New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter III - Policy and Certificate Provisions
Subchapter A - Life, Accident and Health Insurance
Part 39 - Minimum Standards For The New York State Partnership For Long-term Care Program
Section 39.3 - Minimum benefit standards for qualified policies/certificates for the 3/6/50 plan design

(1) Nursing home care. Nursing home care coverage shall be provided for not less than a lifetime maximum total of 36 months for each covered person. A covered person must be permitted to substitute home care benefits for nursing home care benefits on the basis of two home care days for one nursing home day. Coverage of nursing home care shall consist of payment for skilled nursing care, intermediate care, and custodial care in nursing homes of at least $ 387 per day. Payment for nursing home care services may be limited to services rendered in a nursing home licensed by the jurisdiction in which it is located. The minimum nursing home daily benefit shall be increased each year on the first day of January beginning in 2025. Policies/certificates sold after January 1, 2025 shall provide benefits at the increased minimum standard in the year sold. Minimum daily benefits for the next 10 years shall be as follows:

(2) Home care. Home care coverage shall be provided when services are rendered in the insured's place of residence, in a group setting such as an adult day care center, or where human assistance is required by the insured to aid in necessary travel, such as to a physician's office.

(3) Nursing home care bed reservation (holds nursing home bed when must leave the nursing home for a time period). The minimum nursing home bed reservation coverage benefit shall be provided in an amount equal to the nursing home daily benefit amount in effect under the policy/certificate for at least 20 days annually.

(4) Respite care. Respite care, meaning nursing home and/or home care services provided in lieu of informal caregiver services, for at least 14 days coverage, shall be renewable annually. Covered days of respite care need not be consecutive and shall be provided at a daily amount equal to that provided for nursing home care under the policy or certificate regardless of where the respite care services are actually rendered and regardless of the actual cost of such services. Payment for respite care services may be conditioned upon the following:

(5) Hospice care. The minimum hospice care coverage benefit shall be provided in an amount equal to the nursing home daily benefit in effect under the policy/certificate in an inpatient setting and at the home care daily benefit in effect under the policy/certificate in all other settings.

(6) Alternate care. Where an otherwise covered person is unable to obtain access to nursing home care or home care services, and the covered person is in a hospital setting awaiting the availability of such services, and has been determined by the attending physician to be in alternate care status, such covered person shall, for the purpose of benefit eligibility including the satisfaction of any elimination period, be deemed to be receiving the nursing home care or home care services for which such covered person is awaiting placement. Benefit payments while the covered person is in alternate care status shall be the nursing home daily benefit in effect under the policy/certificate.

(7) Care management. The minimum care management coverage benefit shall be provided in an amount equal to the nursing home daily benefit in effect under the policy/certificate for at least two days per year.

(8) Inflation protection. Qualified policies/certificates shall provide lifetime inflation protection of three and one-half percent compounded or five percent compounded on an annual calendar or policy year basis. The insurer shall permit the covered person to choose either the three and one-half percent compounded or the five percent compounded lifetime inflation option. Inflation protection shall be mandatory except if the policy/certificate is purchased at or after age 80.

(9) Level premium. Step rate premiums, policy/certificate options to increase benefits, or any premium payment feature where the premium rate rises automatically after issuance shall not be permitted. Premiums for qualifying policies/certificates shall be level for the duration of the policy/certificate except where a rate increase is granted by the Superintendent of Financial Services for all persons covered by a specific policy/certificate form.

(10) Replacement. If a long-term care insurance policy/certificate qualified under this Part replaces another qualified long-term care insurance policy/certificate under this Part, the replacing insurer shall waive any time periods applicable to preexisting conditions, waiting periods, and probationary periods in the new long-term care policy/certificate to the extent such time has elapsed under the original policy/certificate. The insurer may, however, exercise any legal rights available with regard to alleged fraud or material misrepresentation in obtaining the replacement policy/certificate.

(11) Policy/certificate modification provision in the event of a national long-term care program. Qualified policies/certificates shall include a provision for modification of such policies/certificates in the event of enactment of a national long-term care program using public funds which program duplicates coverage provided under qualified policies/certificates. The modification provision must state that the policy/certificate will be amended to the extent possible to provide benefits appropriately interrelated with the national program. In the event of modification or, if necessary, termination the insurer must submit a plan to the superintendent providing for any premium adjustment or refund required as a result of modification or termination.

(12) Elimination periods. Elimination periods no greater than 100 days are permitted in qualified policies/certificates. Only a single elimination period for all covered services will be permitted. The commencement of a new elimination period is permitted only when a period of care is separated from another period of care by more than six months.

(13) A long term care policy/certificate providing coverage under this section on an indemnity, prepaid, or any basis other than expense incurred may be sold in this State. However, the insurer selling such a policy or certificate must offer a policy/certificate providing coverage on an expense incurred basis at the same time to the prospective insured.