Md. Code Regs. 31.14.02.02

Current through Register Vol. 51, No. 24, December 2, 2024

Section 31.14.02.02 - Definitions

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

B. Terms Defined.

(1) "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.

(2) "Exceptional increase" means only those increases filed by an insurer as exceptional for which the Commissioner determines that the need for a premium rate increase is justified due to:

(a) Changes in laws or regulations applicable to long-term care coverage in the State; or

(b) Increased and unexpected utilization that affects the majority of insurers of similar products.

(3) "Incidental" means that the value of the long-term care benefits provided, as of the date of issue, is less than 10 percent of the total value of the benefits provided over the life of the policy.

(4) 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 provided 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 benefits provided under any life insurance policy, contract, or rider:

(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, permanent institutional confinement, or institutional confinement for a lengthy confinement;

(ii) That provides the option of a lump-sum payment for one or more of the benefits in §B(4)(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.

(5) "Loss ratio" means the ratio of losses incurred to premiums earned on policies issued, delivered, or renewed in the State.

(6) "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.

(7) "Policy" means any group or individual policy, contract, subscriber agreement, rider, certificate, or endorsement delivered or issued for delivery in the State by an insurer, a nonprofit health service plan, health maintenance organization, or a preferred provider organization.

(8) "Qualified actuary" means a member in good standing of the American Academy of Actuaries.

(9) Similar Policy Forms.

(a) "Similar policy forms" means all of the long-term care insurance policies and certificates issued by an insurer in the same long-term care benefit classification as the policy form being considered.

(b) With respect to certificates issued under employer group long-term care insurance policies, "similar policy forms" includes other certificates issued under employer group long-term care insurance policies with the same long-term care benefit classifications.

(c) With respect to certificates issued under employer group long-term care insurance policies, "similar policy forms" does not include certificates or policies issued as long-term care insurance, except those certificates described in §B(9)(b) of this regulation.

(d) For purposes of determining similar policy forms, long-term care policies and certificates shall be considered in the following three separate long-term care benefit classifications:

(i) Institutional long-term care benefits only;

(ii) Noninstitutional long-term care benefits only; or

(iii) Comprehensive long-term care benefits.

Md. Code Regs. 31.14.02.02