Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Section 2012.40 - Policy Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
a) For
			 policies issued after January 1, 2009, no long-term care insurance policy
			 delivered or issued for delivery in this State shall use the terms set forth
			 below, unless the terms are defined in the policy and the definitions satisfy
			 the following requirements.
"Activities of Daily Living" means at least bathing,
				continence, dressing, eating, toileting and transferring.
"Acute Condition" means a condition that causes the individual
				to be medically unstable. Such individual requires frequent monitoring by
				medical professionals, such as physicians and registered nurses, in order to
				maintain his or her health status.
"Adult Day Care" means a program, for 6 or more individuals, of
				social and health-related services provided during the day in a community group
				setting for the purpose of supporting frail, impaired elderly or other disabled
				adults who can benefit from care in a group setting outside the home.
"Assistive Equipment" may include, but is not limited to,
				tangible personal property with a useful life of at least one year, expressly
				designed and used for increasing independent functioning in specific tasks or
				activities of independent living in the home that directly results in a
				demonstrated decrease in need for assistance from another individual in
				performing certain tasks or activities.
"Bathing" means washing oneself by sponge bath, or in either a
				tub or shower, including the task of getting into or out of the tub or
				shower.
"Cognitive Impairment" means a deficiency in a person'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.
"Continence" means the ability to maintain control of bowel and
				bladder function; or, when unable to maintain control of bowel or bladder
				function, the ability to perform associated personal hygiene (including caring
				for catheter or colostomy bag).
"Dressing" means putting on and taking off all items of
				clothing and any necessary braces, fasteners or artificial limbs.
"Eating" means feeding oneself by getting food into the body
				from a receptacle (such as a plate, cup or table) or by a feeding tube or
				intravenously.
"Electronic Home Response Services" may include, but are not
				limited to, services designed to provide a 24 hour per day emergency
				communication link to assistance outside the home for individuals with such
				severe disabilities that they are incapable of using conventional or modified
				communication devices such as the telephone, and who have no other persons
				available in the home should an emergency arise.
"Hands-on Assistance" means physical assistance (minimal,
				moderate or maximal) without which the individual would not be able to perform
				the activity of daily living.
"Home Health Care Services" means medical and nonmedical
				services provided to persons in their residences who are ill or have
				disabilities or infirmities. Examples of such services may include, but are not
				limited to, homemaker services, assistance with activities of daily living and
				respite care services.
"Homemaker Service" may include, but is not limited to,
				non-medical support provided by trained and professionally supervised
				homemakers to maintain, strengthen and safeguard the functioning of individuals
				in their own homes.
"Licensed Health Care Practitioner" means any physician (as
				defined in section 1861(r)(1) of the Social Security Act) and any registered
				professional nurse, licensed social worker, or other individual who meets
				requirements as may be prescribed by the Secretary.
"Maintenance Home Health Care Services" may include, but is not
				limited to, medically related services provided in the home in accordance with
				services prescribed by a physician. Specific components of maintenance home
				health care may include: nursing services; physical, respiratory or speech
				therapy; and medical/health care services provided by a home health care
				aide.
"Medicare" means "The Health Insurance for the Aged Act, Title
				XVIII of the Social Security Amendments of 1965 as Then Constituted or Later
				Amended", or "Title I, Part I of Public Law 89-97, as Enacted by the
				Eighty-Ninth Congress of the United States of America and popularly known as
				the Health Insurance for the Aged Act, as then constituted and any later
				amendments or substitutes thereof", or words of similar import.
"Mental or Nervous Disorder" shall not be defined to include
				more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or
				emotional disease or disorder.
"Personal Care" means the provision of hands-on services to
				assist an individual with activities of daily living, such as bathing, eating,
				dressing, transferring and toileting.
"Plan of Care" in qualified plans means the specific type and
				frequency of all services required to maintain the individual in the community,
				the service providers, and the cost of services. The plan of care shall be
				specified in writing by a licensed health care provider.
