Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 65.00 - Long-term Care Insurance
Section 65.04 - Definitions
ActivitiesofDailyLiving(ADLs) means eating, toileting, transferring, bathing, dressing, and continence.
Agent means either:
(a) a person licensed as an insurance producer under M.G.L. c. 175, §162I; or
(b) any other person legally authorized to represent a carrier in the marketing of long-term care insurance.
Alternate Care Benefits means benefits for services or other items not specified in the long-term care insurance policy, but to be covered as agreedtoby the carrier, the insured, and the insured's caregiver. This includes, but is not limited to, payment for home modifications that allow the insured to continue living at home or a non-institutionalized setting and coverage oflong-termcare services that might not exist on the policy issue date.
Care Management means those procedures employed by a carrier to approve covered services and to determine the appropriate level of care.
Carrier means a commercial insurance company licensed to issue accident and sickness policies under M.G.L. c.175 or a fraternal benefit society licensed under M.G.L. c.176.
Cold-lead Advertising means making use directly or indirectly of any method ofmarketingwhichfails to disclose in a conspicuous manner that one of the purposes of the method of marketing is the solicitation of insurance and that contact will be made by a carrier or its agent.
Commissioner means the commissioner of insurance or his/her designee.
Convertible means a policy feature that gives the insured the right to switch to another policy offered or sponsored by the carrier.
Daily Maximum Benefit means the maximum daily amount that the long-termcare insurance policy pays for specific services.
Deductible means the dollar amount of covered services that are to be paid solely by theinsured before the long-term care insurance policy begins to pay benefits.
Division of Medical Assistance means the state agency responsible for administering programs of medical assistance in Massachusetts pursuant to M.G.L. c. 118E.
Elimination Period means the number of days during which covered services must be received by an insured before the long-term care insurance policy begins to pay benefits.
Employment-based Group Policy means a certificate issued to an insured who is enrolled in a group policy issued to one or more employers or labor organizations, or to the trustees ofa fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
Federally Qualified means a policy that meets standards set forth in the federal Internal Revenue Code and related federal regulations in order to qualify for special tax treatment.
Group Policy means the certificate issued to an insured who is enrolled through a group trust or association to which the carrier has issued a long-term care insurance policy. For the purposes of 211 CMR 65.00, this does not include employment-based group policies.
Guaranteed Renewable means a policy feature that guarantees the insured's right to continue the policy in force by the timely payment of premiums. A carrier cannot cancel, cannot decline to renew, and cannot make any unilateral change in any provision of a guaranteed renewable policy without the agreement of the insured, but subject to the approval of the commissioner, a carrier may revise premium rates for guaranteed renewable policies on a class basis.
High-pressure tactics means employing any method of marketing that has the effect of or tends to induce orrecommend the purchase of any insurance policy through force, fright, threat(whetherexplicit or implied) or undue pressure.
Home Health Care means nursing, home health aide, rehabilitative therapy, and nutrition counseling services.
Individual policy means a policy issued by a carrier directly to an insured.
Insured means the named policyholder or certificateholder under a long-term care insurance policy.
Lifetime maximum benefit period means the maximum number of days of benefits, as chosen by the insured, which the carrier will pay for covered benefits after the satisfaction of any elimination period or deductible.
Lifetime maximum dollar amount means the maximum dollar amount, as chosen by the insured, which the carrier will pay for covered benefits after the satisfaction of any elimination period or deductible.
MassHealth(Medicaid) means the programof medical assistance administered by the Massachusetts Division of Medical Assistance under Title XIX of the federal Social Security Act, 42 USCS §1396 et seq., and M.G.L. c. 118E.
Medical necessity means:
(a) inaccordance with accepted standards of medical practice for the diagnosis and treatment of a condition;
(b) delivered, when possible, in the least intensive setting required by the insured's condition; and
(c) not solely for the convenience of the insured, the insured's family or the insured's health care provider.
Medicare means the federal health insurance program under Title XVIII of the federal Social Security Act, 42 USCS §1395 et seq., as amended.
Mental or nervous condition means a condition as described in the standard nomenclature of the American Psychiatric Association.
Noncancelable means the policy feature that guarantees the insured's right to continue the policy in force at the same premium level by the timelypayment ofpremiums. A carrier cannot cancel, cannot decline to renew, cannot make any unilateral change in any provision of coverage, and cannot revise premium rates for a noncancelable policy without the agreement of the insured.
Nonforfeiture benefit means a benefit to the insured in the eventthatthe long-term care insurance policy lapses due to nonpayment of premium. Nonforfeiture benefits include, but are not limited to, returnof premium and any partial paid-up benefits.
Policy means an individual long-term care insurance policy or a certificate ofa group policythat is not employment-based, as well as the policy application, riders, amendments or other provisions that are attached to the policy to identify the contractual provisions of the insured's coverage.
Pre-existing condition means a medical condition for which an insured received diagnosis or treatment during the 24-month period prior to the effective date of coverage.
Twisting means knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or carriers for the purpose ofinducing, or tendingto induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any policy or to take out a policy with another carrier.
