Current through Register Vol. 46, No. 39, September 25, 2024
Unless otherwise specifically indicated in this section a
policy or certificate that provides for the accelerated payment of the death
benefit pursuant to Insurance Law section 1113(a)(1)(C) or (D) shall meet the
following standards:
(a) Pursuant to
Insurance Law section 1113(a)(1)(C) accelerated payment of the death benefit
shall be based on the qualifying event of certification by a licensed health
care practitioner of any condition which requires continuous care for the
remainder of the insured's life in an eligible facility or at home when the
insured is chronically ill, provided that any such accelerated payments shall
qualify under section 101(g)(3) of the Internal
Revenue Code and all other applicable sections of Federal law in order to
maintain favorable tax treatment.
(b) Pursuant to Insurance Law section
1113(a)(1)(D) accelerated payment of the death benefit shall be based on the
qualifying event of certification by a licensed health care practitioner that
the insured is chronically ill, provided that any such accelerated payments
shall qualify under section 101(g)(3) of the Internal
Revenue Code and all other applicable sections of Federal law in order to
maintain favorable tax treatment.
(c) A policy or certificate intended to be a
qualified long-term care insurance contract for Federal tax purposes shall:
(1) meet the applicable requirements of
section 4980C of the Internal Revenue Code for a
qualified long-term care insurance carrier;
(2) meet all the applicable requirements of
section 7702B of the Internal Revenue Code, as
amended for a qualified long-term care insurance contract or payments;
and
(3) state that it is intended
to be a qualified long-term care insurance contract under section
7702B of the Internal Revenue Code. Such
statement shall be qualified by the disclosure to the effect that "This is not
a health insurance (policy)(certificate) and is not subject to the minimum
requirements of New York Law pertaining to Long-Term Care Insurance and does
not qualify for the New York State Long-Term Care Partnership Program and is
not a Medicare Supplement Policy. The (policy)(certificate) is intended to be a
qualified long-term care insurance contract for Federal tax law
only."
(d) A policy or
certificate that is not intended to be a qualified long-term care insurance
contract for Federal tax purposes shall state that it is not intended to be a
qualified long-term care insurance contract under section
7702B of the Internal Revenue
Code.
(e) The submission of the
policy or certificate for approval to the superintendent shall include a
written certification from a tax counsel that to the best of the counsel's
knowledge and belief the policy or certificate provides for accelerated
payments that qualify under section
101(g)(3) of the Internal
Revenue Code and all other applicable sections of Federal law in order to
maintain favorable tax treatment. The certification by tax counsel for policies
and certificates that accelerate payment of the death benefit pursuant to
Insurance Law section 1113(a)(1)(C) or (D) and is intended to be a qualified
long-term care insurance contract for Federal tax purposes shall also certify
that the policy or certificate meets all the applicable requirements of section
7702B of the Internal Revenue Code, as
amended, for a qualified long-term care contract and the insurer issuing such
policy or certificate meets the applicable requirements of section
4980C of the Internal Revenue
Code.
(f) Payments made shall be
for costs incurred for qualified long-term care services or made on a per diem
basis without regard to the expenses incurred for qualified long-term care
services.
(g) The policy or rider
on its face page shall provide for a free look provision for the accelerated
benefits in accordance with the requirements of Insurance Law section
3203(a)(11), which shall not be less than 30 days.
