Which of the following provisions may a Texas long-term care policy NOT contain, under the long-term care insurance rules adopted by TDI?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under 28 TAC 3.3825, a Texas long-term care policy may not condition the payment of benefits on the insured first being confined in a hospital, and it may not condition benefits on prior institutionalization, apart from narrow exceptions such as a waiver of premium after a period of confinement. Benefit eligibility must relate to the insured's functional or cognitive status under 28 TAC 3.3818, so a hospital stay, which many long-term care claimants never experience, cannot be imposed as a gatekeeping condition. By contrast, requirements about licensed providers, a plan of care and practitioner supervision are ordinary policy terms and remain permissible.
Why the other options are wrong
- B) An activities-of-daily-living trigger is the core permissible benefit trigger, not a prohibited provision.
- C) Requiring that the insured be under the care of a licensed practitioner is an ordinary and permissible policy provision.
- D) Requiring that service providers be appropriately licensed is a permissible quality control, not a prohibited provision.
Memory hook
No hospital stay required to collect long-term care benefits.