Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-020 - Definitions of terms used in this chapter and chapter 48.84 RCW

Current through Register Vol. 24-14, July 15, 2024
For purposes of the administration of
				chapter
				48.84 RCW and this
				chapter:
(1) "Community based care"
			 means services including, but not limited to: (a) Home delivered nursing
			 services or therapy; (b) custodial or personal care; (c) day care; (d) home and
			 chore aid services; (e) nutritional services, both in-home and in a communal
			 dining setting; (f) respite care; (g) adult day health care services; or (h)
			 other similar services furnished in a home-like or residential setting that
			 does not provide overnight care. Such services shall be provided at all levels
			 of care, from skilled care to custodial or personal care.
(2) "Contract" means a long-term care
			 insurance policy or contract, regardless of the kind of insurer issuing it,
			 unless the context clearly indicates otherwise.
(3) "Direct response insurer" means an
			 insurer who, as to a particular contract, is transacting insurance directly
			 with a potential insured without solicitation by, or the intervention of, a
			 licensed insurance agent.
(4) A
			 "gatekeeper provision" is any provision in a contract establishing a threshold
			 requirement which must be satisfied before a covered person is eligible to
			 receive benefits promised by the contract. Examples of such provisions include,
			 but are not limited to the following: A three-day prior hospitalization
			 requirement, recommendations of the attending physician, and recommendations of
			 a case manager.
(5) "Institutional
			 care" means care provided in a hospital, skilled or intermediate nursing home,
			 or other facility certified or licensed by the state primarily affording
			 diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal
			 care services. Such a facility provides twenty-four-hour nursing services on
			 its premises or in facilities available to the institution on a formal
			 prearranged basis.
(6) "Insured"
			 shall mean any beneficiary or owner of a long-term care contract regardless of
			 the type of insurer.
(7) "Insurer"
			 includes insurance companies, fraternal benefit societies, health care service
			 contractors and health maintenance organizations unless the context clearly
			 indicates otherwise.
(8) "Premium"
			 shall mean all sums charged, received or deposited as consideration for a
			 contract and includes any assessment, membership, contract, survey, inspection,
			 service, or similar fees or charges as paid.
(9) "Terminally ill care" means care for an
			 illness, disease, or injury which has reached a point where recovery can no
			 longer be expected and the attending physician has certified that the patient
			 is facing imminent death; or has a life expectancy of six months or
			 less.
(10) "Adult day health care"
			 means a program of community based 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 individual's home.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030 and
				  48.84.050. 95-19-028 (Order R
				  95-5), §
										284-54-020, filed 9/11/95,
				  effective 10/12/95. Statutory Authority:
				  RCW
				   48.02.060,
				  48.84.030 and
				  48.01.030. 94-14-100 (Order R
				  94-10), §
										284-54-020, filed 7/6/94,
				  effective 8/6/94. Statutory Authority:
				  RCW
				   48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-020, filed
				  7/9/87.