Md. Code Regs. 31.14.01.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.14.01.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Activities of daily living" means at least bathing, continence, dressing, eating, toileting, and transferring.

(2) "Acute condition" means that the individual is medically unstable and requires frequent monitoring by physicians, registered nurses, or other medical professionals in order to maintain the individual's health status.

(3) "Adult day care" means a program providing social and health-related services, during the day, in a community group setting for the purpose of supporting frail, impaired, elderly, or other disabled adults who could benefit from care in a group setting outside the home.

(4) "Alzheimer's disease" means a progressive brain disease diagnosed as Alzheimer's disease by the licensed attending physician of the insured or certificate holder and confirmed by a second opinion of a licensed physician.

(5) "Applicant" means in the case of:

(a) An individual long-term care insurance policy or contract, the person who seeks to contract for benefits; and

(b) A group long-term care insurance policy, the proposed certificate holder.

(6) "Association" means any association described in Insurance Article, § 15-302(c)(2), Annotated Code of Maryland.

(7) "Bathing" means washing oneself:

(a) By sponge bath; or

(b) In either a tub or shower, including the task of getting into or out of the tub or shower.

(8) "Certificate" means any certificate issued under a group long-term care insurance policy if the certificate is delivered or issued for delivery in the State and covers individuals who reside in the State.

(9) "Cognitive impairment" means a deficiency in an individual's short or long-term memory, orientation as to person, place, and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.

(10) "Continence" means the ability to:

(a) Maintain control of bowel and bladder function; or

(b) When unable to maintain control of bowel or bladder function, perform associated personal hygiene, including caring for catheter or colostomy bag.

(11) "Domiciliary care" means care, including general supervision and assistance in daily living, such as, but not limited to, aid in walking, getting in and out of bed, bathing, dressing, or eating, which is provided on a prearranged basis in a licensed residential facility for three or more unrelated individuals who need the care because of advanced age, infirmity, or physical or mental limitations.

(12) "Dressing" means putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.

(13) "Eating" means feeding oneself by getting food into the body from a receptable, such as a plate, cup, or table, or by feeding tube or intravenously.

(14) "Employer group long-term care insurance" means a long-term care insurance policy that is:

(a) Issued or delivered in Maryland to:

(i) One or more employers or labor organizations; or

(ii) A trust or the trustees of a fund established by one or more employers or labor organizations, or by a combination of employers or labor organizations; and

(b) Designed for:

(i) Employees or former employees, or a combination of employees and former employees, of the employer or employers; or

(ii) Members or former members, or a combination of members and former members, of the labor organization or labor organizations.

(15) "Field issued" means a policy or certificate issued by an insurance producer or a third-party administrator:

(a) Pursuant to the underwriting authority granted to the insurance producer or third-party administrator by an insurer; and

(b) Using the insurer's underwriting guidelines.

(16) "Guaranteed renewable" means that the:

(a) Policyholder or certificate holder has the right to continue long-term care insurance in force during the lifetime of the covered person by the timely payment of premiums; and

(b) Insurer may not decline to renew the policy or unilaterally make any change in any provision of the policy while the policy is in force, except that the insurer may revise the premium rates on a class basis.

(17) "Hands-on assistance" means physical assistance, whether minimal, moderate, or maximal, without which the individual would not be able to perform the activity of daily living.

(18) Home Health Care Services.

(a) "Home health care services" means medical and nonmedical services provided to ill, disabled, or infirm persons in their residences.

(b) "Home health care services" includes:

(i) Assistance with activities of daily living;

(ii) Homemakers' services; and

(iii) Respite care services.

(19) "Insurance producer" has the meaning stated in Insurance Article, § 1-101, Annotated Code of Maryland.

(20) "Insurer" means an insurance company, nonprofit health service plan, health maintenance organization, or preferred provider organization.

(21) "Limited distribution channel" means through a discrete entity, such as a financial institution or brokerage, for which specialized products are available that are not available for sale to the general public.

(22) Long-Term Care Insurance.

(a) "Long-term care insurance" means any group or individual insurance policy, contract, certificate, or rider issued, delivered, or offered by an insurer that:

(i) Is advertised, marketed, offered, or designed to provide coverage for not less than 24 consecutive months for covered persons on an expense incurred, indemnity, prepaid, or insured basis; and

(ii) Provides one or more necessary or appropriate diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services furnished in a situation other than an acute care unit of a hospital.

(b) Long-term care insurance includes any product that is advertised, marketed, or offered as long-term care insurance.

(c) "Long-term care insurance" does not include any insurance policy, contract, certificate, or rider which is offered primarily to provide:

(i) Basic Medicare supplement coverage;

(ii) Hospital confinement indemnity coverage;

(iii) Basic hospital expense or medical-surgical expense coverage;

(iv) Disability income protection coverage;

(v) Accident only coverage;

(vi) Specified disease or specified accident coverage; or

(vii) Skilled nursing care.

