Kan. Admin. Regs. § 40-4-37 - Long-term care insurance; application; definitions
(a) These
regulations shall apply to individual or group long-term care insurance
policies, subscriber contracts, endorsements, and riders delivered or issued
for delivery in this state by the following:
(1) Insurance companies;
(2) fraternal benefit societies;
(3) nonprofit hospital and medical service
corporations; and
(4) health
maintenance organizations.
(b) A policy, rider, or endorsement shall not
be advertised, described, solicited, or issued for delivery in this state as
long-term care insurance unless it conforms to the requirements of these
regulations.
(c) As used in these
regulations, these terms shall have the following meanings:
(1) "Long-term care insurance," "group
long-term care insurance," "commissioner," "applicant," "certificate," and
"policy" shall have the meanings set forth in
K.S.A.
40-2227, and amendments thereto.
(2) "Medicare" means programs established by
the "health insurance for the aged act," Title XVIII of the social security
amendments of 1965, as then constituted or later amended.
(3) "Nursing facility" means a home,
residence, or institution, other than a hospital, that is primarily engaged in
providing nursing care and related services on an inpatient basis under a
license issued by the appropriate licensing agency. A nursing facility may be a
freestanding facility, including the following:
(A) Nursing facility;
(B) skilled nursing home;
(C) intermediate nursing care home;
(D) assisted living facility; and
(E) residential health care
facility.
Each definition of a nursing facility shall adhere to the above definition unless otherwise approved by the commissioner of insurance.
(4) No insurance
carrier shall define "mental or nervous disorder" more restrictively than any
of the following:
(A) Neurosis;
(B) psychoneurosis;
(C) psychopathy;
(D) psychosis; or
(E) any mental or emotional disease or
disorder. However, no policy, contract, or rider shall exclude or limit
benefits on the basis of organic brain disease, including Alzheimer's disease
or senile dementia.
(5)
The insurer may define "nurse" so that the description is restricted to a
certain type of nurse, whether a registered graduate professional nurse, a
licensed practical nurse, or a licensed vocational nurse. If the words "nurse,"
"trained nurse," or "registered nurse" are used without specific instruction,
then the insurer shall recognize the services of any individual who qualified
under this terminology in accordance with the applicable statutes or
administrative regulations of the licensing or registry board of the state.
(6) The insurer may include the
words "duly qualified physician" or "duly licensed physician" in its definition
of "physician." An insurer using these terms shall recognize and accept, to the
extent of its obligation under the contract, all providers of medical care and
treatment when these services are within the scope of the provider's licensed
authority and are provided pursuant to applicable laws.
(7) "Sickness" shall include an illness or
disease of an insured person that first manifests itself after the effective
date of insurance and while the insurance is in force. A definition of sickness
may provide for a waiting period which shall not exceed 30 days after the
effective date of the coverage of the insured person. The definition may be
further modified to exclude illnesses or diseases for which benefits are
provided under any workers' compensation, occupational disease, employer's
liability, or similar law.
(8)
"Guaranteed renewable" means both of the following:
(A) The insured may continue the long-term
care insurance in force by the timely payment of premiums; and
(B) the insurer shall not unilaterally make
any change in any provision of the policy or rider while the insurance is in
force and shall not decline to renew the policy. However, the insurer may
revise the rates on a class basis.
(9) "Noncancellable" means that the insured
may continue the long-term care insurance in force by timely paying premiums
during which period the insurer shall not unilaterally make any change in any
provision of the insurance or in the premium rate.
(10) "Lapse" means termination of a policy
due to the policyholder's failure to pay the premium within the time required.
(11)
(A) "Exceptional increase" means only an
increase filed by an insurer as exceptional for which the commissioner
determines that the need for the premium rate increase is justified due to
changes in laws or regulations applicable to long-term care coverage in this
state, or due to increased and unexpected utilization that affects the majority
of insurers of similar products.
(B) Exceptional increases shall be subject to
the following:
(i) Except as provided in
K.A.R. 40-4-37t, exceptional increases shall be subject to the same
requirements as those for other premium rate schedule increases.
(ii) A review by an independent actuary or a
professional actuarial body of the basis for a request than an increase be
considered an exceptional increase may be requested by the commissioner.
(iii) Potential offsets to higher
claim costs shall also be determined by the commissioner in determining that
the necessary basis for an exceptional increase exists.
(12) "Incidental," as used in
K.A.R. 40-4-37t(j), means that the value of the long-term care benefits
provided is less than 10 percent of the total value of the benefits provided
over the life of the policy. These values shall be measured from the date of
issue.
(13) "Qualified actuary"
means a member in good standing of the American academy of actuaries.
(14) "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
K.S.A.
40-2227(e), and amendments
thereto, shall not be considered similar to certificates or policies otherwise
issued as long-term care insurance, but shall be considered similar to other
comparable certificates with the same long-term care benefits classifications.
For purposes of determining similar policy forms, long-term care benefit
classifications shall be defined as follows:
(A) Institutional long-term care benefits
only;
(B) noninstitutional
long-term care benefits only; or
(C) comprehensive long-term care benefits.
Notes
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