(h) No policy or certificate shall limit or
exclude the payment of accelerated death benefits by type of illness,
treatment, medical condition or accident, except as follows:
(1) mental or nervous disorders, however,
this shall not permit exclusion or limitation of benefits on the basis of
Alzheimer's Disease or demonstrable organic brain disease;
(2) alcoholism and drug addiction;
(3) illness, treatment or medical condition
arising out of:
(i) war or act of war (whether
declared or undeclared);
(ii)
participation in a felony, riot or insurrection;
(iii) service in the armed forces or units
auxiliary thereto;
(iv) suicide,
attempted suicide or intentionally self-inflicted injury; or
(v) aviation (this exclusion applies only to
non-fare paying passengers);
(4) treatment provided in a government
facility (unless otherwise required by law), services for which benefits are
provided under Medicare or other governmental program (except Medicaid), any
State or Federal workers' compensation, employer's liability or occupational
disease law, or any mandatory motor vehicle no-fault law, services provided by
a member of the covered person's immediate family and services for which no
charge is normally made in the absence of insurance; and
(5) treatment or care received by the insured
outside the United States and its possessions.
(i) The policy or certificate shall not
condition eligibility for any benefits on a prior hospitalization requirement
or condition eligibility for benefits provided in an institutional care setting
on the receipt of a higher level of care or condition eligibility of
noninstitutional benefits on the prior receipt of institutional care.
(j) The policy or certificate shall provide
in the incontestable provision in addition to the requirements of Insurance Law
section 3203(a)(3) or 3220(a)(1), as applicable:
(1) that a policy or certificate that has
been in force for at least six months but less than two years may be rescinded
or an otherwise valid claim for accelerated benefits may be denied upon a
showing of misrepresentation that is both material to the acceptance for
coverage and which pertains to the condition for which benefits are sought;
and
(2) if increases are permitted,
that any increase in the policy or certificate that has been in effect for at
least six months but less than two years which was applied for and subject to
evidence of insurability may be rescinded or an otherwise valid claim for
accelerated benefits on the amount of the increase may be denied upon a showing
of misrepresentation that is both material to the acceptance for coverage and
which pertains to the condition for which benefits are sought.
(k) The policy or certificate may
provide for a maximum monthly amount that may be accelerated, which maximum
amount may differ based on whether the insured is receiving qualified care
services at home or in a long-term care facility.
(l) The insurer shall provide the policyowner
or certificateholder with a report, at least monthly, of any benefits paid out
during the prior month, an explanation of any changes to the policy or
certificate, death benefits and cash values on account of the benefits being
paid out, and the amount of the remaining benefits that can be accelerated at
the end of the prior month. A calendar month or policy/certificate month may be
utilized.
(m) The policy or
certificate may provide that any option otherwise available to the insured to
accelerate less than all of the remaining death benefit on account of a
terminal illness diagnosis shall be suspended while the death benefit is being
so accelerated in accordance with the requirements of this section.
(n) The conversion benefit available pursuant
to Insurance Law section 3220(a)(6) or 3220(a)(7) shall include a benefit
comparable to the acceleration benefit. This requirement may be satisfied by a
separate policy or certificate. This requirement, subject to the approval of
the superintendent, may be satisfied by arrangement with another insurer to
provide the required coverage.
(o)
The policy or certificate may pay a daily per diem benefit without regard to
the amount of expenses the insured incurs for qualified long-term care
services, provided that:
(1) the policy or
certificate otherwise complies with all requirements of this section;
and
(2) the per diem benefit does
not exceed the maximum amount eligible under section
101(g)(3) of the Internal
Revenue Code and all other applicable sections of Federal law for favorable tax
treatment.
(p) In
addition to any of the requirements of Part 51 of this Title the following
shall apply:
(1) The insurer shall follow
procedures consistent with those contained in section
52.29 of this Title with respect
to determining whether the sale of any such policy or certificate is intended
to replace any other similar life policy or any other long-term care insurance,
nursing home insurance, home care insurance policy or coverage or long-term
care insurance policy or coverage provided under the Partnership for Long-Term
Care Program, as defined in Social Services Law section 367-f and Insurance Law
section 3229. An insurer that determines that any such policy is intended to
replace a similar life policy or any other long-term care insurance, nursing
home insurance or home care insurance policy or coverage or long-term care
insurance policy or coverage provided under the Partnership for Long-Term Care
Program, as defined in Social Services Law section 367-f and Insurance Law
section 3229, shall make the disclosures required by section
52.29 of this Title.
