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31 Pa. Code § 89a.104. Policy definitions.

§ 89a.104. Policy definitions.

 (a)  A long-term care insurance policy delivered or issued for delivery in this Commonwealth may not use the terms set forth as follows, unless the terms are defined in the policy and the definitions satisfy the following requirements:

   Activities of daily living—Bathing, continence, dressing, eating, toileting and transferring.

   Acute condition—The term means that the individual is medically unstable. This individual requires frequent monitoring by medical professionals, such as physicians and registered nurses, to maintain the individual’s health status.

   Adult day care—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.

   Bathing—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.

   Cognitive impairment—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.

   Continence—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).

   Dressing—Putting on and taking off all items of clothing and necessary braces, fasteners or artificial limbs.

   Eating—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.

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

   Home health care services—Medical and nonmedical services, provided to ill, disabled or infirm persons in their residences. The services may include homemaker services, assistance with activities of daily living and respite care services.

   Medicare—The program under the Health Insurance for the Aged Act in Title XVIII of the Social Security Amendments of 1965 (42 U.S.C.A. § §  1395—1395ggg) and any later amendments or substitutes thereof.

   Mental or nervous disorder—The term may not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

   Personal care—The provision of supervisory or hands-on services to assist an individual with activities of daily living.

   Skilled nursing care, intermediate care, personal care, home care and other services—These terms 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.

   Toileting—Getting to and from the toilet, getting on and off the toilet and performing associated personal hygiene.

   Transferring—Moving into or out of a bed, chair or wheelchair.

 (b)  All providers of services, including, but not limited to, skilled nursing facility, extended care facility, intermediate care facility, convalescent nursing home, personal care facility and home care agency shall be defined in relation to the services and facilities required to be available and the licensure or degree status of those providing or supervising the services. The definition may require that the provider be appropriately licensed or certified only when the licensure or certification of the provider is required by the state in which the provider is located.

Cross References

   This section cited in 31 Pa. Code §  89a.124 (relating to standards for benefit triggers).

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