Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 65.00 - Long-term Care Insurance › Section 65.04 - Definitions

Current through Register 1525, July 5, 2024
ActivitiesofDailyLiving(ADLs)
means
				eating, toileting, transferring, bathing, dressing, and continence.
Agent
means either:
(a) a person licensed as an insurance producer under M.G.L. c.
				175, §162I; or
(b) any other person legally authorized to represent a carrier
				in the marketing of long-term care insurance.
Alternate Care Benefits
means benefits
				for services or other items not specified in the long-term care insurance
				policy, but to be covered as agreedtoby the carrier, the insured, and the
				insured's caregiver. This includes, but is not limited to, payment for home
				modifications that allow the insured to continue living at home or a
				non-institutionalized setting and coverage oflong-termcare services that might
				not exist on the policy issue date.
Care Management
means those procedures
				employed by a carrier to approve covered services and to determine the
				appropriate level of care.
Carrier
means a commercial insurance
				company licensed to issue accident and sickness policies under M.G.L. c.175 or
				a fraternal benefit society licensed under M.G.L. c.176.
Cold-lead Advertising
means making use
				directly or indirectly of any method ofmarketingwhichfails to disclose in a
				conspicuous manner that one of the purposes of the method of marketing is the
				solicitation of insurance and that contact will be made by a carrier or its
				agent.
Commissioner
means the commissioner of
				insurance or his/her designee.
Convertible
means a policy feature
				that gives the insured the right to switch to another policy offered or
				sponsored by the carrier.
Daily Maximum Benefit
means the
				maximum daily amount that the long-termcare insurance policy pays for specific
				services.
Deductible
means the dollar amount of
				covered services that are to be paid solely by theinsured before the long-term
				care insurance policy begins to pay benefits.
Division of Medical Assistance
means
				the state agency responsible for administering programs of medical assistance
				in Massachusetts pursuant to M.G.L. c. 118E.
Elimination Period
means the number of
				days during which covered services must be received by an insured before the
				long-term care insurance policy begins to pay benefits.
Employment-based Group Policy
means a
				certificate issued to an insured who is enrolled in a group policy issued to
				one or more employers or labor organizations, or to the trustees ofa fund
				established by one or more employers or labor organizations, or 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.
Federally Qualified
means a policy
				that meets standards set forth in the federal Internal Revenue Code and related
				federal regulations in order to qualify for special tax treatment.
Group Policy
means the certificate
				issued to an insured who is enrolled through a group trust or association to
				which the carrier has issued a long-term care insurance policy. For the
				purposes of
				211 CMR
				65.00, this does not include employment-based group
				policies.
Guaranteed Renewable
means a policy
				feature that guarantees the insured's right to continue the policy in force 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 policy without the agreement of the insured, but subject to the
				approval of the commissioner, a carrier may revise premium rates for guaranteed
				renewable policies on a class basis.
High-pressure tactics
means employing
				any method of marketing that has the effect of or tends to induce orrecommend
				the purchase of any insurance policy through force, fright,
				threat(whetherexplicit or implied) or undue pressure.
Home Health Care
means nursing, home
				health aide, rehabilitative therapy, and nutrition counseling services.
Individual policy
means a policy
				issued by a carrier directly to an insured.
Insured
means the named policyholder
				or certificateholder under a long-term care insurance policy.
Lifetime maximum benefit period
means
				the maximum number of days of benefits, as chosen by the insured, which the
				carrier will pay for covered benefits after the satisfaction of any elimination
				period or deductible.
Lifetime maximum dollar amount
means
				the maximum dollar amount, as chosen by the insured, which the carrier will pay
				for covered benefits after the satisfaction of any elimination period or
				deductible.
MassHealth(Medicaid)
means the
				programof medical assistance administered by the Massachusetts Division of
				Medical Assistance under Title XIX of the federal Social Security Act, 42 USCS
				§1396
et seq
., and M.G.L. c. 118E.
Medical necessity
means:
(a) inaccordance 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, 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 policy in force at the same
				premium level by the timelypayment ofpremiums. A carrier cannot cancel, cannot
				decline to renew, cannot make any unilateral change in any provision of
				coverage, and cannot revise premium rates for a noncancelable policy without
				the agreement of the insured.
Nonforfeiture benefit
means a benefit
				to the insured in the eventthatthe long-term care insurance policy lapses due
				to nonpayment of premium. Nonforfeiture benefits include, but are not limited
				to, returnof premium and any partial paid-up benefits.
Policy
means an individual long-term
				care insurance policy or a certificate ofa group policythat is not
				employment-based, as well as the policy application, riders, amendments or
				other provisions that are attached to the policy to identify the contractual
				provisions of the insured's coverage.
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.
Twisting
means knowingly making any
				misleading representation or incomplete or fraudulent comparison of any
				insurance policies or carriers for the purpose ofinducing, or tendingto induce,
				any person to lapse, forfeit, surrender, terminate, retain, pledge, assign,
				borrow on or convert any policy or to take out a policy with another
				carrier.