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 39.7 - Minimum benefit standards for qualified policies/certificates for the 2/4/50 plan design

(1) Nursing home care. Nursing home care coverage shall be provided for not less than a lifetime maximum total of 24 months for each covered person. A covered person must be permitted to substitute home and community-based care benefits or residential care facility benefits for nursing home care benefits on the basis of two home and community-based care or residential care facility service 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 2024. Policies/certificates sold on or after January 1, 2025 shall provide benefits at the increased minimum standard in the year sold. Minimum daily benefits for the years listed below shall be as follows:

(2) Residential care facility services. Coverage of residential care facility services shall include but is not limited to nursing care, maintenance or personal care, therapy services, and room and board accommodations for not less than a lifetime maximum total of 48 months for each covered person. 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 residence or adult care facility.

(3) Home and community-based care. Home and community based care coverage shall be provided for not less than a lifetime maximum total of 48 months for each covered person 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.

(4) The required lifetime maximum totals for nursing home care, residential care facility benefits and home and community-based care benefits may be expressed in monetary terms. The required lifetime maximum total of 48 months of residential care facility benefits and the required lifetime maximum total of 48 months of home and community-based care benefits is one combined lifetime maximum total of 48 months for both benefits for each covered person.

(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 nursing home 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 minimum daily benefit amount for residential care facility services in effect under the policy/certificate for at least 20 days annually.

(7) Respite care. Respite care, meaning nursing home, residential care facility, and/or home and community-based 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:

(8) 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 and community-based care daily benefit in effect under the policy/certificate in all other settings.

(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 care, residential care facility services 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 nursing home daily benefit in effect under the policy/certificate.

(10) 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.

(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 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 shall 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 shall 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.