Title 24-A: MAINE INSURANCE CODE

Chapter 68: NURSING HOME CARE AND LONG-TERM CARE INSURANCE POLICIES

§5051. Definitions

As used in this chapter, unless the context indicates otherwise, the following terms have the following meanings.   [PL 1985, c. 648, §12 (NEW).]

1.  Long-term care policy.  "Long-term care policy" means a group or individual policy of health insurance, a subscriber contract of a nonprofit hospital or medical service organization or nonprofit health care plan or a life insurance rider which is advertised, marketed or designed primarily to provide coverage for not less than 12 consecutive months for each covered person on an expense-incurred basis, indemnity basis, 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. The term does not include:  

A. A policy or contract defined as Medicare supplement insurance pursuant to chapter 67;   [PL 1985, c. 648, §12 (NEW).]

B. A policy or contract issued prior to October 1, 1990, to one or more employers or labor organizations or of the trustees of a fund established by one or more employers or labor organizations, or combination of both, or for members or former members, or combination of both, of the labor organizations;   [PL 1989, c. 556, Pt. B, §1 (AMD).]

C. A policy or contract issued prior to October 1, 1990, to any professional, trade or occupational association for its members, former members or retired members or combination of all members, if the association:  

(1) Is composed of individuals all of whom are actively engaged in the same profession, trade or occupation;  

(2) Has been maintained in good faith for purposes other than obtaining insurance; and  

(3) Has been in existence for at least 2 years prior to the date of its initial offering of the policy or plan to its members; and   [PL 1989, c. 556, Pt. B, §1 (AMD).]

D. Individual policies or contracts issued pursuant to a conversion privilege under a policy or contract of group or individual insurance when that group or individual policy or contract:  

(1) Was issued prior to October 1, 1990; and  

(2) Includes provisions which are inconsistent with the requirements of this chapter; and   [PL 1989, c. 556, Pt. B, §1 (RPR).]

E. A policy or contract offered primarily to provide basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection, accident-only coverage, specified disease or specified accident coverage, home health care coverage or limited benefit health coverage.   [PL 1997, c. 604, Pt. D, §1 (AMD).]

[PL 1997, c. 604, Pt. D, §1 (AMD).]

2.  Nursing home.  "Nursing home" means any facility located in this State which is licensed by the Department of Health and Human Services as a skilled nursing facility or intermediate care facility and any equivalent facility located in another state or country and licensed according to the laws of that jurisdiction.  

[PL 1985, c. 648, §12 (NEW); PL 2003, c. 689, Pt. B, §6 (REV).]

3.  Nursing home care policy.  "Nursing home care policy" means a group or individual policy of health insurance or a subscriber contract of a nonprofit hospital or medical service organization or nonprofit health care plan which is advertised, marketed or designed primarily to provide benefits on either an expense-incurred or indemnity basis for confinements or costs associated with confinements of a covered person in a nursing home. For purposes of this definition, a policy is deemed to primarily provide nursing home benefits if 50% or more of benefits payable or anticipated to be payable under the policy are related to nursing home confinements. The term does not include:  

A. A policy or contract defined as Medicare supplement insurance pursuant to chapter 67;   [PL 1985, c. 648, §12 (NEW).]

B. A policy or contract issued to one or more employers or labor organizations or of the trustees of a fund established by one or more employers or labor organizations, or combination of both, or for members or former members, or combination of both, of the labor organizations;   [PL 1985, c. 648, §12 (NEW).]

C. A policy or contract issued to any professional, trade or occupational association for its members, former members or retired members, or combination of members if, the association:  

(1) Is composed of individuals all of whom are actively engaged in the same profession, trade or occupation;  

(2) Has been maintained in good faith for purposes other than obtaining insurance; and  

(3) Has been in existence for at least 2 years prior to the date of its initial offering of the policy or plan to its members; or   [PL 1985, c. 648, §12 (NEW).]

D. Individual policies or contracts issued pursuant to a conversion privilege under a policy or contract of group or individual insurance, when such group or individual policy or contract includes provisions which are inconsistent with the requirements of this chapter.   [PL 1985, c. 648, §12 (NEW).]

[PL 1985, c. 648, §12 (NEW).]

3-A.  Home health care policy.  "Home health care policy" means a group or individual policy of health insurance or a subscriber contract of a nonprofit hospital or medical service organization or nonprofit health care plan that is advertised, marketed or designed primarily to provide benefits on either an expense-incurred or indemnity basis for confinements or costs associated with home health care services. For purposes of this definition, a policy is deemed to provide primarily home health care benefits if 50% or more of benefits payable or anticipated to be payable under the policy are related to home health care services. The term does not include:  

A. A policy or contract defined as Medicare supplement insurance pursuant to chapter 67;   [PL 1997, c. 604, Pt. D, §2 (NEW).]

B. A policy or contract issued to one or more employers or labor organizations or to the trustees of a fund established by one or more employers or labor organizations, or combination of both, or for members or former members, or combination of both, of the labor organizations;   [PL 1997, c. 604, Pt. D, §2 (NEW).]

C. A policy or contract issued to any professional, trade or occupational association for its members, former members or retired members, or combination of members, if the association:  

(1) Is composed of individuals all of whom are actively engaged in the same profession, trade or occupation;  

(2) Has been maintained in good faith for purposes other than obtaining insurance; and  

(3) Has been in existence for at least 2 years prior to the date of its initial offering of the policy or plan to its members; or   [PL 1997, c. 604, Pt. D, §2 (NEW).]

D. Individual policies or contracts issued pursuant to a conversion privilege under a policy or contract of group or individual insurance, when that group or individual policy or contract includes provisions that are inconsistent with the requirements of this chapter.   [PL 1997, c. 604, Pt. D, §2 (NEW).]

[PL 1997, c. 604, Pt. D, §2 (NEW).]

4.  Home health care provider.  "Home health care provider" has the same meaning as set forth in section 2745.  

[PL 1989, c. 556, Pt. B, §2 (NEW).]

5.  Home health care services.  "Home health care services" has the same meaning as set forth in section 2745, subsections 1 and 2, except that the requirements of section 2745, subsection 1, paragraph A shall not apply.  

[PL 1989, c. 556, Pt. B, §2 (NEW).]

SECTION HISTORY

PL 1985, c. 648, §12 (NEW). PL 1989, c. 556, §§B1,B2 (AMD). PL 1997, c. 604, §§D1,2 (AMD). PL 2003, c. 689, §B6 (REV).