(2) The insurer shall follow procedures
consistent with those contained in section
52.29 of this Title with respect
to determining whether the sale of any life policy providing benefits subject
to this section or any other long-term care insurance, nursing home insurance,
home care insurance policy or coverage or long-term care insurance policy or
coverage provided under the Partnership for Long-Term Care Program, as defined
in Social Services Law section 367-f is intended to replace a policy or
certificate providing benefits subject to this section. An insurer that
determines that such sale is intended to replace a policy or certificate
providing benefits subject to this section shall make the disclosures required
by section
52.29 of this Title.
(3) If a group policy is replaced by another
group policy issued to the same policyholder, the succeeding insurer shall
offer coverage to all persons covered under the previous group policy on its
date of termination. Coverage provided or offered to individuals by the insurer
and premiums charged to persons under the new group policy shall not vary or
otherwise depend on the individual's health or disability status, claim
experience or use of long-term care services.
(q) When payment of an accelerated benefit
results in a pro rata reduction in cash value, the payment may be applied
toward repaying a portion of loan equal to a pro rata portion of any
outstanding policy loans, or may be applied entirely to pay qualified long-term
care expenses or distributed as long-term care payments, if disclosure of the
effect of acceleration upon any remaining death benefit, cash value or
accumulation account, policy loan and premium payments, including a statement
of the possibility of termination of any remaining death benefit, is provided
to the policyowner or certificateholder. The policyowner or certificateholder
shall provide written consent authorizing any other arrangement for the
repayment of outstanding policy loans.
(r) The insurer shall, in addition to
providing any other disclosures required by the applicable provisions of the
Insurance Law pertaining to life insurance or by other provisions of this Part,
provide the applicant with a disclosure statement or outline of coverage in the
form set forth in section 4980C of the Internal
Revenue Code, as amended, for those provisions under which the death benefit
may be so accelerated.
(s) The
policy summary required by Insurance Law section 3209 shall include, in
addition to all other required information:
(1) an explanation of how the accelerated
benefit interacts with other components of the policy, including deductions
from death benefits;
(2) an
explanation of the amount of benefits, the length of benefits, and the
guaranteed lifetime benefits if any, for each covered person;
(3) any exclusions, reductions and
limitations on the accelerated benefits; and
(4) if applicable to the policy type:
(i) a disclosure of the effects of exercising
other rights under the policy;
(ii)
a disclosure of guarantees related to the premium or charges for the
accelerated benefit; and
(iii)
current and projected maximum lifetime benefits.
If the policy or certificate is illustrated and such
illustration is used to satisfy the requirement of Insurance Law section 3209
for a policy summary in accordance with Part 53 of this Title, then such
illustration shall include the information listed in this
subdivision.
(t) The policy or certificate shall be clear
on how any increases or decreases in the face amount and/or death benefit other
than decreases due to the payment of an accelerated death benefit affect the
amount of the death benefit that may be accelerated.
(u)
(1) The
policy and certificate shall not be advertised or marketed as long-term care
insurance, nursing home insurance, home care insurance or long-term care
insurance provided under the Partnership for Long-Term Care Program, as defined
in Social Services Law section 367-f and Insurance Law section 3229. Any
advertisement, description, comparison, marketing material or illustration
shall state in bold that "This is a life insurance (policy)(certificate)
that accelerates the death benefit for qualified long-term care services (The
phrase "on account of chronic illness" may be substituted for the phrase "for
qualified long-term care services" for policies that are not intended to be
qualified long-term care insurance contracts for Federal tax purposes) and is
not a health insurance (policy)(certificate) providing long-term care insurance
subject to the minimum requirements of New York Law, does not qualify for the
New York State Long-Term Care Partnership Program and is not a Medicare
supplement (policy)(certificate)."
