Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Section 2012.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Accelerated Long-Term Care Benefit" means a life insurance
				policy, contract, rider endorsement or amendment that contains benefits
				providing payment from life or endowment or annuity benefits in advance of the
				time they would otherwise be payable at any time during the insured's lifetime
				as an indemnity for long-term care.
"Applicant",
as defined in Section 351A-1 of
				the Illinois Insurance Code,
means
:
in the case of an individual long-term care insurance
				policy, the person who seeks to contract for benefits;
in the case of a group long-term care insurance policy,
				the proposed certificateholder
.
"Certificate",
as defined in Section 351A-1 of
				the Illinois Insurance Code,
means any certificate issued under a group
				long-term care insurance policy, which policy has been delivered or issued for
				delivery in this State.
"Chronically Ill Individual", for all 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) ), 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;
having a level of disability similar (as determined under
				regulations prescribed by the Secretary in consultation with the Secretary of
				Health and Human Services) to the level of disability described in the
				preceding paragraph; or
requiring substantial supervision to protect the individual
				from threats to health and safety due to severe cognitive impairment.
The term does not include any individual otherwise meeting the
				requirements of this definition unless within the preceding 12-month period a
				licensed health care practitioner has certified that the individual meets these
				requirements.
"Code" means the Illinois Insurance Code [ 215 ILCS 5 ].
"Director" means the Director of the Illinois Department of
				Insurance.
"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 long-term care coverage in this State, or to increased and
				unexpected utilization that affects the majority of insurers of similar
				products.
Except as provided in Sections
				2012.112
				and 2012.113, exceptional increases are subject to the same requirements as
				other premium rate schedule increases found in Section
				2012.112
				or 2012.113.
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.
"Group Long-Term Care Insurance",
as defined
				in Section 351A-1 of the Code [
				215 ILCS 5/351A-1 ],
means a
long-term care insurance policy which is
				delivered or issued for delivery in this State and issued to one of the
				following:
One or more employers or labor organizations, or to a
				trust or to the trustee(s) 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.
Any professional, trade or occupational association for
				its members or former or retired members, or combination thereof, if such
				association:
is composed of individuals all of whom are or were
				actively engaged in the same profession, trade or occupation;
				and
has been maintained in good faith for purposes other
				than obtaining insurance.
An association or a trust or the trustee(s) of a fund
				established, created or maintained for the benefit of members of one or more
				associations. Prior to advertising, marketing or offering such policy within
				this State, the association or associations, or the insurer of the association
				or associations, shall file evidence with the Director that the association or
				associations have at the outset a minimum of 100 members and have been
				organized and maintained in good faith for purposes other than that of
				obtaining insurance; have been in active existence for at least one year; and
				have a constitution and by-laws which provide that:
the association or associations hold regular meetings
				not less than annually to further purposes of the members;
except for credit unions, the association or
				associations collect dues or solicit contributions from members;
				and
the members have voting privileges and representation
				on the governing board and committees.
Thirty days after such filing the association or
				associations will be deemed to satisfy such organizational requirements, unless
				the Director makes a finding that the association or associations do not
				satisfy those organizational requirements.
A group other than as described in subparagraphs under
				the definition of Group Long-Term Care Insurance, subject to a finding by the
				Director that:
the issuance of the group policy is not contrary to the
				best interest of the public;
the issuance of the group policy would result in
				economies of acquisition or administration; and
the benefits are reasonable in relation to the premiums
				charged.
"Incidental", as used in Sections
				2012.112(j)
				and 2012.113(j), means that the value of the 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.
"Insurer" includes insurance companies; fraternal benefit
				societies; nonprofit health, hospital, and medical service corporations;
				prepaid health plans; health maintenance organizations or any similar
				organization.
"Long-Term Care Insurance",
as defined in
				Section 351A-1 of the Code,
means any accident and health insurance
				policy or rider advertised, marketed, offered or designed to provide coverage
				for not less than 12 consecutive months 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, or personal care services, provided in a setting other than an
				acute care unit of a hospital. The term includes group and individual
annuities and
life insurance policies or riders which
				provide directly or which supplement long-term care insurance. The term also
				includes a policy or rider which provides for payment of benefits based upon
				cognitive impairment or the loss of functional capacity. The term shall also
				include qualified long-term care insurance contracts. Long-term care insurance
				may be issued by insurers,
fraternal benefit
				societies,
nonprofit health, hospital, and medical service
				corporations,
prepaid health plans,
health
				maintenance organizations or any similar organization
,
to the
				extent they are otherwise authorized to issue life or health insurance.
				Long-term care insurance shall not include any insurance policy which 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.
				Long-term care insurance may include benefits for care and treatment in
				accordance with the tenets and practices of any established church or religious
				denomination
which
teaches reliance on
				spiritual treatment through prayer for healing.
"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).
"Policy",
as defined in Section 351A-1 of the
				Illinois Insurance Code,
means any policy, contract, subscriber
				agreement, rider or endorsement delivered or issued for delivery in this State
				by an insurer, fraternal benefit society, non-profit health
,
hospital, or medical service corporation, prepaid health plan, health
				maintenance organization or any similar organization
.
"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 Insurance Partnership Policy" means a
				policy that meets all of the following requirements:
It covers an insured who was a resident of Illinois when
				coverage first became effective under the policy;
It is a qualified long-term care insurance policy as defined in
				section 7702B(b) of the Internal Revenue Code of 1986 issued not earlier than
				the effective date of the State plan amendment;
It meets the model regulations and requirements of the National
				Association of Insurance Commissioners model specified in paragraph (5) of
				Title VI, section 6021 of the federal Deficit Reduction Act of 2005 (
				42 USC
				1305 ), and the Director of the Department of
				Insurance certifies it as meeting these requirements; and
If the policy is sold to an individual who:
has not attained age 61 as of the date of purchase, the policy
				provides compound annual inflation protection;
has attained age 61 but has not attained age 76 as of the date
				of purchase, the policy provides some level of inflation protection; or
has attained age 76 as of the date of purchase, the policy may,
				but is not required to, provide some level of inflation protection.
"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, that are provided pursuant to a plan of care
				prescribed by a licensed heath care practitioner.
"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.
"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. Certificates
				of groups that meet the definition of "Group Long-Term Care Insurance" found in
				Section 351A-1(e)(1) of the Code are not considered similar to certificates or
				policies otherwise issued as long-term care insurance, but are similar to other
				comparable certificates with the same long-term care benefit classifications.
				For purposes of determining similar policy forms, long-term care benefit
				classifications are defined as follows: institutional long-term care benefits
				only, non-institutional long-term care benefits only, or comprehensive
				long-term care benefits.