(d) "Long-term care insurance" does not include a life insurance policy:

(i) That accelerates the death benefit specifically for one or more of the qualifying events of terminal illness, a medical condition requiring extraordinary medical intervention, or permanent institutional confinement;

(ii) That provides a lump sum payment for any of the events in §B(22)(d)(i) of this regulation; or

(iii) In which neither benefits nor eligibility for benefits is conditioned on receipt of long-term care.

(e) "Long-term care insurance" does not include any certificate issued under an out-of-State employer group contract.

(23) "Medicaid" means the Maryland Medical Assistance Program or any similar program provided by the state in which the insured person resides.

(24) "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended.

(25) "Mental or nervous disorder" means a condition diagnosed as neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

(26) "Noncancellable policy" means a policy which the policyholder has the right to continue in force by the timely payment of premiums, and in which the insurer is precluded from unilaterally making any change in any provision of the policy or in the premium rates while the policy is in force.

(27) "Nursing care" means service for a patient that is ordered by a physician and provided or supervised by a registered or licensed practical nurse.

(28) "Nursing home" means a licensed organized institution that maintains conditions or facilities and equipment to provide domiciliary, personal, or nursing care for a number of unrelated individuals who are dependent on the administrator, operator, or proprietor for nursing care or the subsistence of daily living in a safe, sanitary, and healthy environment, and which admits or retains the individuals for overnight care.

(29) "Out-of-State employer group contract" means a group contract that is:

(a) Entered into with an employer in a state other than Maryland; and

(b) Issued directly to an employer under the laws of that employer's state.

(30) "Partnership policy" means a long-term care insurance policy that is:

(a) Certified by the Commissioner to meet the requirements under § 1917(b) of the Social Security Act; and

(b) Issued on or after the date of the State plan amendment.

(31) "Partnership Program" means the program established by Health-General Article, Title 15, Subtitle 4, Annotated Code of Maryland.

(32) "Personal care" means the provision of hands-on services to assist an individual with the activities of daily living.

(33) Policy.

(a) "Policy" means any policy, contract, individual certificate, subscriber agreement, rider, or endorsement delivered or issued for delivery in this State by:

(i) An insurer;

(ii) A nonprofit health service plan;

(iii) A health maintenance organization; or

(iv) A preferred provider organization.

(b) "Policy" does not include a life insurance policy which contains an optional provision for acceleration of payment of all or a portion of the face amount under stated conditions relating to the medical condition, the disability, or the need for long-term care of the insured.

(34) "Preexisting condition" means a condition for which medical advice or treatment was recommended by or received from a provider of health care services within 6 months before the effective date of coverage of the insured or certificate holder.

(35) "Qualified long-term care insurance" has the meaning stated in §C of this regulation.

(36) "Service benefit long-term care insurance policy" means a long-term care insurance policy that provides for benefits based on the amount of expenses incurred, rather than on an indemnity basis.

(37) "State of policy issue" means the state in which the individual policy or group certificate was originally issued.

(38) "State plan amendment" means an amendment filed by the Department of Health and Mental Hygiene with the Centers for Medicare and Medicaid Services under Title 42, U.S.C., which provides for the disregard of any assets or resources by the Department of Health and Mental Hygiene in an amount equal to the insurance payments that are made to or on behalf of the individual who is covered under a partnership policy.

(39) "Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

(40) "Transferring" means moving into or out of a bed, chair, or wheelchair.

C. Qualified Long-Term Care Insurance.

(1) "Qualified long-term care insurance" means:

(a) An individual or group insurance contract that meets the requirements of § 7702B(b) of the Internal Revenue Code of 1986, as amended, as follows:

(i) The only insurance protection provided under the contract is coverage of qualified long-term care services;

(ii) The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act, as amended, or would be reimbursable under Title XVIII of the Social Security Act but for the application of a deductible or coinsurance amount;

(iii) The contract is guaranteed renewable, within the meaning of §7702B(b)(1)(C) of the Internal Revenue Code of 1986, as amended;

(iv) The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in §C(1)(a)(v) of this regulation;

(v) All refunds of premiums, and all policyholder dividends or similar amounts, under the contract are to be applied as a reduction in future premiums or to increase future benefits, except that a refund on the event of death of the insured or a complete surrender or cancellation of the contract cannot exceed the aggregate premiums paid under the contract; and

(vi) The contract meets the consumer protection provisions set forth in §7702B(g) of the Internal Revenue Code of 1986, as amended; and

(b) The portion of a life insurance contract that:

(i) Provides long-term care insurance coverage by rider or as part of the contract; and

(ii) Satisfies the requirements of §§7702B(b) and (e) of the Internal Revenue Code of 1986, as amended.

(2) A contract may not fail to satisfy the requirements of §C(1)(a)(i) or (ii) of this regulation by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.

(3) The requirements of §C(1)(a)(ii) of this regulation do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor.

Md. Code Regs. 31.14.01.02