OAR 836-052-0516
Policy Definitions

A long-term care insurance policy delivered or issued for delivery in this state shall not use the terms set forth in this rule unless the terms are defined in the policy according to the definitions in this rule and satisfy the requirements in OAR 836-052-0596 (Standards for Covered Services):

(1)

“Activities of daily living” means at least bathing, continence, dressing, eating, toileting and transferring.

(2)

“Acute condition” means that the individual is medically unstable and requires frequent monitoring by medical professionals, such as physicians and registered nurses, in order to maintain the individual’s health status.

(3)

“Adult day care” means a program for six or more individuals, of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside the home.

(4)

“Adult foster care” means any family home or facility in which residential care is provided in a homelike environment for five or fewer adults who are not related to the provider by blood or marriage.

(5)

“Assisted living” services means services to persons with unique needs, such as, but not limited to, dementia or traumatic brain injury.

(6)

“Bathing” means washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower.

(7)

“Cognitive impairment” means a deficiency in a person’s short or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.

(8)

“Continence” means the ability to maintain control of bowel and bladder function or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).

(9)

“Dressing” means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.

(10)

“Eating” means feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously.

(11)

“Hands-on assistance” means physical assistance (minimal, moderate or maximal) without which the individual would not be able to perform the activity of daily living.

(12)

“Home care” services means medical and nonmedical services provided to ill, disabled or infirm persons in their residences. Such services may include homemaker services, assistance with activities of daily living and respite care services.

(13)

“Medicare” means “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended,” or “Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof,” or words of similar import.

(14)

“Mental or nervous disorder” shall not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

(15)

“Personal care” means the provision of hands-on services to assist an individual with activities of daily living.

(16)

“Residential care” means the provision of room and board and services that assist the resident in activities of daily living, such as assistance with bathing, dressing, grooming, eating, medication management, money management or recreation.

(17)

“Skilled nursing care,” “personal care,” “home care,” “specialized care,” “assisted living care” and other services shall be defined in relation to the level of skill required, the nature of the care and the setting in which care must be delivered.

(18)

“Toileting” means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

(19)

“Transferring” means moving into or out of a bed, chair or wheelchair.

(20)

All providers of services, including but not limited to “skilled nursing facility,” “extended care facility,” “convalescent nursing home,” “personal care facility,” “specialized care provider,” “assisted living facility” and “home care agency,” shall be defined in relation to the services and facilities required to be available and the licensure, certification, registration or degree status of those providing or supervising the services. When the definition requires that the provider be appropriately licensed, certified or registered, it shall also state what requirements a provider must meet in lieu of licensure, certification or registration when the state in which the service is to be furnished does not require a provider of these services to be licensed, certified or registered, or when the state licenses, certifies or registers the provider of services under another name.

Source: Rule 836-052-0516 — Policy Definitions, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0516.

836–052–0103
Purpose 836–052–0107
Authority 836–052–0114
Applicability and Scope 836–052–0119
Definitions 836–052–0124
Policy Definitions and Terms 836–052–0129
Policy Provisions 836–052–0132
Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010 836–052–0133
Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 836–052–0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992 836–052–0136
Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 836–052–0138
Open Enrollment 836–052–0139
Medicare Select Policies and Certificates 836–052–0140
Standards for Claims Payment 836–052–0141
Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010 836–052–0142
Guaranteed Issue for Eligible Persons 836–052–0143
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate 836–052–0144
Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020. 836–052–0145
Loss Ratio Standards and Refund or Credit of Premium 836–052–0151
Filing and Approval of Policies and Certificates and Premium Rates 836–052–0156
Permitted Compensation Arrangements 836–052–0160
Required Disclosure Provisions 836–052–0165
Requirements for Application Forms, Replacement Coverage 836–052–0170
Filing Requirements for Advertising 836–052–0175
Standards for Marketing 836–052–0180
Appropriateness of Recommended Purchase and Excessive Insurance 836–052–0185
Reporting of Multiple Policies 836–052–0190
Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates 836–052–0192
Prohibition Against Use of Genetic Information and Requests for Genetic Testing 836–052–0194
Separability 836–052–0225
Durational Limits for Health Maintenance Organizations 836–052–0230
Provider Services Limits for Insurers and Health Care Contractors 836–052–0500
Statutory Authority 836–052–0508
Definitions 836–052–0516
Policy Definitions 836–052–0526
Policy Practices and Provisions 836–052–0531
Long Term Care Insurance Partnership Program 836–052–0546
Required Policy Provisions 836–052–0556
Required Disclosure of Rating Practices to Consumers 836–052–0566
Initial Rate Filing Requirements 836–052–0576
Prohibition Against Post-Claims Underwriting, Applications 836–052–0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies 836–052–0596
Standards for Covered Services 836–052–0606
Use and Definition of “Home” or Similar Wording 836–052–0616
Requirement to Offer Inflation Protection 836–052–0626
Requirements for Application Forms and Replacement Coverage 836–052–0636
Reporting Requirements 836–052–0637
Annual Rate Certification Requirements 836–052–0639
Training for Insurance Producers 836–052–0646
Benefits Provided Through Advancement of Life Insurance Proceeds 836–052–0656
Reserve Standards 836–052–0666
Loss Ratio 836–052–0676
Premium Rate Schedule Increases 836–052–0680
Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings 836–052–0686
Filing Requirements for Out-of-State Group Policies 836–052–0696
Filing Requirements for Advertising 836–052–0706
Standards for Marketing 836–052–0716
Disclosure Statement 836–052–0726
Suitability 836–052–0736
Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates 836–052–0738
Availability of New Services or Providers 836–052–0740
Right to Reduce Coverage and Lower Premiums 836–052–0746
Nonforfeiture Benefit Requirement 836–052–0756
Standards for Benefit Triggers 836–052–0766
Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts 836–052–0768
Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met 836–052–0770
Prompt Payment of Clean Claims 836–052–0776
Standard Format Outline of Coverage 836–052–0786
Requirement to Deliver Shopper’s Guide 836–052–0790
Disclosure of Benefits Paid 836–052–0800
Purpose 836–052–0810
Replacement Upon Termination 836–052–0840
Termination of Coverage 836–052–0850
Multiple Employer Trusts 836–052–0860
Form of Notice to Group Policyholder 836–052–1000
Prosthetic and Orthotic Devices
Last Updated

Jun. 8, 2021

Rule 836-052-0516’s source at or​.us