(2) An insurer may include in any
advertisement or marketing materials for such policies that are not intended to
be qualified long-term care insurance contracts for Federal tax purposes:
(i) a description of the benefits provided by
the policy, including a description of the acceleration of the death benefit to
pay for services when the insured has become chronically ill; and
(ii) a comparison between the benefits
provided by such policies and the benefits provided by long-term care
insurance.
(3) An insurer
may include in any advertisement or marketing materials for such policies that
are intended to be qualified long-term care insurance contracts for Federal tax
purposes:
(i) a statement that the policy or
certificate is intended to be a qualified long-term care insurance contract
under section 7702B of the Internal Revenue
Code;
(ii) a description of the
benefits provided by the policy, including a description of the acceleration of
the death benefit to pay for services when the insured has become chronically
ill; and
(iii) a comparison between
the benefits provided by such policies and the benefits provided by long-term
care insurance.
(v) Every insurer
marketing insurance under this section, directly or through its producers,
shall:
(1) establish marketing procedures to
ensure that any comparison of policies by its producers will be fair and
accurate;
(2) establish marketing
procedures to assure excessive insurance is not sold or issued;
(3) except as provided in paragraph (4) of
this subdivision, display prominently by type, stamp or other appropriate
means, on the first page of the outline of coverage and policy the following:
"Notice to buyer: This policy may not cover all of the
costs associated with long-term care incurred by the buyer during the period of
coverage. The buyer is advised to review carefully all policy
limitations";
(4) for
policies that accelerate death benefits pursuant to Insurance Law section
1113(a)(1)(C) and provide benefits on a per diem basis and are not intended to
be qualified long-term care insurance contracts for Federal tax purposes,
display prominently by type, stamp or other appropriate means, on the first
page of the outline of coverage and the policy the following:
"Notice to buyer: This policy may not cover all of the
costs associated with the chronic illness of the insured. The buyer is advised
to review carefully the policy benefits";
(5) inquire and otherwise make every
reasonable effort to identify whether a prospective applicant or enrollee
already has accident and sickness or long-term care insurance and the types and
amounts of any such insurance; and
(6) establish auditable procedures for
verifying compliance with paragraphs (1) through (5) of this
subdivision.
(w) The following acts and practices in the
sale of insurance under this section are prohibited:
(1) Twisting. Knowingly making any misleading
representation or incomplete or fraudulent comparison of any insurance policies
or insurers for the purpose of inducing, or tending to induce, any person to
lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or
convert any insurance policy or to take out a policy of insurance with another
insurer.
(2) High pressure tactics.
Employing any method of marketing having the effect of or tending to induce the
purchase of insurance through force, fright, threat, whether explicit or
implied, or undue pressure to purchase or recommend the purchase of
insurance.
(3) Cold lead
advertising. Making use directly or indirectly of any method of marketing that
fails to disclose in a conspicuous manner that a purpose of the method of
marketing is solicitation of insurance and that contact will be made by an
insurance producer or insurer.
(x)
(1) For
purposes of this subdivision,
association shall mean any
professional, trade or occupational association for its members or former or
retired members, or combination thereof, if the association:
(i) is composed of individuals all of whom
are or were actively engaged in the same profession, trade or occupation;
and
(ii) has been maintained in
good faith for purposes other than obtaining insurance.
(2) An insurer shall not issue insurance
under this section to an association, as defined in paragraph (1) of this
subdivision, or its members unless the insurer has filed with the
superintendent:
(i) the policy and
certificate;
(ii) a corresponding
outline of coverage;
(iii) all
advertisements; and
(iv) any other
material requested by the superintendent.
