20-1691. Definitions

In this article, unless the context otherwise requires:

1. " Applicant" means:

(a) In the case of an individual long-term care insurance policy, the person who seeks to contract for such benefits.

(b) In the case of a group long-term care insurance policy, the proposed certificate holder.

2. " Certificate" means a certificate issued under a group long-term care insurance policy, which group policy has been delivered or issued for delivery in this state.

3. " Chronically ill individual" means any individual who has been certified by a licensed health care practitioner as meeting the definition of illness established by title III of the health insurance portability and accountability act of 1996 (P.L. 104-191).

4. " Director" means the director of the department of insurance.

5. " Group" means any of the following:

(a) One or more employers or labor organizations, or a trust or the trustees of a fund established by one or more employers or labor organizations for employees or former employees or members or former members of the labor organization.

(b) A professional, trade or occupational association for its members or former or retired members if the association is composed of individuals who were all actively engaged in the same profession, trade or occupation and the association has been maintained in good faith for purposes other than obtaining insurance.

(c) An association or a trust or the trustees of a fund established, created or maintained for the benefit of members of one or more associations, subject to compliance with the requirements of section 20-1691.04, subsection A.

(d) A group other than that described in subdivision (a), (b) or (c) of this paragraph if a policy issued to the group satisfies the criteria under section 20-1691.04, subsection C.

6. " Group long-term care insurance" means a long-term care insurance policy that is delivered or issued for delivery in this state to a group.

7. " Licensed health care practitioner" means any physician licensed pursuant to title 32, chapter 13 or 17, any registered nurse or registered nurse practitioner licensed pursuant to title 32, chapter 15 or any other individual who meets the requirements prescribed by the United States secretary of the treasury.

8. " Long-term care insurance" means an individual or group insurance policy or rider issued by insurers, fraternal benefit societies, nonprofit health, hospital and medical service corporations, prepaid health plans, health care services organizations or any similar organization and advertised, marketed, offered or designed to provide coverage 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, maintenance, personal or custodial care services provided in a setting other than an acute care unit of a hospital. Long-term care insurance includes group and individual annuities, life insurance policies or riders that provide or supplement long-term care insurance and qualified long-term care insurance contracts. Long-term care insurance also includes a policy or rider that provides for payment of benefits based on cognitive impairment or loss of functional capacity. Long-term care insurance does not include any insurance policy that is offered primarily to provide basic medicare supplement coverage, basic hospital expense coverage, basic medical and surgical expense coverage, major medical expense coverage, disability income or related asset protection coverage, hospital confinement indemnity coverage, accident only coverage, specified disease coverage, specified accident coverage or limited benefit health coverage or riders to the insurance policy or a life insurance policy that accelerates the death benefit for terminal illness, medical conditions requiring extraordinary medical intervention or permanent institutional confinement, that provides the option of a lump sum payment for those benefits and in which the benefits or the eligibility for the benefits is not conditioned on the receipt of long-term care.

9. " Long-term care partnership program" means a qualified state long-term care insurance partnership as defined in section 1917(b) of the social security act (42 United States Code section 1396p).

10. " Maintenance or personal care services" means any care the primary purpose of which is to provide assistance needed with any disability that results in the individual being a chronically ill individual, including the protection from threats to health and safety due to severe cognitive impairment.

11. " Policy" means an individual or group 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 or health care services organization or any similar organization.

12. " Preexisting condition" means a condition for which medical advice or treatment was recommended by or received from a health care services provider within six months before the effective date of coverage of an insured person.

13. " Qualified long-term care insurance contract" means:

(a) Any insurance policy that meets the requirements of section 7702B(b) of the internal revenue code of 1986, as amended.

(b) The portion of a life insurance policy that provides long-term care insurance coverage by rider or as a part of the policy and that satisfies the requirements of section 7702B(b) and (e) of the internal revenue code of 1986, as amended.

14. " Qualified long-term care services" means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitative services and maintenance or personal care services to which the insured is eligible under a qualified long-term care insurance contract and that are provided pursuant to a plan of care prescribed by a licensed health care practitioner.

15. " Severe cognitive impairment" means an impairment determined by a licensed health care practitioner as meeting the definition of an impairment as established by title III of the health insurance portability and accountability act of 1996 (P.L. 104-191).