Current through September 24, 2024
(1) In the event the definitions in these
rules and T.C.A. §§
56-42-101, et
seq., conflict, the definitions in the statute control.
(2) "Applicant" means:
(a) In the case of an individual long-term
care insurance policy, the person who seeks to contract for benefits;
and
(b) In the case of a group
long-term care insurance policy, the proposed certificate holder.
(3) "Certificate" means any
certificate issued under a group long-term care insurance policy, which policy
has been delivered or issued for delivery in this state.
(4) "Commissioner" means the commissioner of
commerce and insurance.
(5)
(a) "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:
1. Due to changes in laws or regulations
applicable to long-term care coverage in this state; or
2. Due to increased and unexpected
utilization that affects the majority of insurers of similar
products.
(b) Except as
provided in Rule 0780-1-61-.20, exceptional increases are subject to the same
requirements as other premium rate schedule increases.
(c) 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.
(d) The Commissioner, in determining that the
necessary basis for an exceptional increase exists, shall also determine any
potential offsets to higher claims costs.
(6) "Group long-term care insurance" means a
long-term care insurance policy which is delivered or issued for delivery in
this state and issued to:
(a) One (1) or more
employers or labor organizations, or to a trust or to the trustees of a fund
established by one (1) or more employers or labor organizations, or a
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;
(b) Any
professional, trade or occupational association for its members or former or
retired members, or combination thereof, if such association:
1. Is composed of individuals all of whom are
or were actively engaged in the same profession, trade or occupation;
and
2. Has been maintained in good
faith for purposes other than obtaining insurance;
(c)
1. An
association or a trust or the trustee or trustees of a fund established,
created or maintained for the benefit of members of one (1) or more
associations. Prior to advertising, marketing or offering such policy within
this state, the association or associations, or the insurer of the association
or associations, shall file evidence with the Commissioner that the association
or associations have at the outset a minimum of one hundred (100) persons and
have been organized and maintained in good faith for purposes other than that
of obtaining insurance, have been in active existence for at least one (1)
year; and have a constitution and bylaws which provide that:
(i) The association or associations hold
regular meetings not less than annually to further purposes of the
members;
(ii) Except for credit
unions, the association or associations collect dues or solicit contributions
from members; and
(iii) The members
have voting privileges and representation on the governing board and
committees;
2. Thirty
(30) days after such filing, the association or associations will be deemed to
satisfy such organizational requirements, unless the Commissioner makes a
finding that the association or associations do not satisfy those
organizational requirements; or
(d) A group other than as described in
Paragraphs (5)(a) through (5)(c) of this rule, subject to a finding by the
Commissioner that:
1. The issuance of the
group policy is not contrary to the best interest of the public;
2. The issuance of the group policy would
result in economies of acquisition or administration; and
3. The benefits are reasonable in relation to
the premiums charged.
(7) "Incidental," as used in Rule
0780-1-61-.20(10), 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.
(8) "Long-term care
insurance" means any insurance policy or rider advertised, marketed, offered or
designed to provide coverage for not less than twelve (12) consecutive months
for each covered person on an expense incurred, indemnity, prepaid or other
basis, for one (1) or more necessary or medically necessary diagnostic,
preventive, therapeutic, rehabilitative, maintenance, or personal care
services, provided in a setting other than an acute care unit of a hospital.
"Long-term care insurance" includes group and individual policies or riders
whether issued by insurers, fraternal benefit societies, nonprofit health,
hospital, and medical service corporations, prepaid health plans, health
maintenance organizations or any similar organization. "Long-term care
insurance" does not include any insurance policy which is offered primarily to
provide basic Medicare supplement coverage, basic hospital expense coverage,
basic medical-surgical expense coverage, hospital confinement indemnity
coverage, major medical expense coverage, disability income protection
coverage, accident only coverage, specified disease or specified accident
coverage, or limited benefit health coverage.
(9) "Policy" means any policy, contract,
subscriber agreement, rider or endorsement delivered or issued for delivery in
this state by an insurer, fraternal benefit society, nonprofit health, hospital
or medical service corporation, prepaid health plan, health maintenance
organization or any similar organization.
(10) "Preexisting condition" means a
condition for which medical advice or treatment was recommended by, or received
from, a provider of health care services, within six (6) months preceding the
effective date of coverage of an insured person.
(11) "Qualified actuary" means a member in
good standing of the American Academy of Actuaries.
(12)
(a)
"Qualified long-term care insurance contract" or "federally tax-qualified
long-term care insurance contract" means an individual or group insurance
contract that meets the requirements of Section 7702B(b) of the Internal
Revenue Code of 1986, as amended, as follows:
1. The only insurance protection provided
under the contract is coverage of qualified long-term care services. A contract
shall not fail to satisfy the requirements of this subparagraph by reason of
payments being made on a per diem or other periodic basis without regard to the
expenses incurred during the period to which the payments relate.
2. The contract does not pay or reimburse
expenses incurred for services or items to the extent that the expenses are
reimbursable under Title XVIII of the Social Security Act, as amended, or would
be so reimbursable but for the application of a deductible or coinsurance
amount. The requirements of this subparagraph do not apply to expenses that are
reimbursable under Title XVIII of the Social Security Act only as a secondary
payor. A contract shall not fail to satisfy the requirements of this
subparagraph by reason of payments being made on a per diem or other periodic
basis without regard to the expenses incurred during the period to which the
payments relate.
3. The contract is
guaranteed renewable, within the meaning of Section 7702B(b)(1)(C) of the
Internal Revenue Code of 1986, as amended.
4. The contract does not provide for a cash
surrender value or other money that can be paid, assigned, pledged as
collateral for a loan, or borrowed except as provided in Paragraph (12)(a)5. of
this rule.
5. All refunds of
premiums, and all policyholder dividends or similar amounts, under the contract
are to be applied as a reduction in future premiums or to increase future
benefits, except that a refund on the event of death of the insured or a
complete surrender or cancellation of the contract cannot exceed the aggregate
premiums paid under the contract.
6. The contract meets the consumer protection
provisions set forth in Section 7702B(g) of the Internal Revenue Code of 1986,
as amended.
(b)
"Qualified long-term care insurance contract" or "federally tax-qualified long
term care insurance contract" also means the portion of a life insurance
contract that provides long-term care insurance coverage by rider or as part of
the contract and that satisfies the requirements of Sections 7702B(b) and (e)
of the Internal Revenue Code of 1986, as amended.
(13) "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 this rule 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.
Authority: T.C.A. §
56-42-105.
