Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-015 - Standards for policy definitions and terms

Current through Register Vol. 24-14, July 15, 2024
A long-term care insurance policy or certificate delivered or
				issued for delivery in this state must not use the following terms unless the
				terms are defined in the policy or certificate and the definitions satisfy the
				following standards. This section specifies minimum standards for several terms
				commonly found in long-term care insurance policies, while allowing some
				flexibility in the definitions themselves.
(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. An individual with an acute
			 condition 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" or
			 "adult day health care" means a program of social or 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) "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.
(10) "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 with
			 activities of daily living and respite care services.
(11) "Managed-care plan" or "plan of care"
			 means a health care or assisted living arrangement designed to coordinate
			 patient care or control costs through utilization review, case management or
			 use of specific provider networks.
(12) "Medicare" means "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.
(13) "Personal care" means
			 the provision of hands-on services to assist an individual with activities of
			 daily living.
(14) "Skilled nursing
			 care," "personal care," "home care," "specialized care," "assisted living care"
			 and other services must be defined in relation to the level of skill required,
			 the nature of the care and the setting in which care must be
			 delivered.
(15) "Toileting" means
			 getting to and from the toilet, getting on and off the toilet, and performing
			 associated personal hygiene.
(16)
			 "Transferring" means moving into or out of a bed, chair or
			 wheelchair.
(17) "Skilled nursing
			 facility," "nursing facility," "extended care facility," "convalescent nursing
			 home," "personal care facility," "specialized care providers," "assisted living
			 facility," "home care agency" and terms used to identify other providers of
			 services must be defined in relation to the services and facilities required to
			 be available and the licensure, certification, registration or degree status of
			 those providing or supervising the services. When the definition requires that
			 the provider be appropriately licensed, certified or registered, it must also
			 state what requirements a provider must meet in lieu of licensure,
			 certification or registration if the state in which the service is to be
			 furnished does not require a provider of these services to be licensed,
			 certified or registered, or if the state licenses, certifies or registers the
			 provider of services under another name.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-015, filed 11/24/08,
				  effective 12/25/08.