3) A statement of the amount of benefits paid by the insurer for services rendered during the quarter which qualify for asset protection.

(4) A summary total of the amount paid to date under the policy which qualifies for asset protection.

(A) The format and wording for the asset protection report shall be described in the Plan of Action Requirements provided by the Office of Policy and Management.

(B) Copies of all asset protection reports shall also be sent to the Office of Policy and Management on a quarterly basis.

(C) Asset protection reports shall be subject to audit by the Department of Social Services under the same requirements as specified in subsection (e)(2) of this section which covers the records in subsection (b) of this section.

(d) Preparing A Service Summary. Each insurer shall prepare a service summary at the client's request specifically for the purpose of the policyholder applying for Medicaid. Also the insurer shall prepare a service summary when the policyholder has exhausted his/her benefits under the policy or when the policy ceases to be in force for a reason other than the death of the policyholder, whichever occurs first. The service summary shall identify the specific partnership-approved policy, the total benefits paid for services rendered to date, and the amount qualifying for asset protection. This Service Summary is separate and in addition to the information requirement described above in subsection (b) of this section. The format and wording for the service summary report shall be described in the Plan of Action Requirements provided by the Office of Policy and Management. Copies of all service summary reports shall also be sent to the Office of Policy and Management on a quarterly basis.

(e) Submitting Plan of Action. Each insurer shall, prior to partnership-approval by the commissioner, submit to the Office of Policy and Management a plan for complying with the information maintenance and documentation requirements set forth in this section. No policy shall be partnership-approved until the Office of Policy and Management has approved the insurer's documentation plan for the policy. When the Office of Policy and Management determines that a plan of action is adequate, they shall advise the Commissioner and the insurer of that fact in writing. If the Office of Policy and Management determines that there are shortcomings in a plan of action, they shall advise the Commissioner and the insurer of those shortcomings in writing and shall cooperate with the insurer in efforts to resolve them. The documentation plan shall include, but need not be limited to, the following:

(1) The location where records will be kept. Records required for purposes of the Connecticut Partnership for Long-Term Care shall be available at one location, which is easily available to staff of the Department of Social Services and the Insurance Department.

(2) The insurer shall agree to give the Department of Social Services access to all information, described in subsection (b) of this section, Maintaining Auditing Information, on an aggregate basis for all policyholders and on an individual basis for all policyholders who have ever received any benefits. Access to information on persons who have not applied for Medicaid is required in order for Department of Social Services to determine if an insurer's system for documenting asset protection is functioning correctly. Department of Social Services shall have the final decision concerning the frequency of access to the data and the size of samples for auditing or other purposes. The insurer shall be responsible for any reasonable expenses associated with any audit of its Connecticut Partnership for Long-Term Care records or systems that occurs outside of the state of Connecticut.

(3) The name, job title, address and telephone number of the person primarily responsible for the maintenance of the information required and for acting as liaison with the Office of Policy and Management, and the Department of Social Services, concerning the information.

(4) Methods for determining when insurance benefits qualify for asset protection, including documentation of the insured event, description of services, documentation of charges and benefits paid, and documentation of plans of care when required.

(5) Description of manual and electronic systems which will be used in maintaining the required information.

(6) Information which will be retained which is needed to comply with these regulations.

(7) Forms and descriptions of standard procedures for maintaining and reporting the information required. In the event that all or part of the data will be provided in computer-readable form, the specific medium (i.e., tape, diskette, etc.) shall be specified in addition to a description of the relevant file(s).

(8) The asset protection statement to be used in the policy, certificate when used, and outline of coverage. Format for the asset protection statement is included in the Plan of Action Requirements.

(9) A participation agreement with the Office of Policy and Management to be signed by an officer of the insurer. The participation agreement is included in the Plan of Action Requirements provided by the Office of Policy and Management. The participation agreement shall include, but need not be limited to:

(A) A statement that the insurer agrees to make a good faith effort to make revisions and upgrades to their partnership-approved policies and certificates by no later than the time they make revisions and upgrades to their policies and certificates available in Connecticut that are not partnership-approved; and

(B) A statement that the insurer will provide to the Office of Policy and Management a toll-free phone number that the public can utilize to obtain information regarding the insurer's partnership-approved policies and certificates. Such toll-free phone number shall be staffed with personnel familiar with the insurer's partnership-approved policies and certificates.

(10) Forms filed with the Commissioner for partnership-approval, including, but not limited to, policy forms, outlines of coverage, applications, riders, and endorsements.

(f) Auditing and Correcting Deficiencies In Insurer Record-Keeping. The following represent instances of insurer deficiency, procedures for resolution, asset protection determinations and required penalties:

(1) Within one year of the first time that any policyholder of a particular company's policy has met the criteria for the insured event, and as often as Department of Social Services deems necessary thereafter, Department of Social Services shall conduct a systems audit of that company's records. The insurer shall be responsible for advising Department of Social Services when this one year period has begun. Department of Social Services shall promptly inform each insurer of inaccuracies and other potential problems discovered in its systems audits, and shall cooperate with insurers in efforts to correct any problems in the insurer's methods of operation. It is the responsibility of the insurer to make any necessary corrections.

