Sec.38a-475-2. Definitions

As used in sections 38a-475-1 to 38a-475-6, inclusive:

(a) "Connecticut Partnership for Long-Term Care" means the program authorized in section 17b-252 of the general statutes.

(b) "Long-Term Care Insurance Policy" means an insurance policy or certificate, the form of which has been approved by the commissioner in accordance with section 38a-481 or section 38a-513 of the general statutes, which meets the requirements of section 38a-501 or section 38a-528 of the general statutes and sections 38a-501-8 to 38a-501-24, inclusive, or sections 38a-528-1 to 38a-528-17, inclusive, of the regulations of Connecticut state agencies.

(c) "Partnership-Approved Policy" or "Precertified Long-Term Care Insurance Policy" or "Precertified Policy" means any long-term care insurance policy that is a qualified long-term care policy as defined in section 7702B(b) of the Internal Revenue Code of 1986 issued for delivery to any resident of this state which is designed to provide, within the terms and conditions of the policy, contract or certificate, benefits on an expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury, illness or loss of cognitive or functional capacity provided by a certified or licensed health care provider in a setting other than an acute care hospital, for no less than one (1) year at issue after a reasonable elimination period and the form of which is precertified by the insurance department in accordance with section 38a-475 of the general statutes.

(d) "Commissioner" means the insurance commissioner.

(e) "Activities of Daily Living (ADLs)" means each of the following items: dressing, bathing, eating, toileting, continence and transferring. In each instance, an ADL deficiency is determined by reference to the need for substantial human assistance or supervision in performing that activity.

(f) "Mental Status Questionnaire (MSQ)" means the Short Portable questionnaire comprised of 10 questions for clinicians to grade a person's cognitive status.

(g) "Folstein Mini Mental State Examination" means a method for clinicians to grade a person's cognitive status.

(h) "Asset Protection" means the right extended by sections 17b-252 and 17b-253 of the general statutes to persons purchasing partnership-approved long-term care insurance policies to retain amounts of assets equal to the sum of qualifying insurance payments made on their behalf in determining eligibility for the Medicaid program.

(i) "Authorized Agent" means a person who has been designated as agent by the insured in writing to the insurance company, or is acting for the insured under a duly executed power of attorney, or is the insured's duly appointed conservator or guardian.

(j) (1) "Insured Event" means, for purposes of determining asset protection for a privately insured individual, that any one of the following criteria shall have been satisfied:

(A) The individual has a documented need for substantial human assistance, or supervision, with two or more of the following Activities of Daily Living (ADL's): dressing, bathing, eating, toileting, continence and transferring; or

(B) The individual has been assessed using the Mental Status Questionnaire, and has seven or more incorrect responses on the test; or

(C) The individual exhibits specific behavior problems requiring daily supervision, including but not limited to wandering, abusive or assaultive behavior, poor judgement or uncooperativeness which poses a danger to self or others, and extreme or bizarre personal hygiene habits; and has either taken the MSQ and has four or more incorrect responses, or has taken the Folstein Mini Mental State Examination and achieved a score of 23 or lower.

(2) The "Insured Event", for purposes of determining asset protection, shall be the "Insured Event" as defined in the contract.

(3) For purposes of determining eligibility for benefits under a partnership-approved policy, the "insured event" shall use, at a minimum, the following ADLs: dressing, bathing, eating, toileting, continence and transferring and shall be no less restrictive than the "insured event" used for purposes of determining asset protection as defined in subparagraphs (A), (B), (C) of subdivision (1) of this subsection.

(4) The provisions of this subsection shall be used for purposes of determining asset protection, except that federal regulations promulgated under the Health Insurance Portability and Accountability act of 1996 (Public Law 104-191), shall control to the extent that a provision of this subsection is in conflict with said federal regulations.

(k) "Access Agency" means an organization that provides case management services, including assessments and reassessments, care plan development, and coordination and monitoring of home and community-based services and has been approved as an access agency by the Office of Policy and Management and Department of Social Services as meeting the requirements for such agency as defined in section 17b-342 of the general statutes.

(l) "Connecticut Home Care Program for the Elderly of the Department of Social Services" means the program authorized by section 17b-342 of the general statutes.

(m) "Plan of Care" means a written individualized plan of home and community services (including but not limited to "Home and Community-Based Services") which specifies the type and frequency of all services required to maintain the individual at home or in the community, the service providers, and the cost of services, regardless of whether or not there is an actual charge for the service.

(n) "Family Member" means an individual's husband, wife, natural parent, child or sibling, adopted child or parent, stepparent, stepchild, stepbrother, stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, grandparent or grandchild.

(o) "Service Summary" means a written summary prepared by an insurer for an individual policyholder which identifies the specific partnership-approved policy, the total benefits paid for services rendered to date and the amount qualifying for asset protection.

(p) "Policyholder" means a certificate holder under a group long-term care insurance policy or a partnership-approved group long-term care insurance policy or the owner of an individual long-term care insurance policy or a partnership-approved individual long-term care insurance policy.

(q) "Home And Community-Based Services" means, at a minimum, the provision of skilled services provided in the home or community such as skilled nursing care, physical, occupational, respiratory and speech therapy; and home health aide services and support services provided in the home or community which shall include, homemaker, adult day health care and respite care services.

(r) "Uniform Data Set (UDS)" means the reporting requirements for the Connecticut Partnership for Long-Term Care defined in the document "Partnership for Long-Term Care, Long-Term Care Insurance Uniform Data Set Reporting Requirements and Documentation" issued from time to time by the Office of Policy and Management.

(s) "Plan of Action Requirements" means the set of instructions produced and updated by the Office of Policy and Management that insurance companies shall comply with in order to meet the requirements of section 38a-475-5(e) of the regulations of Connecticut state agencies.

(t) "Partnership-Approval" or "Precertification" means the process by which a long-term care policy or certificate form is precertified by the Insurance Department in accordance with section 38a-475 of the general statutes.

(u) "Before You Buy" means a publication produced, and issued from time to time, by the Office of Policy and Management which includes a complete description of the Connecticut Partnership for Long-Term Care.

(Effective October 1, 1991; Amended July 30, 1999; Amended January 2, 2008)