"Respite Service" may include, but is not limited to, temporary
				care for insureds aimed at relieving stress for the insureds' families. Respite
				service shall be provided for vacation, rest, errands, family crisis or
				emergency.
"Skilled Nursing Care", "Intermediate Care", "Personal Care",
				"Home Care", "Specialized Care", "Assisted Living Care" and other services
				shall be defined in relation to the level of skill required, the nature of the
				care and the setting in which care must be delivered.
"Toileting" means getting to and from the toilet, getting on
				and off the toilet, and performing associated personal hygiene.
"Transferring" means moving into or out of a bed, chair or
				wheelchair.
b) For policies
			 issued after January 1, 2009, all providers of services, including, but not
			 limited to, "skilled nursing facility", "intermediate care facility", "extended
			 care facility", "specialized care providers", "assisted living facility",
			 "convalescent nursing home", "personal care facility", and "home care agency"
			 shall be defined in relation to the services and facilities required to be
			 available and the licensure, certification, registration or degree status of
			 those providing or supervising the services. When the definition requires that
			 the provider be appropriately licensed, certified or registered, it shall also
			 state what requirements a provider must meet in lieu of licensure,
			 certification or registration when the state in which the service is to be
			 furnished does not require a provider of these services to be licensed,
			 certified or registered, or when the state licenses, certifies or registers the
			 provider of services under another name.
c) For policies issued prior to January 1,
			 2009, no insurance policy or certificate may be advertised, solicited,
			 delivered or issued for delivery in this State as a traditional long-term care
			 policy unless the policy or subscriber contract contains definitions or terms
			 that are not more restrictive than the requirements of this Section.
"Activities of Daily Living" means at least bathing,
				continence, dressing, eating, toileting and transferring.
"Acute Condition" means a condition that causes the individual
				to be medically unstable. Such individual requires frequent monitoring by
				medical professionals, such as physicians and registered nurses, in order to
				maintain his or her health status.
"Adult Day Care" means a program for 6 or more individuals, of
				social and health-related services provided during the day in a community group
				setting for the purpose of supporting frail, impaired elderly or other adults
				with disabilities who can benefit from care in a group setting outside the
				home.
All providers of services, including but not limited to skilled
				nursing facility, intermediate care facility, convalescent nursing home,
				personal care facility, and home care agency shall be defined in relation to
				the services and facilities required to be available and the licensure or
				degree status of those providing or supervising the services. The definition
				may require that the provider be appropriately licensed or certified.
"Bathing" means washing oneself by sponge bath, or in either a
				tub or shower, including the task of getting into or out of the tub or
				shower.
"Chronically Ill Individual", for all traditional long-term
				care policies that are marketed as "qualified" pursuant to the Internal Revenue
				Code of 1986, as amended (
				26 USC
				7702B(c)(2)(A) ), the term
				"chronically ill individual" means any individual who has been certified by a
				licensed health care practitioner as:
being unable to perform (without substantial assistance from
				another individual) at least 2 activities of daily living for a period of at
				least 90 days due to a loss of functional capacity,
requiring substantial supervision to protect such individual
				from threats to health and safety due to severe cognitive impairment.
Such term shall not include any individual otherwise meeting
				the requirements of the preceding sentence unless within the preceding 12-month
				period a licensed health care practitioner has certified that such individual
				meets such requirements.
"Cognitive Impairment" means a deficiency in a person'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.
"Continence" means the ability to maintain control of bowel and
				bladder function; or, when unable to maintain control of bowel or bladder
				function, the ability to perform associated personal hygiene (including caring
				for catheter or colostomy bag).
"Dressing" means putting on and taking off all items of
				clothing and any necessary braces, fasteners or artificial limbs.
"Eating" means feeding oneself by getting food into the body
				from a receptacle (such as a plate, cup or table) or by a feeding tube or
				intravenously.
"Exceptional Increase" means only those increases filed by an
				insurer as exceptional for which the Director determines the need for the
				premium rate increase is justified:
Due to changes in laws or regulations applicable to traditional
				long-term care coverage in this State; or
Due to increased and unexpected utilization that affects the
				majority of insurers of similar products.
