N.Y. Comp. Codes R. & Regs. tit. 11 § 39.5

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

Section 39.5 - Minimum benefit standards for qualified policies/certificates for the 4/4/100 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. 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.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 39.5

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