2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514G - LONG=TERM CARE INSURANCE ACT
514G.103 - DEFINITIONS.

        514G.103  DEFINITIONS.
         As used in this chapter, unless the context requires otherwise:
         1.  "Activities of daily living" means at least bathing,
      continence, dressing, eating, toileting, and transferring.
         2.  "Applicant" means either of the following:
         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.
         3.  "Benefit trigger" means a contractual provision in a
      policy of long-term care insurance that conditions the payment of
      benefits on a determination of the insured's ability to perform
      activities of daily living and on cognitive impairment, or on other
      conditions of the insured as specified in the policy.  For purposes
      of a qualified long-term care insurance contract, "benefit
      trigger" means a determination by a licensed health care
      practitioner that an insured is a chronically ill individual.  For
      purposes of this definition, "licensed health care practitioner"
      means the same as defined in section 7702B(c)(4) of the Internal
      Revenue Code.
         4.  "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.
         5.  "Chronically ill individual" means the same as defined in
      section 7702B(c)(2) of the Internal Revenue Code.
         6.  "Claim" means a request for payment of benefits under an
      in-force long-term care insurance policy, regardless of whether the
      benefit claimed is covered under the policy or any terms or
      conditions of the policy have been met.
         7.  "Cognitive impairment" means a deficiency in a person's
      short-term or long-term memory; orientation as to person, place, and
      time; deductive or abstract reasoning; or judgment as it relates to
      safety awareness.
         8.  "Commissioner" means the commissioner of insurance.
         9.  "Group long-term care insurance" means a long-term care
      insurance policy that is delivered or issued for delivery in this
      state to any of the following:
         a.  One or more employers or labor organizations, or to a
      trust or to the trustee or trustees of a fund established, created,
      or maintained by one or more employers or labor organizations or a
      combination thereof, for the benefit of employees or former employees
      or a combination thereof, or for members or former members or a
      combination thereof, of the employers or labor organizations.
         b.  Any professional, trade, or occupational association for
      its members or former or retired members, or a combination thereof,
      if the association meets both of the following requirements:
         (1)  Is composed of individuals all of whom are or were actively
      engaged in the same profession, trade, or occupation.
         (2)  Has been maintained in good faith for purposes other than
      obtaining insurance.
         c. (1)  An association or associations, or to a trust or to
      the trustee or trustees of a fund established, created, or maintained
      for the benefit of members of one or more associations, which files
      evidence with the commissioner prior to advertising, marketing, or
      offering a policy within this state by the association or
      associations, or their insurer, that the following organizational
      requirements have been met:
         (a)  At the outset, there is a minimum of one hundred members of
      the association or associations.
         (b)  The association or associations have been organized and
      maintained in good faith for purposes other than that of obtaining
      insurance.
         (c)  The association or associations have been in active existence
      for at least one year at the time of filing.
         (d)  The association or associations have a constitution and
      bylaws that require all of the following:
         (i)  The association or associations have regular meetings, not
      less than annually, to further the purposes of the members.
         (ii)  Except for credit unions, the association or associations
      collect dues or solicit contributions from members.
         (iii)  The members have voting privileges and representation on a
      governing board and committees.
         (2)  Thirty days after the required evidentiary filings have been
      made, the association or associations shall be deemed to satisfy the
      organizational requirements, unless the commissioner makes a finding
      that the association or associations do not satisfy those
      requirements.
         d.  A group other than those described in paragraphs "a"
      through "c", subject to a finding by the commissioner that all of
      the following are true:
         (1)  The issuance of the group policy is not contrary to the best
      interests of the public.
         (2)  The issuance of the group policy would result in economies of
      acquisition or administration.
         (3)  The benefits are reasonable in relation to the premiums
      charged.
         10.  "Independent review entity" means a review entity
      certified by the commissioner pursuant to section 514G.110,
      subsection 5.
         11.  "Insurer" means an entity qualified and licensed by the
      insurance division to transact the business of insurance in this
      state by a certificate issued pursuant to chapter 508, 512B, 514, or
      514B.
         12.  "Licensed health care professional" means a qualified
      professional in an appropriate field for determining an insured's
      functional or cognitive impairment as it relates to the insured's
      specific diagnosis.  Licensed health care professionals include but
      are not limited to physical therapists, occupational therapists,
      neurologists, physical medicine specialists, and rehabilitation
      medicine specialists.
         13. a.  "Long-term care insurance" means any insurance policy
      or rider advertised, marketed, offered, or designed to provide
      coverage for not less than twelve consecutive months for each covered
      person on an expense-incurred, indemnity, prepaid, or other basis,
      for one or more necessary or medically necessary diagnostic,
      preventive, therapeutic, rehabilitative, maintenance, or personal
      care services that are provided in a setting other than an acute care
      unit of a hospital.  "Long-term care insurance" includes group
      and individual annuities and life insurance policies or riders that
      directly provide or supplement long-term care insurance.  The term
      also includes a policy or rider that provides for payment of benefits
      based upon cognitive impairment or the loss of functional capacity.
      The term also includes a qualified long-term care insurance contract.
      Long-term care insurance may be issued by an insurer.
         b.  "Long-term care insurance" does not include any insurance
      policy that 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, "long-term care insurance" does
      not include life insurance policies that accelerate the death benefit
      specifically for one or more 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, where neither
      the benefits nor the eligibility for the benefits is conditioned upon
      the receipt of long-term care.
         c.  Notwithstanding any other provision of this chapter, any
      product advertised, marketed, or offered as long-term care insurance
      shall be subject to the provisions of this chapter.
         14.  "Policy" means any policy, contract, subscriber
      agreement, 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; or health maintenance organization or any similar organization.

