§431:10H-104  Definitions.  As used inthis article, unless the context requires otherwise, the definitions in thissection apply throughout this article.

"Applicant" means:

(1)  In the case of an individual long-term careinsurance policy, the person who seeks to contract for benefits; and

(2)  In the case of a group long-term care insurancepolicy, the proposed certificate holder.

"Certificate" means, for the purposesof this article, any certificate issued under a group long-term care insurancepolicy, which policy has been delivered or issued for delivery in this State.

"Exceptional increase" means onlythose increases filed by an insurer that are extraordinary and for which thecommissioner determines the need for the premium rate increase is justified:

(1)  Due to:

(A)  Changes in laws or rules applicable tolong-term care coverage in this State; or

(B)  Increased and unexpected utilization thataffects the majority of insurers of similar products;

(2)  Except as provided in section 431:10H-232, exceptionalincreases are subject to the same requirements as other premium rate scheduleincreases;

(3)  The commissioner may request a review by anindependent actuary or a professional actuarial body of the basis for a requestthat an increase be considered an exceptional increase; and

(4)  The commissioner, in determining that thenecessary basis for an exceptional increase exists, shall also determine anypotential offsets to higher claims costs.

"Group long-term care insurance"means a long-term care insurance policy which is delivered or issued fordelivery in this State and issued to:

(1)  One or more employers or labor organizations, ora trust or to the trustees of a fund established by one or more employers orlabor organizations, or a combination thereof, for employees or formeremployees or a combination thereof or for members or former members or acombination thereof, of the labor organizations; or

(2)  Any professional, trade, or occupationalassociation for its members or former or retired members, or combinationthereof, if the association:

(A)  Is composed of individuals all of whom areor were actively engaged in the same profession, trade, or occupation; and

(B)  Has been maintained in good faith forpurposes other than obtaining insurance; or

(3)  An association or a trust or the trustees of afund established, created, or maintained for the benefit of members of one ormore associations.  Prior to advertising, marketing, or offering the policywithin this State, the association or the insurer of the association shall fileevidence with the commissioner that the association has at the outset a minimumof one hundred persons; has been organized and maintained in good faith forpurposes other than that of obtaining insurance; has been in active existencefor at least one year; and has a constitution and bylaws which provide that:

(A)  The association holds regular meetings notless than annually to further purposes of the members;

(B)  Except for credit unions, the associationcollects dues or solicits contributions from members; and

(C)  The members have voting privileges andrepresentation on the governing board and committees.

Thirty days after the filing the associationwill be deemed to satisfy the organizational requirements unless thecommissioner makes a finding that the association does not satisfy thoseorganizational requirements; or

(4)  A group other than as described in paragraphs(1), (2), and (3), subject to a finding by the commissioner that:

(A)  The issuance of the group policy is notcontrary to the best interest of the public;

(B)  The issuance of the group policy wouldresult in economies of acquisition or administration; and

(C)  The benefits are reasonable in relation tothe premiums charged.

"HIPAA" means the Health InsurancePortability and Accountability Act of 1996, P.L. 104-191.

"Incidental", as used in section431:10H-207.5(j), means that the value of the long-term care benefits providedis less than ten per cent of the total value of the benefits provided over thelife of the policy.  These values shall be measured as of the date of issue.

"Long-term care insurance" means anyinsurance policy or rider advertised, marketed, offered, or designed to providecoverage for not less than twelve consecutive months for each covered person onan expense incurred, indemnity, prepaid, or other basis, for one or morenecessary or medically necessary diagnostic, preventive, therapeutic,rehabilitative, maintenance, or personal care services, provided in a settingother than an acute care unit of a hospital.  The term includes group andindividual annuities and life insurance policies or riders that providedirectly or that supplement long-term care insurance.  The term also includes apolicy or rider that provides for payment of benefits based upon cognitiveimpairment or loss of functional capacity.  The term shall also includequalified long-term care insurance contracts.  Long-term care insurance may beissued by insurers, fraternal benefit societies, nonprofit health, hospital,and medical service corporations, prepaid health plans, health maintenanceorganizations, or any similar organization to the extent they are otherwiseauthorized to issue life or health insurance.

Long-term care insurance shall not include any insurancepolicy 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 related asset-protection coverage, accident only coverage,specified disease or specified accident coverage, or limited benefit healthcoverage.

With regard to life insurance, this term doesnot include life insurance policies that accelerate the death benefitspecifically for one or more of the qualifying events of terminal illness,medical conditions requiring extraordinary medical intervention, or permanentinstitutional confinement, and that provide the option of a lump-sum paymentfor those benefits and in which neither the benefits nor the eligibility forthe benefits is conditioned upon the receipt of long-term care.

Notwithstanding any other provision containedherein, any product advertised, marketed, or offered as long-term careinsurance shall be subject to this article.

"NAIC" means the National Associationof Insurance Commissioners.

"Policy" means, for the purposes ofthis article, any policy, contract, subscriber agreement, rider, or endorsementdelivered or issued for delivery in this State by an insurer; fraternal benefitsociety; nonprofit health, hospital, or medical service corporation; prepaidhealth plan; health maintenance organization; or any similar organization.

"Qualified long-term care insurancecontract" or "federally tax-qualified long-term care insurancecontract" means an individual or group insurance contract that meets therequirements of section 7702B(b) of the Internal Revenue Code of 1986, asamended, as follows:

(1)  The only insurance protection provided under thecontract is coverage of qualified long-term care services.  A contract shallnot fail to satisfy the requirements of this paragraph by reason of paymentsbeing made on a per diem or other periodic basis without regard to the expensesincurred during the period to which the payments relate;

(2)  The contract does not pay or reimburse expensesincurred for services or items to the extent that the expenses are reimbursableunder Title XVIII of the Social Security Act, as amended, or would be soreimbursable but for the application of a deductible or coinsurance amount. The requirements of this paragraph do not apply to expenses that arereimbursable under Title XVIII of the Social Security Act only as a secondarypayor.  A contract shall not fail to satisfy the requirements of this paragraphby reason of payments being made on a per diem or other periodic basis withoutregard to the expenses incurred during the period to which the payments relate;

(3)  The contract is guaranteed renewable, within themeaning of section 7702B(b)(1)(C) of the Internal Revenue Code of 1986, asamended;

(4)  The contract does not provide for a cashsurrender value or other money that can be paid, assigned, pledged ascollateral for a loan, or borrowed except as provided in paragraph (5);

(5)  All refunds of premiums and all policyholderdividends or similar amounts under the contract are to be applied as areduction in future premiums or to increase future benefits, except that arefund on the event of death of the insured or a complete surrender orcancellation of the contract cannot exceed the aggregate premiums paid underthe contract; and

(6)  The contract meets the consumer protectionprovisions set forth in section 7702B(g) of the Internal Revenue Code of 1986,as amended.

"Qualified long-term care insurancecontract" or "federally tax‑qualified long-term care insurancecontract" also means the portion of a life insurance contract thatprovides long-term care insurance coverage by rider or as part of the contractand that satisfies the requirements of section 7702B(b) and (e) of the InternalRevenue Code of 1986, as amended. [L 1999, c 93, pt of §2; am L 2007, c 233,§§5, 6]