(3) The insurer shall certify to the
superintendent, before a new policy and the first certificate is issued, and
annually thereafter by December 31st:
(i)
that all compensation to the association complies with all applicable statutes
and regulations;
(ii) when making
insurance under this section available to its members, the association has:
(a) taken steps to educate its members
concerning long-term care issues so that its members can make informed
decisions; and
(b) furnished only
objective information as provided by the insurer regarding the policies or
certificates that are available to the association's members;
(iii) in any solicitation for
insurance under this section the solicitation:
(a) discloses the specific nature of any
compensation arrangements, including the amount that the association or any of
its related entities receives, with respect to the insurance;
(b) includes a brief description of the
process under which such policies or certificates and the insurer issuing such
policies or certificates were selected; and
(c) if the association and the insurer have
interlocking directorates or trustee arrangements, discloses such fact to the
members;
(iv) the board
of directors of an association making the insurance policies or certificates
available to its members has reviewed and approved such insurance policies or
certificates as well as the compensation arrangements made with the insurer;
and
(v) the association has:
(a) engaged the services of a licensed
insurance consultant or licensed insurance producer with expertise in long-term
care insurance not affiliated with the insurer to conduct an examination of the
policies and certificates, including benefits, features, and rates, at the time
of the association's decision to have the insurance made available to its
members and at the time of any material change;
(b) established procedures to actively
monitor the marketing efforts of the insurer and its agents; and
(c) reviewed and approved all marketing
materials or other insurance communications used to promote sales or sent to
members regarding the policies or certificates.
(4) This subdivision shall not apply to any
individual policy of life insurance issued to a member of an association where
the sale of the policy was entirely independent from the association.
(y) Except as otherwise provided
in Part 224 of this Title (Insurance Regulation 187), in recommending the
purchase or replacement of any policy or certificate issued under this section
a producer shall make reasonable efforts to determine the appropriateness of a
recommended purchase or replacement.
(z) Accelerated death benefit payments
subject to this section shall be designed such that, on a standalone basis, the
benefit payments will be subject to favorable tax treatment by the Federal
government. Accordingly, on a standalone basis, accelerated payments shall only
be made if they qualify under section
101(g)(3) of the Internal
Revenue Code and all other applicable sections of Federal law in order to
maintain favorable tax treatment. An insurer may, on a non-discriminatory
basis, coordinate the insurer's benefit payments with payments made by other
insurers, and may deny claims for payments that would not receive favorable tax
treatment by the Federal government.
(1) For
insurers that elect to coordinate benefits and that will only make payments if
the payments will receive favorable tax treatment by the Federal government,
the claim form to receive benefits pursuant to this section shall include the
following statement: "Benefit payments will only be made if the payments are
subject to favorable tax treatment by the Federal government. Receipt of
benefit payments from multiple policies exceeding the applicable limits may
result in tax consequences. Therefore, when determining whether the benefit
payments will receive favorable tax treatment, the payment of benefits from all
insurance policies must be considered."
(i)
The claim form shall include a question as to whether the insured is covered by
other insurance policies that will pay similar benefits.
(ii) The insurer shall have written
procedures for use during the claim handling process for confirming that the
benefit payments at the time of their payment are expected to receive favorable
tax treatment by the Federal government.
(2) For insurers that do not elect to
coordinate benefits, the claim form to receive benefits pursuant to this
section shall include the following statement: "Benefit payments may not be
subject to favorable tax treatment by the Federal government. When determining
whether the benefit payments will receive favorable tax treatment, the payment
of benefits from all insurance policies must be considered. Receipt of benefit
payments under multiple policies exceeding the applicable limits may result in
tax consequences. This insurer does not coordinate benefits to ensure that the
payments receive favorable tax treatment by the Federal government.
Accordingly, prior to applying for benefits, you should seek assistance from a
qualified tax advisor."
