Utah Admin. Code 590-148-3

Current through Bulletin 2024-24, December 15, 2024

Section R590-148-3 - Definitions

Terms used in this rule are defined in Sections 31A-1-301 and 31A-22-1402. Additional terms are defined as follows:

(1) "Attained age rating" means a schedule of premiums starting from the issue date that increases with age at least 1% per year before age 50, and at least 3% per year beyond age 50.

(2)

(a) "Benefit trigger" means a provision conditioning the payment of a benefit on a determination of the insured's:

(i) ability to perform activities of daily living; and

(ii) cognitive impairment.

(b) "Benefit trigger," when used in a tax-qualified long-term care insurance contract, includes a determination by a licensed health care practitioner that an insured is a chronically ill individual.

(3) "Cold lead advertising" means using, directly or indirectly, any method of marketing that fails to disclose in a conspicuous manner the method of marketing is a solicitation of insurance and that contact will be made by a producer or an insurer.

(4) "Chronically ill individual" has the same meaning as defined in Section 7702B(c)(2), Internal Revenue Code.

(5) "Continuation of coverage" means a provision that:

(a) maintains coverage under the existing group policy when the coverage would otherwise terminate; and

(b) is subject only to the continued timely payment of premium when due.

(6) "Conversion of coverage" means a provision that an individual whose coverage under the group policy would otherwise terminate or has been terminated for any reason, including discontinuance of the group policy in its entirety or with respect to an insured class, is entitled to the issuance of a converted policy by the insurer, without evidence of insurability, if the individual was continuously insured under the group policy or another group policy that it replaced six months immediately before termination.

(7) "Exceptional increase" means a premium rate increase filed by an insurer as exceptional that the commissioner determines is justified due to:

(a) a change in laws applicable to long-term care insurance; or

(b) an increased and unexpected utilization that affects the majority of insurers of a similar product.

(8) "High pressure tactics" means using a method of marketing to induce, or tend to induce, the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

(9) "Incidental" means the value of the long-term care benefits provided is less than 10% of the total value of the benefits provided over the life of the policy measured as of the date of issue.

(10) "Independent review organization" means an organization that conducts an independent review of a long-term care benefit trigger decision.

(11) "Licensed health care practitioner" has the same meaning as defined in Section 7702B(c)(4), Internal Revenue Code.

(12) "Licensed health care professional" means an individual qualified by education and experience in an appropriate field to determine, by record review, an insured's actual functional or cognitive impairment.

(13)

(a) "Maintenance or personal care services" means any care that is primarily intended to provide needed assistance with any disability that causes an individual to be certified as a chronically ill individual.

(b) "Maintenance or personal care services" includes protection from threats to health and safety due to severe cognitive impairment.

(14) "Managed care plan" 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.

(15) "Misrepresentation" means presenting a material fact in an incomplete, incorrect, partially complete, or partially correct manner when selling or offering to sell a policy or certificate.

(16) "Policy" means a long-term care insurance policy, contract subscriber agreement, rider, or endorsement that is delivered or issued in this state.

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

(18) "Qualified long-term care services" has the same meaning as defined in Section 7702B(c), Internal Revenue Code.

(19)

(a) "Similar policy forms" means all 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.

(b) A group long-term care insurance certificate issued under Subsection 31A-22-504(1)(a) is not considered similar to policies or certificates otherwise issued as long-term care insurance, but are similar to other comparable certificates with the same long-term care benefit classifications.

(c) For purposes of determining "similar policy forms," a long-term care benefit classification is defined as:

(i) institutional long-term care benefits only;

(ii) non-institutional long-term care benefits only; or

(iii) comprehensive long-term care benefits.

(20) "Twisting" means knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policy or insurer to induce, or tend to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out an insurance policy with another insurer.

Utah Admin. Code R590-148-3

Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024