§ 26-38-103 — Definitions

Wyoming § 26-38-103

• Jurisdiction: Wyoming
• Title 26: Insurance Code
• Ch. 38: LONG-TERM CARE INSURANCE

Text

(a) As used in this article:
(i) "Applicant" means:
(A) In the case of an individual long-term care
insurance policy, the person who seeks to contract for benefits;
(B) In the case of a group long-term care
insurance policy, the proposed certificate holder.
(ii) "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;
(iii) "Commissioner" means the insurance commissioner
of this state;
(iv) "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 the association:
(I) Is composed 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; or
(C) An association or a trust or the trustee of
a fund established, created or maintained for the benefit of
members of one (1) or more associations. Prior to advertising,
marketing or offering the 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 has met the organizational
requirements of this subparagraph. Thirty (30) days after
filing, the association or associations will be deemed to
satisfy the organizational requirements unless the commissioner
makes a finding that the association or associations do not
satisfy those organizational requirements. The evidence filed
shall establish that the association or associations has at the
outset a minimum of one hundred (100) persons and has been
organized and maintained in good faith for purposes other than
that of obtaining insurance, has been in active existence for at
least one (1) year and has 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.
(D) A group other than as described in
subparagraphs (A), (B) and (C) of this paragraph, subject to a
finding by the commissioner that:
(I) The issuance of the group policy is in
the best interest of the public;
(II) The issuance of the group policy will
result in economies of acquisition or administration; and
(III) The benefits are reasonable in
relation to the premiums charged.
(v) "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. The
term includes group and individual annuities and life insurance
policies or riders which provide directly or which supplement
long-term care insurance. The term also includes a policy or
rider which provides for payment of benefits based upon
cognitive impairment or the loss of functional capacity. The
term shall also include qualified long-term care contracts.
Long-term care insurance may be issued by insurers, fraternal
benefit societies, nonprofit health, hospital and medical
service corporations, prepaid health plans, health maintenance
organizations or any similar organization to the extent the
entity is otherwise authorized to issue life or health
insurance. 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 or related asset protection coverage, accident only
coverage, specified disease or specified accident coverage or
limited benefit health coverage. With regard to life insurance,
the term "long-term care insurance" does not include life
insurance policies which accelerate the death benefit
specifically for one (1) 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. Notwithstanding any other provision contained in this
article, other than W.S. 26-38-109(e), any product advertised,
marketed or offered as long-term care insurance shall be subject
to the provisions of this article;
(vi) "Policy" means any policy, contract, subscriber
agreement, certificate, 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;
(vii) "Preexisting condition" means a condition for
which medical advice, diagnosis, care 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;
(viii) "Qualified long-term care insurance contract"
means any life insurance contract which provides long-term care
coverage by rider or as part of the contract so long as it is in
compliance with the applicable provisions of section 7702B of
the Internal Revenue Code, as amended. The term also means any
other individual or group insurance contract if it meets the
requirements of section 7702(B) of the Internal Revenue Code, as
amended, and if:
(A) The only insurance protection provided under
the contract is coverage of qualified long-term care services;
(B) 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 in
which Medicare is a secondary payor, or if the contract makes
per diem or other periodic payments without regard to expenses;
(C) The contract is guaranteed renewable;
(D) 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
(E) The contract contains the consumer
protection provisions set forth in section 7702B(g) of the
Internal Revenue Code.
(ix) "Qualified long-term care services" means
necessary diagnostic, preventive, therapeutic, curing, treating,
mitigating, and rehabilitative services, and maintenance for
personal care services to which an insured is eligible for 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.