W. Va. Code R. § 114-32-2

Current through Register Vol. XLI, No. 49, December 6, 2024

Section 114-32-2 - Definitions

For the purpose of this rule the terms "long-term care insurance," "qualified long-term care insurance," "group long-term care insurance," "Commissioner," "applicant," "policy" and "certificate" shall have the meanings set forth in W. Va. Code § 33-15A-4. In addition, the following definitions apply.

2.1. "Benefit trigger", for the purposes of independent review, means a contractual provision in the insured's policy of long-term care insurance conditioning the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. For purposes of a tax-qualified long-term care insurance contract, as defined in section 7702B of the Internal Revenue Code of 1986, as amended, "benefit trigger" shall include a determination by a licensed health care practitioner that an insured is a chronically ill individual.

2.2. "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:

2.2.a. Due to changes in laws or regulations applicable to long-term care coverage in this state; or

2.2.b. Due to increased and unexpected utilization that affects the majority of insurers of similar products.

2.3. "Incidental," as used in subsection 18.10 of this rule, 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.

2.4. "Independent review organization" means an organization that conducts independent reviews of long-term care benefit trigger decisions.

2.5. "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.

2.6. "Qualified actuary" means a member in good standing of the American Academy of Actuaries.

2.7. "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 W. Va. Code § 33-15A-4(e)(1) 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.

W. Va. Code R. § 114-32-2