2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10254 - Definitions

For purposes of this chapter:
(a) Certificate.— Means any certificate issued under a group long-term care insurance policy, policy has been delivered or issued for delivery in Puerto Rico.
(b) Qualified long-term care insurance contract or federally tax-qualified long-term care insurance contract.— Means an individual or group insurance contract that meets the requirements of the U.S. Internal Revenue Code of 1986, as amended, as follows:
(1) The only insurance protection provided under the contract is coverage of qualified long-term care services established in accordance with federal income tax laws. A contract shall not fail to satisfy the requirements of this paragraph by reason of payments being made on a periodic basis (per diem or other period) without regard to the expenses incurred during such period;
(2) the contract does not provide for the payment or reimbursement of expenses incurred for services or items that are reimbursable under Title XVIII of the Social Security Act, as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount. The requirements of this clause do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor. A contract shall not fail to satisfy the requirements of this clause by reason of payments being made on a periodic basis (per diem or other period)without regard to the expenses incurred during such period;
(3) the contract is guaranteed renewable, as defined in the U.S. Internal Revenue Code of 1986, as amended;
(4) 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 Section 66.040B(1)(e) of this Chapter [sic];
(5) all refunds of premiums, and all policyholder dividends or similar amounts, under the contract shall be applied as a reduction in future premiums or to increase future benefits, except that a refund on the event of death of the enrollee or a complete surrender or cancellation of the contract cannot exceed the aggregate premiums paid under the contract, and
(6) the contract meets the consumer protection provisions set forth in the U.S. Internal Revenue Code of 1986, as amended.
“Qualified Long-term Care Insurance Contract” or “Federally Tax-qualified Long-term Care Insurance Contract” also means the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of the U.S. Internal Revenue Code of 1986, as amended.
(c) Policy.— Means any policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery in Puerto Rico by an issuer authorized to market disability insurance in Puerto Rico.
(d) Long-term care insurance.— Means:
(1) Any insurance policy or rider advertised, marketed, offered or designed to provide coverage for not less than twelve (12) consecutive months on an expense incurred, indemnity, prepaid or other basis; for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services, provided in a setting other than an acute care unit of a hospital.
(2) The term includes group and individual annuities and life insurance policies or riders that provide directly or supplement long-term care insurance. The term also includes a policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. The term shall also include federally tax-qualified long-term care insurance contracts.
(3) Long-term care insurance may be issued by issuers authorized to issue disability insurance.
(4) Long-term care insurance shall not include any insurance policy that 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.
(5) With regard to life insurance, this term shall not include life insurance policies that accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention or permanent institutional confinement, and that provide the option of a lump-sum payment for those benefits and where neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. Notwithstanding any other provision of this chapter, any product advertised, marketed or offered as long-term care insurance shall be subject to the provisions of this chapter.
(e) Group long-term care insurance.— Means a long-term care insurance policy that is delivered or issued for delivery in Puerto Rico and issued to:
(1) One (1) 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 the 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 trustees of a fund established, created or maintained for the benefit of members of one or more associations. Prior to advertising, marketing, or offering the policy in Puerto Rico, the association or the issuer of the association, shall file evidence with the Commissioner, since the beginning, that the association has been organized and maintained in good faith for purposes other than obtaining insurance; has been in active existence for at least one (1) year; and has a constitution and bylaws that provide that:
(A) The association holds regular meetings not less than annually to further purposes of the members;
(B) except for cooperative banks, the association collects dues or solicit contributions from members, and
(C) the members have voting privileges and representation on the governing board and committees.
Thirty (30) days after the filing the association will be deemed to satisfy the organizational requirements, unless the Commissioner determines otherwise.
(4) To qualify as a group long-term care insurance, the issuer shall ensure that the minimum requirements regarding the number of covered persons or enrollees set forth in §§ 1401–1411 of this title are met.
(f) Applicant.— Means:
(1) In the case of an individual long-term care insurance policy, the person who seeks to obtain insurance.
(2) In the case of a group long-term care insurance policy, the proposed certificate holder.
History —Aug. 29, 2011, No. 194, § 66.040, eff. 180 days after Aug. 29, 2011.