Section 1117. Health insurance plans for long term care  


Latest version.
  • (a) An authorized
      insurer subject to the provisions of this chapter and organized to write
      the kind of insurance specified in paragraph three of subsection (a)  of
      section one thousand one hundred thirteen of this article, a corporation
      or  health  maintenance  organization  authorized  pursuant  to  article
      forty-three of this chapter or article forty-four of the  public  health
      law,  and a fraternal benefit society organized under article forty-five
      of this chapter, may  be  authorized  by  the  superintendent  to  issue
      contracts  in  connection  with  plans  providing benefits for long term
      care, provided such plans satisfy the criteria set forth  in  subsection
      (b)  of  this section and the superintendent has made the determinations
      set forth in subsection (f) of this section.
        (b) The superintendent may authorize such contracts in connection with
      a plan for long term care pursuant to the following criteria:
        (1) the plan's provisions are not misleading or confusing;
        (2) the plan's provisions are not inconsistent with the needs  of  the
      public;
        (3) the plan's benefit structure provides options for use of long term
      care services;
        (4)  the  plan,  the  contract and other materials describing the plan
      fully and clearly state the benefits and limitations of such plan;
        (5)  the  authorized  insurer,  health  maintenance  organization,  or
      fraternal  benefit  society  agrees  to  provide  such  reports  of  the
      experience of the plan as may be requested by  the  superintendent.  The
      superintendent  may  prepare  abstracts and summaries of such reports at
      the request of other government agencies for purposes  of  research  and
      studies  related  to long term care financing, provided however that the
      insurer, health maintenance organization, or fraternal  benefit  society
      may  request  that  specified  information  included  in  the  report be
      considered confidential; and
        (6) prior to the earlier of the execution of a policy  or  certificate
      in connection with a plan providing a home care benefit and/or a nursing
      home  benefit,  or  the  payment of any premium or fee related to such a
      policy or  certificate,  the  authorized  insurer,  corporation,  health
      maintenance  organization or fraternal benefit society shall provide the
      prospective insured or his  or  her  representative  with  a  disclosure
      statement, which contains the following:
        (A)  The  maximum  daily  and  lifetime benefit levels, if applicable,
      provided by the policy or certificate for home care services and nursing
      home services;
        (B) The percentage of coverage provided for  home  care  services  and
      nursing  home  services,  if  applicable,  and  an  explanation  of  the
      methodology on which the reasonable charge used in conjunction with such
      percentage amount is based;
        (C) A description of any inflation protection feature included  in  or
      available   for  purchase  under  the  policy  or  certificate  and  the
      additional premium required to purchase such option or options;
        (D) (i) If available and accessible by the  insurer  or  other  entity
      from  the  department  of  health,  the most recently-published average,
      statewide rate for care in a nursing home, as well as the average  rates
      for  care  in  nursing homes for both the New York city-metropolitan and
      upstate regions of the state; or
        (ii) If available and accessible by the insurer or other  entity  from
      the  department  of  health,  the  most  recently-published  map  of the
      estimated average regional rates in New  York  state  for  nursing  home
      care; and
        (E)  A graphic demonstration of the maximum daily nursing home benefit
      level provided by the policy or certificate, and  the  impact  that  the
    
