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 39.5 - Minimum benefit standards for qualified policies/certificates for the 4/4/100 plan design
Universal Citation: 11 NY Comp Codes Rules and Regs ยง 39.5
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Basic program minimum coverage requirements. All program participating insurers issuing this plan design must offer a basic policy/certificate providing minimum coverage under this section. Additional products which exceed the basic policy/certificate minimum coverage will be permitted. The insurer selling a policy/certificate providing minimum coverage under this section must offer a policy/certificate providing the basic 2/2/100 minimum plan design and the basic 1.5/3/50 minimum plan design under sections 39.4 and 39.6 of this Part to the prospective insured at the same time.
(b) Minimum benefit standards for the 4/4/100 plan design. To be approved as a qualified policy/certificate under this section a policy/certificate shall provide coverage on an expense incurred, indemnity, prepaid, or other basis and shall provide at least all the benefits in this section and:
(1) The
policy/certificate shall provide at least a lifetime maximum total of 48 months
coverage for each covered person. The policy/certificate may express the
requirement for at least a lifetime maximum total of 48 months coverage for
each covered person in monetary terms. The monetary expression shall be at
least a lifetime maximum total of 1,460 days of coverage for each covered
person multiplied by a daily benefit amount of at least $ 387 per day for
policies/certificates sold in 2024. The minimum 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:
(i)
January 1, 2024 - $ 387;
(ii)
January 1, 2025 - $ 401;
(iii)
January 1, 2026 - $ 415;
(iv)
January 1, 2027 - $ 430;
(v)
January 1, 2028 - $ 445;
(vi)
January 1, 2029 - $ 461;
(vii)
January 1, 2030 - $ 477;
(viii)
January 1, 2031 - $ 494;
(ix)
January 1, 2032 - $ 511;
(x)
January 1, 2033 - $ 529.
(2) Nursing home care. Coverage of nursing
home care shall consist of payment for skilled nursing care, intermediate care,
and custodial care in nursing homes. 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 care coverage benefit shall be
provided in an amount equal to the minimum daily benefit amount as stated in
this section.
(3) Residential care
facility services. Coverage of residential care facility services shall include
but are not limited to nursing care, maintenance or personal care, therapy
services, and room and board accommodations. Services must be rendered by an
entity that is legally operating as a residential care facility as required
under the laws of the jurisdiction in which it is located. Examples of a
residential care facility include an assisted living facility or adult care
facility. The minimum residential care facility services benefit shall be
provided in an amount equal to the minimum daily benefit amount as stated in
this section.
(4) Home and
community-based care. Home and community-based 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.
(i) Home and community-based care benefits
shall be provided for at least the following services: skilled nursing care,
home health care, personal care (including homemaker services), assisted living
(other than in a facility) and adult day care, provided that such services are
rendered by entities licensed and/or certified by the Department of Health or
agencies exempt from licensure or certification in accordance with articles 28
and/or 36 of the Public Health Law and regulations promulgated thereunder or
section 505.14 of Title 18 NYCRR. Payment
for home and community-based care services received outside of New York State
may be limited to services rendered by an entity licensed to provide such
services in the jurisdiction where the services were rendered. It is also
required that the insured has incurred expense for the cost of a covered
service.
(ii) The minimum home and
community-based care coverage benefit shall be provided in an amount equal to
the minimum daily benefit amount as stated in this section.
(iii) Home and community-based care coverage
which exceeds the minimum benefit standards shall not affect the requirement
for a lifetime maximum total of 48 months of home and community-based care
benefits. However, at the discretion of the insurer, it shall be permissible to
combine benefit days to pay an amount in excess of the daily benefit amount set
forth in the policy/certificate. In no case where benefit days have been
combined shall the equivalent of more than 31 days of home and community-based
care benefits be provided in any one-month period.
(5) Nursing home care bed reservation (holds
nursing home bed when the insured 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 daily benefit amount in effect under the
policy/certificate for at least 20 days annually.
(6) Residential care facility bed reservation
(holds residential care facility bed when the insured must leave the
residential care facility for a time period). The minimum residential care
facility bed reservation coverage benefit shall be provided in an amount equal
to the daily benefit amount in effect under the policy/certificate for at least
20 days annually.
(7) Respite care.
The minimum respite care coverage benefit, meaning nursing home, residential
care facility, and/or home and community-based care services provided in lieu
of informal caregiver services, shall be provided in an amount equal to the
daily benefit amount in effect under the policy/certificate for at least 14
days annually. Covered days of respite care need not be consecutive and shall
be provided at the daily benefit amount 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:
(i) a covered person's eligibility
to receive policy/certificate benefits for a period not to exceed six
consecutive months without regard to receipt of formal nursing home,
residential care facility and/or home and community-based care services and
without regard to satisfaction of policy/certificate waiting periods;
(ii) expenses for respite services qualifying
under the policy/certificate are incurred;
(iii) once the requirement of subparagraph
(i) of this paragraph has been met an insurer may not impose another such
requirement unless the covered person is no longer eligible to receive
policy/certificate benefits; or the policy/certificate is lapsed or cancelled;
or benefits under the policy/certificate are exhausted.
(8) Hospice care. The minimum hospice care
coverage benefit shall be provided in an amount equal to the daily benefit
amount in effect under the policy/certificate regardless of where the hospice
care services are actually rendered and regardless of the actual cost of such
services.
(9) Alternate care. Where
an otherwise covered person is unable to obtain access to nursing home care,
residential care facility services, or home and community-based 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, residential care facility, or home and
community-based care services for which such covered person is awaiting
placement. Benefit payments while the covered person is in alternate care
status shall be the daily benefit amount in effect under the
policy/certificate.
(10) Care
management. The care management coverage benefit shall be provided in an amount
equal to the daily benefit amount in effect under the policy/certificate for at
least two days per year.
(11)
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.
(12) 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.
(13) 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.
(14) 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.
(15) 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.
(16) 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.
(c) Additional and optional benefits. One or more of the following long-term care services may be offered in a qualified policy/certificate up to a required aggregate lifetime maximum per covered person equal to but not exceeding the minimum daily benefit amount as stated in this section multiplied by 50 and:
(1) The
long-term care services shall be:
(i)
additional nursing home care and residential care facility bed reservation
benefits;
(ii) additional respite
care benefits;
(iii) additional
care management benefit;
(iv) home
modification benefit;
(v) informal
caregiver training benefit;
(vi)
emergency response system benefit;
(vii) therapeutic device benefit;
(viii) supportive/durable medical equipment
benefit;
(ix) specialized
transportation benefit, such as specialized transportation to and from adult
day care.
(2) Additional
and optional benefits provided shall be deducted from the policy/certificate
lifetime maximum coverage of at least 48 months per covered person subject to
the limit stated in this subdivision.
(d) Tax qualification. Qualified policies/certificates providing coverage under this section shall meet the standards required under Federal and New York State laws and regulations for favorable tax qualification status.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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