N.Y. Comp. Codes R. & Regs. tit. 11 § 39.4

Current through Register Vol. 46, No. 51, December 18, 2024

Section 39.4 - Minimum benefit standards for qualified policies/certificates for the 1.5/3/50 plan design

(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, but no more than a 2.5/5/50 (maximums of 2.5 years of nursing home coverage and 5 years of home care coverage) plan design shall be offered under this section. 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 under section 39.6 of this Part to the prospective insured at the same time.

(b) Minimum benefit standards for the 1.5/3/50 plan design. To be approved as a qualified policy/certificate under this section, a policy/certificate shall provide coverage on an expense incurred basis for 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 18 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:

(i) January 1, 2024 - $ 387 (nursing home), $ 193 (home care - 50 percent);

(ii) January 1, 2025 - $ 401 (nursing home), $ 200 (home care - 50 percent);

(iii) January 1, 2026 - $ 415 (nursing home), $ 207 (home care - 50 percent);

(iv) January 1, 2027 - $ 430 (nursing home), $ 215 (home care - 50 percent);

(v) January 1, 2028 - $ 445 (nursing home), $ 222 (home care - 50 percent);

(vi) January 1, 2029 - $ 461 (nursing home), $ 230 (home care - 50 percent);

(vii) January 1, 2030 - $ 477 (nursing home), $ 238 (home care - 50 percent);

(viii) January 1, 2031 - $ 494 (nursing home), $ 247 (home care - 50 percent);

(ix) January 1, 2032 - $ 511 (nursing home), $ 255 (home care - 50 percent);

(x) January 1, 2033 - $ 529 (nursing home), $ 264 (home care - 50 percent).

(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.

(i) Home care benefits shall be provided for at least the following services: skilled nursing care, home health care, personal care, assisted living 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 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 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. Complete substitution of home care benefits for nursing home care benefits would result in a lifetime maximum total of 36 months of home care benefits.

(iii) The minimum home care coverage to be offered will 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 care coverage amount shall continue to be the minimum home care benefit standard regardless of the amount of nursing home coverage actually purchased.

(iv) Home care coverage which exceeds the minimum benefit standards shall not affect the requirement for a lifetime maximum total of 36 months of home care benefits.

(3) 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 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 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 and/or home 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.

(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 60 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.

(c) Additional and optional feature. The following long-term care payment feature may be offered in a qualified policy/certificate:

(1) At the discretion of the insurer, it shall be permissible to combine home care benefit days to pay an amount in excess of the home care daily benefit amount set forth in the policy/certificate. In no case where home care benefit days have been combined shall the equivalent of more than 31 days of home care benefits be provided in any one-month period. If the insurer offers this payment feature, each prospective insured must also be offered a minimum 1.5/3/50 plan without this payment feature.

(d) Tax qualification. Qualified policies/certificates for the 1.5/3/50 plan design shall meet the standards required under Federal and New York State laws and regulations for favorable tax qualification status for an expense incurred policy/certificate. A policy/certificate offering coverage on a per diem or other periodic basis (as permitted by the Internal Revenue Code) does not meet the standard set forth in subdivision (b) of this section for expense incurred coverage and is not permitted for this plan design.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 39.4

Amended New York State Register January 3, 2024/Volume XLVI, Issue 1, eff. 1/3/2024