(aa) Policies or certificates that are
intended to be qualified long-term care insurance contracts for Federal tax
purposes shall provide the following protections against unintentional lapse:
(1) No individual policy or certificate shall
be issued until the insurer has received from the applicant either, a written
designation of at least one person, in addition to the applicant, who is to
receive notice of lapse or termination of the policy or certificate for
nonpayment of premium; or a written waiver dated and signed by the applicant
electing not to designate additional persons to receive notice. The applicant
has the right to designate at least one person who is to receive the notice of
termination, in addition to the insured. Designation shall not constitute
acceptance of any liability on the third party for services provided to the
insured. The form used for the written designation shall provide space clearly
designated for listing at least one person. The designation shall include each
person's full name and home address. In the case of an applicant who elects not
to designate an additional person, the waiver shall state: "Protection against
unintended lapse. I understand that I have the right to designate at least one
person other than myself to receive notice of lapse or termination of this
long-term care insurance policy for nonpayment of premium. I understand that
notice will not be given until thirty (30) days after a premium is due and
unpaid. I elect NOT to designate any person to receive such notice." The
insurer shall notify the insured of the right to change this written
designation, no less often than once every two years.
(2) When the policyowner or certificateholder
pays premium for the policy or certificate through a payroll or pension
deduction plan, the requirements contained in paragraph (1) of this subdivision
need not be met until 60 days after the policyowner or certificateholder is no
longer on such a payment plan. The application or enrollment form for such
policies or certificates shall clearly indicate the payment plan selected by
the applicant.
(3) No individual
policy or certificate shall lapse or be terminated for nonpayment of premium
unless the insurer, at least 30 days before the effective date of the lapse or
termination, has given notice to the insured and to those persons designated to
receive notice, at the address provided by the insured for purposes of
receiving notice of lapse or termination. Notice shall be given by first class
United States mail, postage prepaid; and notice may not be given until 30 days
after a premium is due and unpaid. Notice shall be deemed to have been given as
of five days after the date of mailing.
(4) In addition to the requirements of
Insurance Law section 3203(a)(10), the policy or certificate shall include a
provision which provides for reinstatement of coverage, in the event of lapse
if the insurer is provided proof of the policyowner's or certificateholder's
cognitive impairment or the loss of functional capacity. This option shall be
available to the insured if requested within five months after termination and
shall allow for the collection of past due premium, where appropriate. The
standard of proof of cognitive impairment or loss of functional capacity shall
not be more stringent than the benefit eligibility criteria on cognitive
impairment or the loss of functional capacity, if any, contained in the policy
and certificate.
(ab) For
policies or certificates that are intended to be qualified long-term care
insurance contracts for Federal tax purposes the insurer shall provide the
following:
(1) Except for riders or
endorsements by which the insurer effectuates a request made in writing by the
insured under a policy, all riders or endorsements added to a policy after date
of issue or at reinstatement or renewal which reduce or eliminate benefits or
coverage in the policy shall require signed acceptance by the individual
insured.
(2) After the date of
policy issue, any rider or endorsement which increases benefits or coverage
with a concomitant increase in premium during the policy term shall be agreed
to in writing signed by the insured, except if the increased benefits or
coverage are required by law.
(3)
Where a separate additional premium is charged for benefits provided in
connection with riders or endorsements, such premium charge shall be set forth
in the policy, rider or endorsement.
(ac) For policies or certificates that are
intended to be qualified long-term care insurance contracts for Federal tax
purposes the insurer shall be subject to the following:
(1) insurers, whether or not they have
obtained information concerning the applicant's health condition prior to the
issuance of the policy or certificate, are prohibited from post-claim
underwriting;
(2) if an insurer
requests information on an application concerning medications being taken by
the applicant and the medications listed in such application were known to the
insurer, or should have been known by the insurer at the time of application to
be directly related to a medical condition for which coverage would have been
otherwise denied, then the policy or certificate shall not be rescinded for
that condition; and
(3) except for
policies or certificates that are guaranteed issue:
(i) the following language shall be set out
in bold type, conspicuously and in close conjunction with the applicant's
signature block on an application for a policy or enrollment form for a
certificate:
Caution: If your answers on this
(application)(enrollment form) fail to include all material information
requested, (company) has the right to deny benefits or rescind your
(policy)(certificate).; and
(ii) the following language, or language
substantially similar to the following, shall be set out conspicuously in bold
type on the policy or certificate at the time of delivery:
Caution: The issuance of this (policy)(certificate)
is based upon your responses to the questions on your (application)(enrollment
form). A copy of your (application)(enrollment form) (is enclosed)(was retained
by you when you applied). If your answers fail to include all material
information requested, the company has the right to deny benefits or rescind
your (policy)(certificate). The best time to clear up any questions is now,
before a claim arises! If for any reason, any of your answers are incorrect,
contact the company at this address: (insert address).
