Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.104 - Policy definitions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				long-term care insurance policy delivered or issued for delivery in this
				Commonwealth may not use the terms set forth as follows, unless the terms are
				defined in the policy and the definitions satisfy the following requirements:
Activities of daily living
-Bathing,
				  continence, dressing, eating, toileting and transferring.
Acute condition
-The term means that the
				  individual is medically unstable. This individual requires frequent monitoring
				  by medical professionals, such as physicians and registered nurses, to maintain
				  the individual's health status.
Adult day care
-A program for six 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.
Bathing
-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
-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
-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
-Putting on and taking off all items
				  of clothing and necessary braces, fasteners or artificial limbs.
Eating
-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.
Hands-on assistance
-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
-Medical and
				  nonmedical services, provided to ill, disabled or infirm persons in their
				  residences. The services may include homemaker services, assistance with
				  activities of daily living and respite care services.
Medicare
-The program under the Health
				  Insurance for the Aged Act in Title XVIII of the Social Security Amendments of
				  1965 (42 U.S.C.A.
				  §§
											1395-1395gg g) and any
				  later amendments or substitutes thereof.
Mental or nervous disorder
-The term may not
				  be defined to include more than neurosis, psychoneurosis, psychopathy,
				  psychosis, or mental or emotional disease or disorder.
Personal care
-The provision of supervisory
				  or hands-on services to assist an individual with activities of daily living.
Skilled nursing care, intermediate care, personal
				  care, home care and other services
-These terms 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
-Getting to and from the toilet,
				  getting on and off the toilet and performing associated personal hygiene.
Transferring
-Moving into or out of a bed,
				  chair or wheelchair.
(b) All
				providers of services, including, but not limited to, skilled nursing facility,
				extended care 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 only when the
				licensure or certification of the provider is required by the state in which
				the provider is located.
This section cited in 31 Pa. Code §
											89a.124 (relating to standards for
					 benefit triggers).