Except as proved in Sections
				2012.112
				and 2012.113, exceptional increases are subject to the same requirements as
				other premium rate schedule increases.
The Director may request a review by an independent actuary or
				a professional actuarial body of the basis for a request that an increase be
				considered an exceptional increase.
The Director, in determining that the necessary basis for
				exceptional increase exists, shall also determine any potential offsets to
				higher claims costs.
"Hands-on Assistance" means physical assistance (minimal,
				moderate or maximal) without which the individual would not be able to perform
				the activity of daily living.
"Home Health Care Services" means medical and nonmedical
				services provided to persons in their residences who are ill or have
				disabilities or infirmities. Examples of such services may include but are not
				limited to homemaker services, assistance with activities of daily living and
				respite care services.
"Incidental", as used in Sections
				2012.112(j)
				and 2012.113(j), means that the value of the traditional long-term care benefit
				provided is less than 10% of the total value of the benefits provided over the
				life of the policy. These values shall be measured as of the date of
				issue.
"Licensed Health Care Practitioner" means any physician (as
				defined in Section 1861(r)(1) of the Social Security Act) and any registered
				professional nurse, licensed social worker, or other individual who meets
				requirements as may be prescribed by the Secretary.
"Maintenance or Personal Care Services" within the meaning of
				the internal Revenue Code of 1986, as amended (
				26 USC
				7702B(c)(3) ), means any
				care the primary purpose of which is the provision of needed assistance with
				any of the disabilities as a result of which the individual is a chronically
				ill individual (including the protection from threats to health and safety due
				to severe cognitive impairment).
"Medicare" means "The Health Insurance for the Aged Act, Title
				XVIII of the Social Security Amendments of 1965 as Then Constituted or Later
				Amended", or "Title I, Part I of Public Law 89-97, as Enacted by the
				Eighty-Ninth Congress of the United States of America and popularly known as
				the Health Insurance for the Aged Act, as then constituted and any later
				amendments or substitutes thereof", or words of similar import.
"Mental or Nervous Disorder" shall not be defined to include
				more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or
				emotional disease or disorder.
"Personal Care" means the provision of hands-on services to
				assist an individual with activities of daily living, such as bathing, eating,
				dressing, transferring and toileting.
"Plan of Care" in qualified plans means the specific type and
				frequency of all services required to maintain the individual in the community,
				the service providers, and the cost of services. The plan of care shall be
				specified in writing by a licensed health care provider.
"Qualified Actuary" means a member in good standing of the
				American Academy of Actuaries.
"Qualified Long-Term Care Contract" has the same meaning as
				that for a "Qualified long-term care insurance contract" described in Section
				351A-1 of the Code.
"Qualified Long-Term Care Services" means necessary diagnostic,
				preventive, therapeutic, curing, treating, mitigating and rehabilitation
				services, and maintenance or personal care services that are required by a
				chronically ill individual and provided pursuant to a plan of care prescribed
				by a licensed heath care practitioner.
"Similar Policy Forms" means all of the traditional long-term
				care insurance policies and certificates issued by an insurer in the same
				traditional long-term care benefit classification as the policy form being
				considered. Certificates of groups that meet the definition found in Section
				2012.30 are not
				considered similar to certificates or policies otherwise issued as traditional
				long-term care insurance, but are similar to other comparable certificates with
				the same traditional long-term care benefit classifications. For purposes of
				determining similar policy forms, traditional long-term care benefit
				classifications are defined as follows: institutional traditional long-term
				care benefits only, non-institutional traditional long-term care benefits only,
				or comprehensive traditional long-term care benefits.
"Skilled Nursing Care", "Intermediate Care", "Personal Care",
				"Home Care", and other services shall be defined in relation to the level of
				skill required, the nature of the care and the setting in which care must be
				delivered.
"Toileting" means getting to and from the toilet, getting on
				and off the toilet, and performing associated personal hygiene.
"Transferring" means moving into or out of a bed, chair or
				wheelchair.