N.J. Admin. Code § 11:4-34.3

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:4-34.3 - Policy definitions

(a) No long-term care insurance policy delivered or issued for delivery in this State shall use the terms set forth below, unless the terms are defined in the policy and the definitions are consistent with the following:

1. "Activities of daily living" means at least bathing, continence, dressing, eating, toileting and transferring.

2. "Acute condition" means a condition that renders an individual 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" means a program for six or more individuals of 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 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 a catheter or colostomy bag).

7. "Dressing" means putting on and talking 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 any physical assistance (minimal, moderate or maximal) without which the individual would not be able to perform the activities of daily living.

10. "Home health care services" means medical and non-medical 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. "Immediate family" means parents, spouse or domestic partner, children and siblings.

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 1, Part 1 of Public Law 8 9-97, 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."

13. "Mental or nervous disorder" means neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

14. "Personal care" means the provision of hands-on services to assist an individual with activities of daily living.

15. "Preexisting condition" shall not be more restrictive than a condition for which medical advice or treatment was recommended by, or received from, a provider of health care services, within six months preceding the effective date of coverage of an insured person.

16. "Skilled nursing care," "intermediate care," "personal care," "home 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 care must be delivered.

17. "Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

18. "Transferring" means moving into or out of a bed, chair or wheelchair.

19. "Usual, customary and reasonable" shall be no more restrictive than:

i. "Usual" means the fee ordinarily charged by the provider for a particular service or supply;

ii. "Customary" means the range of usual fees charged by providers for the same service or supply under like circumstances within the geographic or socio-economic area where the service or supply is performed or furnished. The range of usual fees charged by physicians shall consider training and experience; and

iii. "Reasonable" means a fee above usual and customary which is justified by unusual complexity of the treatment required.

20. All providers of services, including, but not limited to, "skilled nursing facility," "extended care facility," "intermediate care facility," "convalescent nursing home," "personal care facility," and "home care agency" shall be defined in relation to the services and facilities required to be available and the licensure or degree status of those providing or supervising the services. The definition may require that the provider be appropriately licensed or certified.

N.J. Admin. Code § 11:4-34.3