Kansas Administrative Regulations

Agency 40.  Insurance Department

Article 4.  Accident and Health Insurance

 

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. 1991 Supp. 40-2227.

(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, which is primarily engaged in providing nursing care and related services on an inpatient basis under a license issued by the appropriate licensing agency. It may be a freestanding facility including the following:

(A)  nursing facility;

(B)  skilled nursing home;

(C)  intermediate nursing care home;

(D)  assisted living facility; or

(E)  residential health care facility.

Any 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 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 rules 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'' includes the following: an illness or disease of an insured person which 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 will not exceed 30 days from 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 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 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.

(d)  K.A.R. 40-4-37a, 40-4-37f and 40-4-37i shall not apply to group long-term care insurance policies issued to an employer-employee group.


(Authorized by K.S.A. 40-103, K.S.A. 40-2228; implementing K.S.A. 40-2228; effective, T-89-9, March 18, 1988; effective Sept. 12, 1988; amended Jan. 6, 1992; amended Jan. 4, 1993; amended Feb. 9, 1996.)