Definitions

Definitions For the purpose of this regulation, the following terms shall have the following meanings: A. “Long-term care insurance” means any insurance policy or rider advertised, marketed, offered or designed to provide coverage for not less than twelve (12) consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis; for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, or maintenance or personal care services, provided in a setting other than an acute care unit of a hospital. Such term includes group and individual annuities and life insurance policies or riders which provide directly or which supplement long-term care insurance. Such term also includes a policy or rider which provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. Long-term care insurance may be issued by insurers; fraternal benefit societies; nonprofit health, hospital, and medical service corporations; prepaid health plans; health maintenance organizations or any similar organization to the extent they are otherwise authorized to issue life or health insurance. Long-term care insurance shall not include any insurance policy which is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical- surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset –protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage. B. “Applicant” means: 1. In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits, and 2. In the case of a group long-term care insurance policy, the proposed certificate holder. C. “Certificate” means, for the purposes of this Regulation, any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this state. D. “Commissioner” means the Insurance Commissioner of this state. E. “Group long-term care insurance” means a long-term care insurance policy which is delivered or issued for delivery in this state and issued to: 1. One or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof, of the labor organizations; or 2. Any professional, trade or occupational association for its members or former or retired members, or combination thereof, if such association: a. Is composed of individuals all of whom are or were actively engaged in the same profession, trade or occupation; and b. has been maintained in good faith for purposes other than obtaining insurance; or 3. An association or a trust or the trustee(s) of a fund established, created or maintained for the benefit of members of one or more associations. Prior to advertising, marketing or offering such policy within this state, the association or associations, or the insurer of the association or associations, shall file evidence with the Commissioner that the association or associations have at the outset a minimum of 100 persons and have been organized and maintained in good faith for purposes other than that of obtaining insurance, have been in active existence for at least one year; and have a constitution and bylaws which provide that: a. The association or associations hold regular meetings not less than annually to further purposes of the members; b. Except for credit unions, the association or associations collect dues or solicit contributions from members; and c. The members have voting privileges and representation on the governing board and committees. d. Thirty (30) days after such filing the association or associations will be deemed to satisfy such organizational requirements, unless the Commissioner makes a finding that the association or associations do not satisfy those organizational requirements. 4. A group other than as described in Subsections E(1), E(2) and E(3), subject to a finding by the Commissioner that: a. The issuance of the group policy is not contrary to the best interest of the public; b. The issuance of the group policy would result in economies of acquisition or administration; and c. The benefits are reasonable in relation to the premiums charged. F. “Policy” means, for the purposes of this Regulation, any policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery in this state by an insurer; fraternal benefit society; nonprofit health, hospital, or medical service corporation; prepaid health plan; health maintenance organization or any similar organization.