Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 65.00 - Long-term Care Insurance › Section 65.102 - Appendix A: Sample Definitions

Current through Register 1525, July 5, 2024
The following represent sample definitions of terms used in
				long-term care insurance policies. Any marketing or sales practices will be
				considered to be in compliance with the law if policies use substantially the
				same definitions and comply with all other laws related to the marketing of
				insurance policies.
Adult day care
means dementia day care
				or social day care.
Adult day health
means those nursing,
				educational, and rehabilitative services provided by an adult day health
				program.
Adult day health program
means a
				program approved by the Massachusetts Division of Medical Assistance or by a
				program meeting the requirements of the state in which the adult day health
				services are provided.
Adult foster care
means personal care
				and other related services provided ina family-like setting that are provided
				by programs approved bythe MassachusettsDivision of Medical Assistance or that
				meet the requirements of the state in which services are provided.
Assisted living facility
means a
				facility that has been certified as an assisted living residence by the
				Massachusetts Executive Office of Elder Affairs or a facility meeting the
				requirements of the state in which services are provided.
Chore care
means non-medical services
				that are provided in the insured's home and are designed to maintainthe
				insured's home so that it remains habitable, including at a minimum: vacuuming
				(including the moving of furniture), washing floors and walls, defrosting
				freezers, cleaning ovens, cleaning attics and basements to remove fire and
				health hazards, changing storm windows, performing heavy yardwork, shoveling
				snow, and making minor home repairs (such as replacing windows, door/window
				locks, handrails and safety rails, making minor repairs to stairs or floors and
				weatherizing the home).
Class
means the underwriting and
				rating classifications originally used at the time that the policy was
				issued.
Community care benefits
means those
				services provided to the insured in a home or community setting by a
				community-based service provider, including, but not limited to, personal care,
				home care and respite care.
Custodial care
means non-medical
				services provided by a nursing home or a home health care agency.
Dementia day care
means services
				provided by a dementia day care program operating in accordance with standards
				issued by the Executive Office of Elder Affairs, including a structured, secure
				environment for individuals with cognitive disabilities to maximize the
				individual's functional capacity, to reduce agitation, disruptive behavior, and
				the need for psychoactive medication, and to enhance cognitive functioning or a
				programmeeting the requirements of the state in which the dementia care is
				being provided.
Disability
means the functional or
				cognitive inability to engage in the regular and customary activities of daily
				living without human assistance as measured by Activities of Daily Living
				(ADLs).
Elimination Period
means the number of
				days of covered services that are to be paid solely by the insured before the
				insurance policy begins to pay benefits.
Guaranteed Renewable
means the policy
				feature that guarantees the insured's right to continue the inforce insurance
				policy by the timely payment of premiums. A carrier cannot cancel, cannot
				decline to renew, and cannot make any unilateral change in any provision of a
				guaranteed renewable coverage without the agreement of the insured, but on a
				class basis, the carrier may revise premium rates for guaranteed renewable
				policies subject to the approval of the commissioner.
Home care
means non-medical assistance
				with activities of daily living provided by a home care provider which are
				designed to maintain the insured's abilityto live independently and include,
				but are not limited to, shopping, planning menus, preparing meals, home
				delivered meals, laundry, and light house cleaning and maintenance, including
				vacuuming, dusting, dry mopping, dishwashing, cleaning the kitchen/bathroom and
				changing beds.
Home care provider
means an entity
				that provides home care services and meets the provider requirements set forth
				by the Executive Office of Elder Affairs or a programmeetingthe requirements of
				the state in which the home care services are being provided.
Home Health Care
means nursing, home
				health aide, rehabilitative therapy, and nutrition counseling services.
Home health care agency
meansanagencycertifiedby the Massachusetts Department of Public Health or
				anagencyor programmeetingthe requirements of the state in which the home health
				care services are provided.
Hospice care
means those palliative
				services provided by a hospice to a patient deemed to be terminally ill.
Hospice
means an agency or program
				licensed by the Massachusetts Department ofPublic Healthor an agency or program
				meeting the requirements of the state in which hospice services are
				provided.
Hospita
l means a facility licensed by
				the Massachusetts Department of Public Health or meeting the requirements of
				the state in which the facility is located.
Intermediate nursing care
means
				routine nursing services with the periodic availability of skilled nursing and
				rehabilitative services that are provided by a nursing home, a home health care
				agency, or by an adult day health program.
Lifetime maximum benefit period
means
				the maximum number of days of benefits, as chosen by the insured, which the
				carrier shall payfor covered benefits after the satisfaction of any elimination
				period or deductible.
Lifetime maximum dollar amount
means
				the maximumdollar amount, as chosen by the insured, which the carrier shall pay
				for covered benefits after the satisfaction of any elimination period or
				deductible.
Medicaid
means the program of medical
				assistance administered by the Massachusetts Division of MedicalAssistance
				under Title XIXofthe federal Social Security Act, 42 USCS §1396
et
				seq
., and M.G.L. c 118E.
Medical necessity
means:
(a) in accordance with accepted standards of
			 medical practice for the diagnosis and treatment of a condition;
(b) delivered, when possible, in the least
			 intensive setting required by the insured's condition; and
(c) not solely for the convenience of the
			 insured or the insured's family or the insured's health care provider.
Medicare
means the federal health
				insurance program under Title XVIII of the federal Social Security Act, 42 USCS
				§1395
et seq
., as amended.
Mental or nervous condition
means a
				condition as described in the standard nomenclature of the American Psychiatric
				Association.
Noncancelable
means the policy feature
				that guarantees the insured's right to continue the in-force insurance policy
				at the same premium level by the timely payment of premiums. A carrier cannot
				cancel, cannot decline to renew, cannot make anyunilateralchange inany
				provision of coverage, and cannot revise premium rates for a noncancelable
				policy without the agreement of the insured.
Nurse
means all nurses, including, but
				not limited to, registered nurses (R.N.), licensed practical nurses (L.P.N.),
				or licensed vocational nurses (L.V.N.) meeting the appropriate licensing or
				registration requirements of the state in which the nurse provides
				services.
Nursing home
means a facility that is
				primarily engaged in providing nursing care and related services on an
				inpatient basis under a license issued by the Department of Public Health or
				the appropriate licensing agency of the state in which it is located.
Personal care
means services provided
				by a personal care provider to assist in activities of daily living. Services
				provided by a personal care provider include, but are not limited to,
				assistance with bathing, bedpan routines, foot care, dressing, and care of
				dentures; shaving and grooming; assistance with eating; and assistance with
				ambulating and transfers.
Personal care provider
means an entity
				that provides personal care services and meets the provider requirements set
				forth by the Executive Office of Elder Affairs or a programmeetingthe
				requirements of the state in which the personal care services are being
				provided.
Pre-existing condition
means a medical
				condition for which an insured received diagnosis or treatment during the
				24-month period prior to the effective date of coverage.
Respite care
means services to
				temporarily relieve a caregiver of the daily stresses and demands of care for
				the insured. In addition to home care, personal care and home health care,
				respite care services may include but are not limited to short-termplacements
				inadult foster care, nursing facilities or rest homes.
Skilled nursing care
means skilled
				nursing, rehabilitative and other related services provided by a nursing home
				or home health care agency.
Social day care
means training,
				counseling, and social services as defined by standards issued by the Executive
				Office of Elder Affairs, including assistance with walking, grooming, and
				eating and planned recreational and social activities suited to the needs of
				the participants and designed to encourage physical and mental exercise and
				stimulate social interaction.