Title II, SEC. 2326. REQUIREMENTS RELATING TO PAYMENT OF BENEFITS. 
      (a) In General. The Secretary, after considering (where appropriate) 
    recommendations of the Advisory Council, shall promulgate regulations 
    establishing requirements with respect to claims for and payment of 
    benefits under long-term care insurance policies, which shall include at a 
    minimum the requirements specified in this section. 

      (b) Standards Relating to Threshold Conditions for Receipt of Covered 
    Benefits. Each long-term care insurance policy shall meet the following 
    requirements with respect to identification of, and determination of 
    whether an insured individual meets, the threshold conditions for receipt 
    of benefits covered under such policy: 

        (1) Declaration of threshold conditions. 

          (A) In general. The policy shall specify the level (or levels) of 
        functional or cognitive mental impairment (or combination of 
        impairments) required as a threshold condition of entitlement to 
        receive benefits under the policy (which threshold condition or 
        conditions shall be consistent with any regulations promulgated by the 
        Secretary pursuant to subsection (B)). 

          (B) Secretarial responsibility. The Secretary (after considering the 
        views of the Advisory Council on current practices of insurers 
        concerning, and the appropriateness of standardizing, threshold 
        conditions) may promulgate such regulations as the Secretary finds 
        appropriate establishing standardized thresholds to be used under such 
        policies as preconditions for varying levels of benefits. 

        (2) Independent professional assessment. The policy shall provide for a 
      procedure for determining whether the threshold conditions specified 
      under paragraph (1) have been met with respect to an insured individual 
      which 

          (A) applies such uniform assessment standards, procedures, and 
        formats as the Secretary may specify, after consideration of 
        recommendations by the Advisory Council; 

          (B) permits an initial evaluation (or, if the initial evaluation was 
        performed by a qualified independent assessor selected by the insurer, 
        a reevaluation) to be made by a qualified independent assessor selected 
        by the insured individual (or designated representative) as to whether 
        the threshold conditions for receipt of benefits have been met; 

          (C) permits the insurer the option to obtain a reevaluation by a 
        qualified independent assessor selected and reimbursed by the insurer; 

          (D) provides that the insurer will consider that the threshold 
        conditions have been met in any case where 

            (i) the assessment under subparagraph (B) concluded that such 
          conditions had been met, and the insurer declined the option under 
          subparagraph (C), or 

            (ii) assessments under both subparagraphs (B) and (C) concluded 
          that such conditions had been met; and 

          (E) provides for final resolution of the question by a State agency 
        or other impartial third party in any case where assessments under 
        subparagraphs (B) and (C) reach inconsistent conclusions. 

        (3) Qualified independent assessor. For purposes of paragraph (2), the 
      term ``qualified independent assessor'' means a licensed or certified 
      professional, as appropriate, who 

          (A) meets such standards with respect to professional qualifications 
        as may be established by the Secretary, after consulting with the 
        Secretary of the Treasury, and 

          (B) has no significant or controlling financial interest in, is not 
        an employee of, and does not derive more than 5 percent of gross income 
        from, the insurer (or any provider of services for which benefits are 
        available under the policy and in which the insurer has a significant 
        or controlling financial interest). 

      (c) Requirements Relating to Claims for Benefits. Insurers shall be 
    required 

        (1) to promptly pay or deny claims for benefits submitted by (or on 
      behalf of) insured individuals who have been determined pursuant to 
      subsection (b) to meet the threshold conditions for payment of benefits; 

        (2) to provide an explanation in writing of the reasons for payment, 
      partial payment, or denial of each such claim; and 

        (3) to provide an administrative procedure under which an insured 
      individual may appeal the denial of any claim.