         15.  "Preexisting condition" means a condition for which
      medical advice or treatment was recommended by, or received from, a
      provider of health care services within six months preceding the
      effective date of coverage of an individual.
         16.  "Qualified long-term care insurance contract" or
      "federally tax-qualified long-term care insurance contract" means
      any of the following:
         a.  An individual or group insurance contract that meets the
      requirements of section 7702B(b) of the Internal Revenue Code, as
      follows:
         (1)  The only insurance protection provided under the contract is
      coverage of qualified long-term care services.  A contract does not
      fail to satisfy the requirements of this subparagraph because
      payments are made on a per diem or other periodic basis without
      regard to the expenses incurred during the period to which the
      payments relate.
         (2)  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 federal Social Security Act, as amended, or
      would be reimbursable but for the application of a deductible or
      coinsurance amount.  The requirements of this subparagraph do not
      apply to expenses that are reimbursable under Title XVIII of the
      federal Social Security Act only as a secondary payor.  A contract
      does not fail to satisfy the requirements of this subparagraph
      because payments are made on a per diem or other periodic basis
      without regard to the expenses incurred during the period to which
      the payments relate.
         (3)  The contract is guaranteed renewable within the meaning of
      section 7702B(b)(1)(C) of the Internal Revenue Code.
         (4)  The contract does not provide for a cash surrender value or
      for other money that can be paid, assigned or pledged as collateral
      for a loan, or borrowed except as provided in subparagraph (5).
         (5)  All refunds of premiums and all policyholder dividends or
      similar accounts under the contract are to be applied as a reduction
      in future premiums or to increase future benefits, except that a
      refund in the event of the death of the insured or a complete
      surrender or cancellation of the contract shall not exceed the
      aggregate premiums paid under the contract.
         (6)  The contract meets the consumer protection provisions set
      forth in section 7702B(g) of the Internal Revenue Code.
         b.  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 section 7702B(b) and (e) of
      the Internal Revenue Code.  

         2008 Acts, ch 1175, §4
         Referred to in § 514G.104, 514G.105, 514G.107, 514G.110, 514H.1