Okla. Admin. Code § 365:10-5-42

Current through Vol. 42, No. 7, December 16, 2024

Section 365:10-5-42 - Policy definitions

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

(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. 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 four (4) 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 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)"Exceptional increase" means only those increases filed by an insurer as exceptional for which the Commissioner determines the need for the premium rate increase is justified:

(A) Due to changes in laws or regulations applicable to long-term care coverage in this state; or

(B) Due to increased and unexpected utilization that affects the majority of insurers of similar products. Except as provided in O.A.C. 365:10-5-47, exceptional increases are subject to the same requirements as other premium rate schedule increases. The Commissioner may request a review by an independent actuary or a professional actuarial body of the basis for a request that an increase be considered an exceptional increase. The Commissioner, in determining that the necessary basis for an exceptional increase exists, shall also determine any potential offsets to higher claims costs.

(10)"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.

(11)"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 and activities of daily living and respite care services.

(12)"Incidental," as used in O.A.C. 365:10-5-47.1(j), means that the value of the long-term care benefits provided is less than ten percent (10%) of the total value of the benefits provided over the life of the policy. These values shall be measured as of the date of issue.

(13)"Medicare" shall be defined as "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 Laws 89-97, As Enacted by the Eighty-Ninth Congress of the United States of American 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.

(14)"Mental or Nervous Disorder" shall not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

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

(16)"Qualified Actuary" means a member in good standing of the American Academy of Actuaries.

(17)"Similar policy forms" means all of the long-term care insurance policies and certificates issued by an insurer in the same long-term care benefit classification as the policy form being considered. Certificates of groups that meet the definition in 36 O.S. § 4424(4)(a) and are not considered similar to certificates or policies otherwise issued as long-term care insurance, but are similar to other comparable certificates with the same long-term care benefit classifications. For purposes of determining similar policy forms, long-term care benefit classifications are defined as follows: institutional long-term care benefits only, non-institutional long-term care benefits only, or comprehensive long-term care benefits.

(18)"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.

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

(20)"Transferring" means moving into or out of a bed, chair or wheelchair.

(b) All providers of services, including but not limited to "skilled nursing facility", "extended care facility",, "convalescent nursing home", "personal care facility", "specialized care providers," "assisted living facility," and "home care agency" shall 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 shall also state what requirements a provider must meet in lieu of licensure, certification or registration when 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 when the state licenses, certifies or registers the provider of services under another name.

Okla. Admin. Code § 365:10-5-42

Amended at 10 Ok Reg 397, eff 11-12-92 (emergency); Amended at 10 Ok Reg 3033, eff 7-15-93; Amended at 15 Ok Reg 3207, eff 7-13-98; Amended at 18 Ok Reg 1277, eff 7-14-01; Amended at 26 Ok Reg 1529, eff 7-14-09