Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-42 - Policy definitions

Current through Vol. 41, No. 20, July 1,
				  2024
(a) No long-term
				  care insurance policy delivered or issued for delivery in the State of Oklahoma
				  shall use the terms set forth below, unless the terms are defined in the policy
				  and the definitions satisfy the following requirements:
(1)
"Activities of daily living"
means at least bathing, continence, dressing, eating, toileting and
				  transferring.
(2)
"Acute
				  condition"
means that the individual is medically unstable. Such an
				  individual requires frequent monitoring by medical professionals, such as
				  physicians and registered nurses, in order to maintain his or her health
				  status.
(3)
"Adult day
				  care"
means a program for four (4) 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.
(4)
"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.
(5)
"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.
(6)
"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).
(7)
"Dressing"
means putting on and taking off all items of clothing
				  and any necessary braces, fasteners or artificial limbs.
(8)
"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.
(9)
"Exceptional increase"
means
				  only those increases filed by an insurer as exceptional for which the
				  Commissioner determines the need for the premium rate increase is justified:
(A) Due to changes in laws or regulations
				  applicable to long-term care coverage in this state; or
(B) Due to increased and unexpected
				  utilization that affects the majority of insurers of similar products. Except
				  as provided in O.A.C.
				  365:10-5-47,
				  exceptional increases are subject to the same requirements as other premium
				  rate schedule increases. The Commissioner 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 Commissioner, in
				  determining that the necessary basis for an exceptional increase exists, shall
				  also determine any potential offsets to higher claims costs.
(10)
"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.
(11)
"Home health
				  care services"
means medical and nonmedical services, provided to ill,
				  disabled or infirm persons in their residences. Such services may include
				  homemaker services, assistance and activities of daily living and respite care
				  services.
(12)
"Incidental,"
as used in O.A.C.
				  365:10-5-47.1(j),
				  means that the value of the long-term care benefits provided is less than ten
				  percent (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.
(13)
"Medicare"
shall be defined
				  as "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 Laws 89-97, As Enacted by the Eighty-Ninth Congress of the United
				  States of American 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.
(14)
"Mental or Nervous Disorder"
shall not be defined to include more
				  than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional
				  disease or disorder.
(15)
"Personal care"
means the provision of hands-on services to assist
				  an individual with activities of daily living.
(16)
"Qualified Actuary"
means a
				  member in good standing of the American Academy of Actuaries.
(17)
"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 in 36 O.S.
				  §
											4424(4)(a)
				  and 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.
(18)
"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.
(19)
"Toileting"
means getting
				  to and from the toilet, getting on and off the toilet, and performing
				  associated personal hygiene.
(20)
"Transferring"
means moving into or out of a bed, chair or
				  wheelchair.