Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 1 - GENERAL PROVISIONS › Section 3.3804 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as otherwise provided by law or
					 this subchapter, no long-term care insurance policy, certificate, group
					 hospital service corporation subscriber contract, rider attached to a life
					 insurance policy or certificate or annuity contract or certificate may be
					 delivered or issued for delivery in this state, unless it complies with, and
					 contains definitions in conformance with, this subchapter.
(b) The following words and terms, when used
					 in this subchapter, shall have the following meanings, unless the context
					 clearly indicates otherwise.
(1) Activities
					 of daily living--Bathing, continence, dressing, eating, toileting and
					 transferring, as those terms are defined in this subsection.
(2) Acute condition--The individual's medical
					 condition 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--A social and
					 health-related services program 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) Adult Day Care
					 Facility--Provider of Adult Day Care services, operated pursuant to the
					 provisions of the Human Resources Code, Chapter 103 (concerning licensing and
					 quality of care requirements in the provision of adult day care).
(5) Applicant--The person who seeks to
					 contract for benefits or services, in the instance of an individual long-term
					 care insurance policy; or the proposed certificate holder or enrollee, in the
					 instance of a group long-term care insurance policy.
(6) Attained age rating--A schedule of
					 premiums starting from the issue date which increases with age at least one
					 percent per year prior to age 50, and at least three percent per year beyond
					 age 50.
(7) 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.
(8) Care--Terms referring to care, such as
					 "home health care," "intermediate care," "maintenance or personal care,"
					 "skilled nursing 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 the
					 care must be delivered.
(9)
					 Certificate--Any certificate issued under a group long-term care insurance
					 policy, which certificate has been delivered or issued for delivery in this
					 state. For purposes of these sections, the term:
(A) Also includes any evidence of coverage
					 issued pursuant to a group health maintenance organization contract for
					 long-term care health coverage.
(B)
					 Does not include certificates that are delivered or issued for delivery in this
					 state under a single employer or labor union group policy that is delivered or
					 issued for delivery outside this state.
(10) 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).
(11) Dressing--Putting on and taking off all
					 items of clothing and any necessary braces, fasteners or artificial
					 limbs.
(12) 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.
(13) Exceptional premium rate
					 increases--Increases filed by an insurer as exceptional and for which the
					 department 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 long term care
					 products.
(14) Group
					 long-term care insurance--A long-term care insurance policy or certificate of
					 group long-term care insurance that is delivered or issued for delivery in this
					 state and issued to an eligible group as defined by the Insurance Code Chapter
					 1251 Subchapter B (relating to Group Accident Health Insurance: Eligible
					 Policyholders) but subject to the exemptions in the Insurance Code §
												1651.002 (relating to
					 Exemptions), or a long-term care rider issued to an eligible group as defined
					 by the Insurance Code §
												1131.002
					 (relating to Certain Group Life Insurance Authorized).
(15) Home health agency--A business which
					 provides home health service and is licensed by the Texas Health and Human
					 Services Commission.
(16) Home
					 health care services--Medical or nonmedical services provided to ill, disabled
					 or infirm persons in their residences. Such services may include homemaker
					 services, assistance with activities of daily living, respite care services,
					 case management services, and maintenance or personal care services.
(17) Level premium long-term care policy--A
					 non-cancellable long-term care policy.
(18) Long-term care benefit
					 classifications--Institutional long-term care benefits only, non-institutional
					 long-term care benefits only, or comprehensive long-term care
					 benefits.
(19) Long-term care
					 benefit plan--An insurance policy or group certificate, or rider to the policy
					 or certificate, or evidence of coverage issued by a health maintenance
					 organization subject to the Texas Health Maintenance Organization Act
					 (Insurance Code Chapter 843) that is advertised or marketed as providing, or
					 offered or designed to provide, coverage for not less than 12 consecutive
					 months for each covered individual 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. Pursuant to
					 the Insurance Code §
												1651.003(b),
					 the term includes a plan or rider, other than a group or individual annuity or
					 life insurance policy, that provides for payment of benefits based on cognitive
					 impairment or for the loss of functional capacity. The term does not include an
					 insurance policy, group certificate, or evidence of coverage that is offered
					 primarily to provide Medicare supplement coverage, basic hospital expense
					 coverage, basic medical-surgical expense coverage, hospital confinement
					 indemnity coverage, major medical expense coverage, disability income
					 protection coverage, accident-only coverage, specified disease or specified
					 accident coverage, or limited benefit health coverage or basic or single health
					 care services. With regard to life insurance, this term does not include life
					 insurance policies:
(A) that accelerate the
					 death benefit specifically for one or more of the qualifying events of terminal
					 illness, medical conditions requiring extraordinary medical intervention or
					 permanent institutional confinement; and
(B) that provide the option of a lump-sum
					 payment for those benefits; and
(C)
					 where neither the benefits nor the eligibility for the benefits is conditioned
					 upon the receipt of long-term care.
