Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-030 - Standards for definitions applicable to long-term care contracts

Current through Register Vol. 24-14, July 15, 2024
The following definitions are applicable to long-term care
				contracts and the implementation of
				chapter
				48.84 RCW and this
				chapter, and no contract may be advertised, solicited, or issued for delivery
				in this state as a long-term care contract which uses definitions more
				restrictive or less favorable to an insured than the following:
(1) "Acute care" means care provided for
			 patients who are not medically stable. These patients require frequent
			 monitoring by health care professionals in order to maintain their health
			 status.
(2) "Benefit period" means
			 the period of time for which the insured is eligible to receive benefits or
			 services under a contract. A benefit period begins on the first day that the
			 insured is eligible for and begins to receive the benefits of the contract. The
			 benefit period ends when the insured is no longer eligible to receive benefits
			 or has received the lifetime maximum benefits available. Such benefit period
			 must be stated in terms of days rather than in terms of months of
			 benefit.
(3) "Case manager" or
			 "case coordinator" means an individual qualified by training and/or experience
			 to coordinate the overall medical, personal and social service needs of the
			 long-term care patient. Such coordination activities shall include but are not
			 limited to: Assessing the individual's condition to determine what services and
			 resources are necessary and by whom they might most appropriately be delivered;
			 coordination of elements of a treatment or care plan and referral to the
			 appropriate medical or social services personnel or agency; control
			 coordination of patient services and continued monitoring of the patient to
			 assess progress and assure that services are delivered. Such activities shall
			 be conducted in consultation with the attending physician.
(4) "Chronic care" or "maintenance care"
			 means care that is necessary to support an existing level of health and is
			 intended to preserve that level from further failure or decline. The care
			 provided is usually for a long, drawn out or lingering disease or infirmity
			 showing little change or slowly progressing with little likelihood of complete
			 recovery, whether such care is provided in an institution or is community-based
			 and whether such care requires skilled, intermediate or custodial/personal
			 care.
(5) "Convalescent care" or
			 "rehabilitative care" is nonacute care which is prescribed by a physician and
			 is received during the period of recovery from an illness or injury when
			 improvement can be anticipated, whether such care requires skilled,
			 intermediate or custodial/personal care, and whether such care is provided in
			 an institutional care facility or is community-based.
(6) "Custodial care" or "personal care" means
			 care which is mainly for the purpose of meeting daily living requirements. This
			 level of care may be provided by persons without professional skills or
			 training. Examples are: Help in walking, getting out of bed, bathing, dressing,
			 eating, meal preparation, and taking medications. Such care is intended to
			 maintain and support an existing level of health or to preserve the patient
			 from further decline. Custodial or personal care services are those which may
			 be recommended by the case manager in consultation with the patient's attending
			 physician and are not primarily for the convenience of the insured or the
			 insured's family.
(7) "Guaranteed
			 renewable" means that renewal of a contract may not be declined by an insurer
			 for any reason except for nonpayment of premium, but the insurer may revise
			 rates on a class basis.
(8) A "home
			 health aide" is a person who is providing care under the supervision of a
			 physician, licensed professional nurse, physical therapist, occupational
			 therapist, or speech therapist. Care provided may include ambulation and
			 exercise, assistance with self-administered medications, reporting changes in a
			 covered person's conditions and needs, completing appropriate records, and
			 personal care or household services needed to achieve medically desired
			 results.
(9) "Home care services"
			 or "personal care services" are services of a personal nature including, but
			 not limited to, homemaker services, assistance with the activities of daily
			 living, respite care services, or any other nonmedical services provided to
			 ill, disabled, or infirm persons which services enable those persons to remain
			 in their own residences consistent with their desires, abilities and safety. An
			 insurer may require that services are provided by or under the direction of a
			 home health care agency or home care agency regulated by this state, or that
			 services are administered in accordance with a plan of treatment developed by
			 or with the assistance of health care professionals.
(10) "Home health care" shall mean, but is
			 not limited to, any of the following health or medical services: Nursing
			 services, home health aide services, physical therapy, occupational therapy,
			 speech therapy, respiratory therapy, nutritional services, medical or social
			 services, and medical supplies or equipment services. An insurer may require
			 that services are provided by or under the direction of a regulated home health
			 care agency regulated by this state, or that services are administered in
			 accordance with a plan of treatment developed by or with the assistance of
			 health care professionals.
(11)
			 "Intermediate care" means technical nursing care which requires selected
			 nursing procedures for which the degree of care and evaluation is less than
			 that provided for skilled care, but greater than that provided for
			 custodial/personal care. This level of care provides a planned continuous
			 program of nursing care that is preventive or rehabilitative in
			 nature.
(12) "Long-term care total
			 disability" means the functional inability due to illness, disease or infirmity
			 to engage in the regular and customary activities of daily living which are
			 usual for a person of the same age and sex.
(13) "Managed long-term care delivery system"
			 means a system or network of providers arranged or controlled by a managed
			 long-term care plan. Such systems provide a range of long-term care services
			 with provisions for effective utilization controls and quality assurance. In
			 the case of provision of long-term care in the managed care environment, a case
			 manager or other qualified individual may be used to develop and coordinate a
			 care plan of appropriate long-term care services.
(14) "Managed long-term care plan" means a
			 plan which on a prepaid basis assumes the responsibility and the risk for
			 delivery of the covered long-term care services set forth in the benefit
			 agreement. Actual services are rendered by the plan through its own staff,
			 through capitation, or other contractual arrangements with providers. Managed
			 long-term care plans may include but are not limited to those offered by health
			 maintenance organizations, and health care service contractors, if their
			 services are provided through a managed long-term care delivery
			 system.
(15) "Noncancellable" means
			 that renewal of a contract may not be declined except for nonpayment of
			 premium, nor may rates be revised by the insurer.
(16) "One period of confinement" means
			 consecutive days of institutional care received as an inpatient in a health
			 care institution, or successive confinements due to the same or related causes
			 when discharge from and readmission to the institution occurs within a period
			 of time not more than ninety days or three times the maximum number of days of
			 institutional care provided by the policy to a maximum of one hundred eighty
			 days, whichever provides the covered person with the greater benefit.
(17) "Preexisting condition," as defined by
			 RCW
			  48.84.020(3), means a
			 covered person's medical condition that caused that person to have received
			 medical advice or treatment during the specified time period before the
			 effective date of coverage.
(18)
			 "Respite care" is short-term care which is required in order to maintain the
			 health or safety of the patient and to give temporary relief to the primary
			 caretaker from his or her caretaking duties.
(19) "Skilled care" means care for an illness
			 or injury which requires the training and skills of a licensed professional
			 nurse, is prescribed by a physician, is medically necessary for the condition
			 or illness of the patient, and is available on a twenty-four-hour
			 basis.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030 and
				  48.84.050. 95-19-028 (Order R
				  95-5), §
										284-54-030, filed 9/11/95,
				  effective 10/12/95. Statutory Authority:
				  RCW
				   48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-030, filed
				  7/9/87.