§36-4424. Definitions.
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/ok/title-36-insurance/36-4424·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Unless the context requires otherwise, the definitions in this section apply throughout the Long-Term Care Insurance Act.
1. a. "Long-term care insurance" means any insurance policy,
certificate or rider, including qualified long-term
care insurance contracts and long-term care
partnership program contracts, which are advertised,
marketed, offered or designed primarily 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 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.
b. This term includes group and individual health
policies or riders or group and individual life
policies or annuities or riders which provide,
directly or as a supplement, coverage for long-term
care, whether issued by insurers, fraternal benefit
societies, nonprofit health, hospital, and medical
service corporations, prepaid health plans, health
maintenance organizations, life care communities, or
any similar organization.
c. This term also includes a policy or rider which
provides for payment of long-term care benefits based
upon cognitive impairment or the loss of functional
capacity.
d. Long-term care insurance shall 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 or related asset-protection
coverage, catastrophic coverage, comprehensive
coverage, accident only coverage, specified disease or
specified accident coverage, or limited benefit health
coverage.
e. With regard to life insurance, this term does not
include life insurance policies which accelerate the
death benefit specifically for one or more of the
qualifying events of terminal illness, medical
conditions requiring extraordinary medical
intervention, or permanent institutional confinement,
and which provide the option of a lump-sum payment for
those benefits and in which neither the benefits nor
the eligibility for the benefits is conditioned upon
the receipt of long-term care.
f. Notwithstanding any other provision contained herein,
any product advertised, marketed or offered as long-
term care insurance shall be subject to the provisions
of the Long-Term Care Act.
2. "Applicant" means:
a. in the case of an individual long-term care insurance
policy, the person who seeks to contract for such
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 certificate has been delivered, or issued for delivery, in this state.
4. "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 or more employers or labor organizations, or to a
trust or to the trustees of a fund established by one
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, or
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
has been maintained in good faith for purposes
other than insurance, or
c. an association, a trust, or the trustee or trustees of
a fund established, created, or maintained for the
benefit of members of one 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 Insurance Commissioner that the
association or associations shall have at the outset
of transacting long-term care insurance in this state
a minimum of one hundred
(100)persons in the
association or associations and shall have been
organized and maintained in good faith for purposes
other than that of obtaining insurance; shall have
been in active existence for at least one
(1)year;
and shall 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. Thirty
(30)days after such
filing the association or associations shall 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 subparagraphs a, b
and c of this paragraph, 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.
5. "Not-for-Profit Life care community" within the meaning of Section 1-853.1 of Title 63 of the Oklahoma Statutes means any not- for-profit organization that enters into an arrangement pursuant to which a person contracts for a place of residence and personal care services, including but not limited to services which progress from independent living to semi-dependent nursing care to acute nursing care, in consideration of an endowed prepayment, license or entry fee which has been actuarially established to meet the cost of the promised services and accommodations. For communities commencing
operations after January 1, 2016, the amount of the endowed prepayment must be independently, actuarially determined, in compliance with the Actuarial Standards of Practice promulgated by the Actuarial Standards Board of the American Academy of Actuaries, prior to opening the community and annually thereafter to ensure that sufficient payments are collected to meet the future services of the residents. The actuarial study shall take into consideration projected or actual project costs, resident fees and charges, resident contract provisions and any other factors affecting the operation of the facility.
It shall contain mortality and morbidity data and an actuary's signed opinion that the proposed is feasible and that the study has been prepared in accordance with standards adopted by the American Academy of Actuaries. A not-for-profit life care community shall not include the following:
a. traditional landlord and tenant agreements utilizing
periodic rental and security deposit payments,
b. residential care homes licensed pursuant to the
Oklahoma Residential Care Act,
c. assisted living centers and continuum of care
facilities licensed pursuant to the Oklahoma Continuum
of Care and Assisted Living Act,
d. facilities licensed pursuant to the Oklahoma Nursing
Home Care Act, or
e. any facility where the endowed prepayment, license or
entry fee is less than Fifty Thousand Dollars
($50,000.00).
6. "Policy" means any policy, contract, certificate, 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, life care community, or any similar organization.
7. "Qualified long-term care insurance contract" means any:
a. individual or group insurance contract if the contract
meets the requirements of Section 7702(B) of the
Internal Revenue Code, as amended, and if:
(1)the only insurance protection provided under the
contract is coverage of qualified long-term care
services,
(2)the contract does not pay or reimburse expenses
incurred for services or items to the extent that
such 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
contracts where Medicare is a secondary payor, or
where the contract makes per diem or other
periodic payments without regard to expenses,
(3)the contract is guaranteed renewable,
(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. All refunds of premiums and all
policyholder dividends or similar amounts, under
such contract are to be applied as a reduction in
future premiums or to increase future benefits,
except that a refund of the aggregate premium
paid under the contract may be allowed in the
event of death of the insured or a complete
surrender or cancellation of the contract, and
(5)the contract contains the consumer protection
provisions set forth in Section 7702(B)(g) of the
Internal Revenue Code, or
b. life insurance contract which provides long-term care
coverage by rider or as part of the contract if the
contract complies with the applicable provisions of
Section 7702(B) of the Internal Revenue Code, as
amended.
8. "Qualified long-term care services" means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating, and rehabilitative services, and maintenance for personal care services for which an insured is eligible under a qualified long- term care insurance contract, and which are provided pursuant to a plan of care prescribed by a licensed health care practitioner. Added by Laws 1987, c. 175, § 28, eff. Nov. 1, 1987. Amended by Laws 1989, c. 107, § 3, eff. Nov. 1, 1989;
Laws 1989, c. 320, § 5, eff. Nov. 1, 1989; Laws 1993, c. 136, § 1, eff. Sept. 1, 1993; Laws 1997, c. 180, § 1, emerg. eff. May 12, 1997; Laws 2000, c. 171, § 2, emerg. eff. May 2, 2000; Laws 2008, c. 184, § 19, eff. July 1, 2008; Laws 2016, c. 264, § 1, eff. Nov. 1, 2016; Laws 2018, c. 95, § 9, eff. Nov. 1, 2018.