26-38-103. Definitions.

(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.