Fla. Admin. Code Ann. R. 69O-157.103 - Definitions

As used in these rules and as used in long-term care policies, the following terms shall have meanings no more restrictive than the following:

(1) "Adult day care center" means a program for 6 or more individuals of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside the home.

(2) "Assisted living facility" shall be defined in the policy and shall be defined in relation to the services and facilities required to be available and the licensure or degree status of those providing or supervising the services.

(3)

(a) "Exceptional increase" means only those increases filed by an insurer as exceptional for which the Office 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 69O-157.113, F.A.C., exceptional increases are subject to the same requirements as other premium rate schedule increases.

(c) If the insurer is unable to provide justification that the reason for the rate increase meets the definition of "exceptional increase", the Office shall contract a review by an independent actuary or a professional actuarial body, at the expense of the insurer making the filing, of the basis for a request that an increase be considered an exceptional increase. If the review does not determine the basis to be an exceptional increase or if the company does not agree to the contract proposed by the Office, the filing shall be considered as not meeting the definition of exceptional increase.

(d) The Office, in determining that the necessary basis for an exceptional increase exists, shall also determine any potential offsets to higher claims costs.

(4) "Hands-on assistance" or "services" means physical assistance (minimal, moderate or maximal) without which the individual would not be able to perform the activity of daily living.

(5) "Home health services" means medical and non-medical services provided to ill, disabled, or infirm persons in their residences. Such services may include homemaker services, assistance with activities of daily living, and respite care services.

(6) "Hospital" means a hospital as defined and licensed pursuant to the provisions of Chapter 395, F.S., or pursuant to substantially similar provisions of another state's licensing laws.

(7) "Incidental," as used in subsection 69O-157.113(9), F.A.C., 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 as of the date of issue.

(8) "Institutionalization" means that confinement to a hospital, facility, or center licensed pursuant to any parts of Chapter 400 or 395, F.S., or pursuant to substantially similar provisions of another state's licensing laws.

(9) "Medicare" means "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import.

(10) "Mental or nervous disorder" shall not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

(11) "Nursing home facility" or "nursing home" as defined in Section 400.021(13), F.S.

(12) "Nurse registry" as defined in Section 400.462(15), F.S.

(13) "Personal care" means the provision of hands-on services to assist an individual with activities of daily living.

(14) "Personal information" means any individually identifiable information gathered in connection with an insurance transaction from which judgments can be made about an individual's character, habits, avocations, finances, occupation, general reputation, credit, health or any other personal characteristics. "Personal information" includes an individual's name and address and "medical record information" but does not include "privileged information".

(15) "Privileged information" means any individually identifiable information that:

(a) Relates to a claim for insurance benefits or a civil or criminal proceeding involving an individual; and

(b) Is collected in connection with or in reasonable anticipation of a claim for insurance benefits or civil or criminal proceeding involving an individual.

(16) "Qualified actuary" means a member in good standing of the American Academy of Actuaries.

(17) "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.

(a) Certificates of groups that meet the definition in Section 627.9405(1)(a), F.S., 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.

(b) 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.

(18) "Waiting period" or "probationary period" as used in a long-term care policy means that period of time which follows the date a person is initially insured under the policy before the coverage or coverages of the policy shall become effective as to that person.

Notes

Fla. Admin. Code Ann. R. 69O-157.103

Rulemaking Authority 624.308(1), 626.9611, 627.9407(1), 627.9408 FS. Law Implemented 624.307(1), 626.9541, 627.9407(1) FS.

New 1-13-03, Formerly 4-157.103.

New 1-13-03, Formerly 4-157.103.