§ 1 — Definitions

Massachusetts § 1

• Jurisdiction: Massachusetts
• Part I: ADMINISTRATION OF THE GOVERNMENT
• Title XXII: CORPORATIONS
• Ch. 176U: LONG-TERM CARE INSURANCE

Text

Section 1. As used in this chapter, the following words shall have the following meanings unless the context requires otherwise:''Applicant'', in the case of an individual long-term care insurance policy, the person who seeks to contract for benefits and, in the case of a group long-term care insurance policy, the proposed certificate holder.''Certificate'', a certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery within the commonwealth.''Commissioner'', the commissioner of insurance.''Group long-term care insurance'', a long-term care insurance policy that is delivered or issued for delivery within the commonwealth and issued to:(1) an employer or labor organization or to a trust or to the trustees of a fund established by an employer or labor organization, or a combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of a labor organization;(2) a professional, trade or occupational association for its members or former or retired members, or a combination thereof, if the association: (i) is comprised of individuals all of whom are, or were, actively engaged in the same profession, trade or occupation; and (ii) has been maintained in good faith for purposes other than obtaining insurance;(3) an association, or a trust or the trustees of a fund established, created or maintained for the benefit of members of any such association; provided, however, that before advertising, marketing or offering the policy within the commonwealth, the association, or the insurer of the association, shall file evidence with the commissioner that the association: (i) has, at the outset, at least 100 persons; (ii) has been organized and maintained in good faith for purposes other than that of obtaining insurance; (iii) has been in active existence for at least 1 year; and (iv) has a constitution and by-laws that provide that: (A) the association holds regular meetings not less than annually to further purposes of the members; (B) except for credit unions, the association collects dues or solicits contributions from members; and (C) the members have voting privileges and representation on the governing board and committees; provided further, that 30 days after the filing, the association shall be considered to have satisfied the organizational requirements unless the commissioner makes a finding that the association does not satisfy those organizational requirements; or(4) a group other than those described in clauses (1) to (3), inclusive, subject to a finding by the commissioner that: (i) the issuance of the group policy is not contrary to the best interests of the public; (ii) the issuance of the group policy would result in economies of acquisition or administration; and (iii) the benefits are reasonable in relation to the premiums charged.''Long-term care insurance'', an insurance policy or rider: (i) advertised, marketed, offered or designed to provide coverage for not less than 12 consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis; (ii) for necessary or medically-necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services, including home and community care services; and (iii) provided in a setting other than an acute care unit of a hospital; provided, however, that ''long-term care insurance'' shall include group and individual annuities and life insurance policies or riders that provide directly, or supplement, long-term care insurance; provided further, that ''long-term care insurance'' shall also include a policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity; provided further, that ''long-term care insurance'' shall also include qualified long-term care insurance policies; provided further, that ''long-term care insurance'' shall not include an insurance policy 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 or related asset-protection coverage, accident only coverage, specified disease or specified accident coverage or limited benefit health coverage; provided further, that with regard to life insurance, ''long-term care insurance'' shall not include life insurance policies that accelerate the death benefit specifically for any of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention or permanent institutional confinement and that provide the option of a lump-sum payment for those benefits and where neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care; and provided further, that notwithstanding any other provision of this chapter, any other product advertised, marketed or offered as long-term care insurance shall be subject to this chapter.''Policy'', a policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery in the commonwealth by: (i) an insurer authorized to issue policies upon the lives of persons in the commonwealth or to provide accident and health insurance under chapter 175; (ii) a fraternal benefit society authorized under chapter 176; (iii) a nonprofit hospital service corporation authorized under chapter 176A; (iv) a nonprofit medical service corporation authorized under chapter 176B; or (v) a health maintenance organization authorized under chapter 176G.''Qualified long-term care insurance contract'' or ''federally tax-qualified long-term care insurance contract'', an individual or group insurance contract that meets the requirements of 26 U.S.C. 7702B(b) as follows: (i) the only insurance protection provided under the contract is coverage of qualified long-term care services; provided, however, that a contract shall not fail to satisfy the requirements of this clause 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; (ii) 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 or would be so reimbursable but for the application of a deductible or coinsurance amount; provided, however, that the requirements of this clause shall not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor; and provided further, that a contract shall not fail to satisfy the requirements of this clause 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; (iii) the contract is guaranteed renewable within the meaning of said 26 U.S.C. 7702B(b)(1)(C); (iv) 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 clause (v); (v) 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; and (vi) the contract meets the consumer protection provisions set forth in said 26 U.S.C. 7702B(g); and provided further, that ''Qualified long-term care insurance contract'' or ''federally tax-qualified long-term care insurance contract'' shall also include 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 said 26 U.S.C. 7702B(b) and 7702B(e) and as set forth in clauses (i) to (vi), inclusive.