(20) Long-term care insurance--
(A) Any insurance policy, group certificate,
					 rider to such policy or certificate, or evidence of coverage that is
					 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, per diem or other basis for one or more necessary or
					 medically necessary services of the following types, administered in a setting
					 other than an acute care unit of a hospital: diagnostic, preventive,
					 therapeutic, curing, treating, mitigating, rehabilitative, maintenance, or
					 personal care. The term includes riders for group and individual annuities and
					 life insurance policies that provide long-term care insurance. The term also
					 includes a policy, certificate, or rider that 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; and
					 health maintenance organizations or any similar organization to the extent they
					 are otherwise authorized to issue life or health insurance.
(B) The term "long-term care insurance" shall
					 not include any insurance policy, group certificate, subscriber contract, or
					 evidence of coverage that 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 asset-related protection coverage,
					 accident only coverage, specified disease or specified accident coverage, or
					 limited benefit health coverage.
(C) With regard to life insurance, this term
					 does not include life insurance policies:
(i)
					 that accelerate the death benefit specifically for one or more of the
					 qualifying events of terminal illness, medical conditions requiring
					 extraordinary medical intervention or permanent institutional confinement;
					 and
(ii) that provide the option of
					 a lump-sum payment for those benefits; and
(iii) where neither the benefits nor the
					 eligibility for the benefits is conditioned upon the receipt of long-term
					 care.
(D)
					 Notwithstanding any other provision of this subchapter, any product advertised,
					 marketed or offered as long-term care insurance shall be subject to the
					 provisions of this subchapter.
(21) Long-term care partnership insurance
					 policy--A long-term care insurance policy and/or certificate established under
					 the Human Resources Code Chapter 32 Subchapter C and that meets the
					 requirements of the Federal Deficit Reduction Act of 2005,
					 Pub. L. No.
					 109-171 and Chapter 1651 Subchapter C of the
					 Insurance Code. This term does not include a life insurance policy or annuity
					 contract that provides long-term care benefits by rider.
(22) Maintenance or Personal Care
					 Services--Any care the primary purpose of which is the provision of needed
					 assistance under §
												3.3818
					 of this subchapter (relating to Standards for Eligibility for Benefits),
					 including the protection from threats to health and safety due to impairment of
					 cognitive ability.
(23)
					 Medicare--"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 Law 89-97, as Enacted by the Eighty-Ninth Congress of the
					 United States of America 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.
(24)
					 Mental or Nervous Disorder--A neurosis, psychoneurosis, psychopathy, psychosis,
					 or mental or emotional disease or disorder of any kind.
(25) Policy--Any policy, contract, subscriber
					 agreement, rider, or endorsement, delivered or issued for delivery in this
					 state by an insurer, fraternal benefit society, nonprofit group hospital
					 service corporation, or health maintenance organization subject to the Texas
					 Health Maintenance Organization Act Insurance Code Chapter 843.
(26) Preexisting Condition--A condition for
					 which medical advice was given or treatment was recommended by, or received
					 from, a physician within six months before the effective date of
					 coverage.
(27) Qualified
					 actuary--An actuary who is a member of either the Society of Actuaries or the
					 American Academy of Actuaries.
(28)
					 Qualified long-term care insurance contract--A long-term care insurance
					 contract meeting the requirements as contained in Internal Revenue Code of
					 1986, §7702B(b).
(29)
					 Qualified long-term care services--As the term is defined in Internal Revenue
					 Code of 1986, §7702B(c).
(30)
					 Similar policy forms--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. Those certificates issued
					 or delivered pursuant to one or more employers or labor union organizations, or
					 to a trust or to the trustees 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, 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.
(31)
					 Toileting--Getting to and from the toilet, getting on and off the toilet, and
					 performing associated personal hygiene.
(32) Transferring--Sufficient mobility to
					 move into or out of a bed, chair or wheelchair or to move from place to place,
					 either via walking, a wheelchair or other means.