(2) Department of Social Services shall periodically audit a sample of individual applications to Medicaid of persons who have qualified for asset protection. Department of Social Services shall have the final decision concerning sample sizes and other auditing methods. Department of Social Services shall promptly advise insurers of any problems discovered, and shall cooperate with insurers in efforts to correct any problems in the insurer's methods of operation. Department of Social Services shall also notify the insurer of any obligations described in this subsection to hold clients harmless.

(3) The Commissioner of Social Services may enter into voluntary arrangements with insurers of partnership-approved long-term care insurance policies under which the Commissioner of Social Services, or his designee, would issue binding determinations as to whether or not services qualify for asset protection. Policyholders may submit requests for information and advice through their insurer or access agency. When the procedures described in this subdivision are followed in all material respects, the written determinations of the Commissioner of Social Services or his designee concerning whether services qualify for asset protection shall be binding upon the Department of Social Services in all subsequent actions, and the Department of Social Services shall not make any assertion contradicting these determinations in any action arising in this subsection:

(A) All requests for determinations as to whether or not services qualify for asset protection shall be submitted to the Commissioner of Social Services or his designee in writing. These requests may include but are not limited to requests for determinations in the following areas:

(i) Whether the insured event has occurred and has been adequately documented;

(ii) Whether a plan of care is required;

(iii) Whether a revision of a plan of care is required;

(iv) Whether a service or services is in accord with the Plan of Care;

(v) Whether a service is of such a nature as to qualify for asset protection as defined in Department of Social Services' Uniform Policy Manual;

(vi) Whether the applicable amount is the amount paid by the insurer or the amount charged for the service;

(vii) Whether a provider or proposed provider of service(s) is a "family member" as defined in Department of Social Services' Uniform Policy Manual.

(B) The Commissioner of Social Services or his designee may require insurers and access agencies submitting requests for determinations to provide all records and other information necessary for making a determination. These may include, but not necessarily be limited to, assessments, plans of care, and invoices for services rendered. The party providing the records and other information shall be responsible for their accuracy. If any records or other information are later determined to be materially inaccurate, the determination based on the inaccurate information shall not be binding on Department of Social Services in subsequent actions. In the case of a policyholder for whom a determination has been invalidated because information provided was determined to be inaccurate, the provisions of this subsection will apply in the same manner as for any other policyholder.

(C) The Commissioner of Social Services or his designee shall render a determination on each request in writing. Each determination of the Commissioner of Social Services or his designee shall state the reason(s) for the determination, including the relevant facts, documentation of facts, statutes, regulations, and policies.

(D) A copy of all determinations of the Commissioner of Social Services or his designee shall be kept on file at Department of Social Services, together with the related records and information. The original of the determination shall be sent to the insurer or the access agency who originally requested it. The recipient of the original determination shall be responsible for notifying the policyholder or policyholder's authorized agent.

(4) When an audit or other review by the Department of Social Services reveals deficiencies in the record keeping procedures of an insurer, Department of Social Services shall notify the insurer of the deficiencies, and establish a reasonable deadline for correction. If an insurer fails to correct deficiencies within a reasonable period of time, the Department of Social Services shall notify the Commissioner of the deficiencies.

(5) The Commissioner reserves the right to remove partnership-approval status of a long-term care insurance policy on account of an insurer's failure to comply with any of the provisions of sections 38a-475-1 to 38a-475-6, inclusive, of the regulations of Connecticut state agencies. If the Commissioner removes partnership-approval status from a long-term care insurance policy, policyholders who purchased their policies while the policy was partnership-approved will retain their right to asset protection. Policyholders who purchase their policies after the removal of partnership-approval status will have no right to asset protection.

When a policy's partnership-approval status is removed, or an insurer discontinues selling a partnership-approved policy, the insurer shall continue to comply with the documentation and reporting requirements in this section regarding policies already issued. In the event an insurer enters into an assumption agreement covering partnership-approved policies, the insurer shall obtain an undertaking from the assuming insurer that it will continue to comply with the documentation and reporting requirements applicable to the assumed policies.

(6) If an insurer prepares a Service Summary or Asset Protection Report which is used in a Medicaid application for a policyholder, and the client is found eligible for Medicaid, and the policyholder after receiving Medicaid services is found to be ineligible for Medicaid solely by reason of errors in the insurer's Service Summary, Asset Protection Report or documentation of services, the Department of Social Services may require the insurer to pay for services counting towards asset protection required by the policyholder until the insurer has paid an amount equal to the amount of the insurer's errors; after which the policyholder, if otherwise eligible, shall qualify for Medicaid coverage.

(7) If the Department of Social Services determines that an insurer's records pertaining to a policyholder who has received Medicaid benefits are in such condition that the Department of Social Services cannot determine whether the policyholder qualifies for asset protection, the Department of Social Services may require the insurer to pay for services counting towards asset protection required by the policyholder until the insurer has paid an amount equal to the amount of the insurers errors; after which the policyholder, if otherwise eligible, shall qualify for Medicaid coverage.

Compliance with subparagraphs (6) and (7) above, is a requirement for a policy to retain partnership-approval.

(Effective October 1, 1991; Amended July 30, 1999; Amended January 2, 2008)