Current through Register Vol. 46, No. 12, March 20, 2024
(b) Minimum benefit standards for the 2/4/50 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 provide at least the following benefits:
(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:
(i) January 1, 2024 - $ 387 (nursing
home), $ 193 (residential care facility and home and community-based care - 50
percent);
(ii) January 1, 2025 - $ 401
(nursing home), $ 200 (residential care facility and home and community-based care -
50 percent);
(iii) January 1, 2026 - $
415 (nursing home), $ 207 (residential care facility and home and community-based
care - 50 percent);
(iv) January 1, 2027
- $ 430 (nursing home), $ 215 (residential care facility and home and
community-based care - 50 percent);
(v)
January 1, 2028 - $ 445 (nursing home), $ 222 (residential care facility and home
and community-based care - 50 percent);
(vi) January 1, 2029 - $ 461 (nursing home), $ 230
(residential care facility and home and community-based care - 50
percent);
(vii) January 1, 2030 - $ 477
(nursing home), $ 238 (residential care facility and home and community-based care -
50 percent);
(viii) January 1, 2031 - $
494 (nursing home), $ 247 (residential care facility and home and community-based
care - 50 percent);
(ix) January 1, 2032
- $ 511 (nursing home), $ 255 (residential care facility and home and
community-based care - 50 percent);
(x)
January 1, 2033 - $ 529 (nursing home), $ 264 (residential care facility and home
and community-based care - 50 percent).
(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.
(i) The minimum
residential care facility coverage to be offered shall be provided in an amount of
at least 50 percent of the current minimum nursing home care benefit as stated in
this section. This minimum residential care facility coverage amount shall continue
to be the minimum residential care facility benefit standard regardless of the
amount of nursing home coverage actually purchased. Residential care facility
coverage which exceeds the minimum benefit standards shall not affect the
requirement for a lifetime maximum total of 48 months of residential care facility
benefits.
(ii) For the purpose of
special eligibility for long-term care protection through the New York State
Medicaid program under a qualified policy/certificate, a covered person must be
permitted to substitute residential care facility benefits for nursing home care
benefits on the basis of two residential care facility days for one nursing home
day. Complete substitution of residential care facility benefits for nursing home
care benefits shall result in a lifetime maximum total of 48 months of residential
care facility benefits.
(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.
(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 18 NYCRR section 505.14.
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) For the purpose of special eligibility for
long-term care protection through the New York State Medicaid program under a
qualified policy/certificate, a covered person also must be permitted to substitute
home and community-based care benefits for nursing home care benefits on the basis
of two home and community-based care days for one nursing home day. Complete
substitution of home and community-based care benefits for nursing home care
benefits shall result in a lifetime maximum total of 48 months of home and
community-based care benefits.
(iii) The
minimum home and community-based care coverage to be offered shall be provided in an
amount of at least 50 percent of the current minimum nursing home care benefit as
stated in this section. This minimum home and community-based care coverage amount
shall continue to be the minimum home and community-based care benefit standard
regardless of the amount of nursing home coverage actually purchased.
(iv) 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.
(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:
(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 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.