(4) A copy of the completed
application or enrollment form (whichever is applicable) shall be delivered to
the insured no later than at the time of delivery of the policy or certificate
unless it was retained by the applicant at the time of application.
(5) Prior to the issuance of a policy or
certificate to an applicant age 80 or older, the insurer shall obtain one or
more of the following:
(i) a report of a
physical examination;
(ii) an
assessment of functional capacity;
(iii) an attending physician's statement;
or
(iv) copies of medical
record.
(ad)
Every insurer selling or issuing policies or certificates that are intended to
be qualified long-term care insurance contracts for Federal tax purposes shall
maintain a record of all policy or certificate rescissions, both State and
countrywide, except those which the insured voluntarily effectuated and shall
annually furnish this information in the format prescribed by the
superintendent.
(ae) For policies
or certificates that are intended to be qualified long-term care insurance
contracts for Federal tax purposes the insurer shall comply with the following:
(1) a policy shall not, if it provides
benefits for home health care or community care services, limit or exclude
benefits:
(i) by requiring that the
insured/claimant would need care in a skilled nursing facility if home health
care services were not provided;
(ii) by requiring that the insured/claimant
first or simultaneously receive nursing and/or therapeutic services in a home,
community or institutional setting before home health care services are
covered;
(iii) by limiting eligible
services to services provided by registered nurses or licensed practical
nurses;
(iv) by requiring that a
nurse or therapist provide services covered by the policy that can be provided
by a home health aide, or other licensed or certified home care worker acting
within the scope of his or her licensure or certification;
(v) by excluding coverage for personal care
services provided by a home health aide;
(vi) by requiring that the provision of home
health care services be at a level of certification or licensure greater than
that required by the eligible service;
(vii) by requiring that the insured/claimant
have an acute condition before home health care services are covered;
(viii) by limiting benefits to services
provided by Medicare-certified agencies or providers; and
(ix) by excluding coverage for adult day care
services.
(2) A policy,
if it provides for home health or community care services, shall provide total
home health or community care coverage that is a dollar amount equivalent to at
least one-half of one year's coverage available for nursing home benefits under
the policy or certificate, at the time covered home health or community care
services are being received. This requirement shall not apply to policies
issued to residents of continuing care retirement communities.
(3) Home health care coverage may be applied
to the nonhome health care benefits provided in the policy or certificate when
determining maximum coverage under the terms of the policy or
certificate.
(af) For
policies or certificates that are intended to be qualified long-term care
insurance contracts for Federal tax purposes, the termination of the
accelerated death benefits shall be without prejudice to any benefits payable
for any claim pursuant to Insurance Law section 1113(a)(1)(C) or (D) if such
claim began while the accelerated death benefits were in force and continues
without interruption after termination. Such extension of benefits beyond the
period the insurance was in force may be limited to the duration of the benefit
period, if any, or to payment of the maximum benefits and may be subject to any
policy waiting period, and all other applicable provisions of the
policy.
(ag) For policies or
certificates that are intended to be qualified long-term care insurance
contracts for Federal tax purposes the insurer shall maintain records of
replacement sales and the number of lapses of such policies and certificates as
set forth in section 4980C of the Internal
Revenue Code as amended.