      selection of any inflation protection options would have on such maximum
      daily nursing home benefit level.
      For  the  purpose of this paragraph, "home care services" shall have the
      same meaning as defined in subdivision one of section thirty-six hundred
      two of the public health law. The prospective insured,  or  his  or  her
      representative,  shall acknowledge that the required disclosure has been
      made by signing the disclosure statement prior to  or  contemporaneously
      with the effective date of the policy or certificate.
      Failure  to  provide  information  required  by subparagraph (D) of this
      paragraph shall not be construed as a violation of this section if  such
      information has not been made available by the department of health.
        (c)  The  duration  of  such  contracts  and  the  extent  of exposure
      thereunder by insurers, health maintenance  organizations  or  fraternal
      benefit societies shall be in the discretion of the superintendent.
        (d)  Contracts issued pursuant to the provisions of this section shall
      be subject to all other provisions of this chapter and  the  regulations
      promulgated  thereunder  applicable  to  the insurer, health maintenance
      organization, or fraternal benefit society which  issues  the  contract,
      provided  however  that  in order to permit the development of long term
      care plans, the superintendent may modify or suspend any such  provision
      or regulation upon making the determinations set forth in subsection (f)
      of this section.
        (e)  The  superintendent  may  permit  an  authorized  insurer, health
      maintenance organization, or fraternal benefit society  subject  to  the
      provisions  of  this  chapter to reinsure the risk of any long term care
      services plan, provided such plan satisfies  the  requirements  of  this
      section.  Such reinsurance agreements shall provide for the payment of a
      reasonable premium.
        (f) The superintendent may take the actions set forth  in  subsections
      (a),  (d)  and (e) of this section only if the superintendent determines
      that:
        (1) the plan is a legitimate approach to expand  the  availability  of
      insurance coverage for long term care services;
        (2)  any  proposed  modification  or suspension of a provision of this
      chapter or a regulation  promulgated  thereunder  is  essential  to  the
      development  of  long  term  care plans pursuant to this section, and is
      directly related to the essential features of such plans;
        (3) the premium rates for the  long  term  care  plan  are  reasonably
      related to the benefits provided, and are self-supporting; and
        (4) the plan proposed by the insurer, health maintenance organization,
      or   fraternal   benefit  society,  and  any  proposed  modification  or
      suspension pursuant to subsection (d) of this section, will not cause or
      constitute  an  impairment  of   the   insurer's,   health   maintenance
      organization's,  or  fraternal  benefit society's ability to satisfy its
      existing and anticipated contracts and other obligations, including such
      standards as the  superintendent  shall  prescribe  concerning  adequate
      capital and financial requirements.
        (g) (1) Except for certain group contracts described in paragraph four
      of  this  subsection,  in  order for premium payments for long-term care
      insurance to  qualify  for  purposes  of  section  one  hundred  ninety,
      subdivision twenty-five-a of section two hundred ten, subsection (aa) of
      section  six  hundred  six,  subsection (k) of section one thousand four
      hundred fifty-six and  subsection  (m)  of  section  one  thousand  five
      hundred  eleven  of  the  tax  law, the long-term care insurance must be
      approved by the superintendent pursuant to  this  subsection.  Prior  to
      approving  any such insurance, the superintendent shall conclude that it
      meets minimum standards, including minimum loss  ratio  standards  under
      this  section  or section three thousand two hundred twenty-nine of this
    
      chapter and is a qualified long-term care insurance contract as  defined
      in section 7702B of the internal revenue code.
        (2)  (A)  No  insurer,  agent, broker, person, business or corporation
      doing business in  or  into  this  state  shall  in  any  manner  state,
      advertise  or claim that a long-term care insurance policy qualifies for
      purposes of the  above-referenced  provisions  of  the  tax  law  unless
      either:  (i)  the  superintendent  has  issued a letter or other written
      instrument to the insurer stating that the policy has been determined to
      qualify under this  subsection,  or  (ii)  the  policy  qualifies  under
      paragraph  four  of this subsection without the need for approval by the
      superintendent.
        (B) Any policy which is held out or purported to be a  long-term  care
      insurance  policy  by  any  insurer,  agent, broker, person, business or
      corporation doing business in or into this  state  which  has  not  been
      determined  by  the superintendent to qualify and which does not qualify
      under paragraph four of  this  subsection  for  purposes  of  the  above
      referenced provisions of the tax law shall so state clearly, legibly and
      in  close  physical  proximity  to  any  description  of the policy as a
      long-term care insurance policy  that  it  does  not  so  qualify.  This
      subsection shall also be deemed to cover any statement, advertisement or
      claim  concerning  such  policy  by  any insurer, agent, broker, person,
      business or corporation doing business in or into this state.
        (C)   Violation   of   this   paragraph   shall   be   considered    a
      misrepresentation  under section twenty-one hundred twenty-three of this
      chapter.
        (3) The  superintendent  shall  maintain  an  ongoing  list  of  those
      policies  requiring  approval  of  the  superintendent  that  are  found
      eligible for purposes of the above-referenced provisions of the tax law.
        (4) Group contracts delivered or issued for delivery  outside  of  the
      state,  but  which  are  qualified long-term care insurance contracts as
      defined in section 7702B of the internal revenue code shall be deemed to
      qualify for purposes of the provisions  of  the  tax  law  specified  in
      paragraph  one  of this subsection without the need to seek the approval
      of the superintendent pursuant to this subsection.  Provided  that  they
      otherwise  meet the requirements of this paragraph, such group contracts
      include, but are not limited to,  those  offered:  (a)  by  professional
      associations  and societies, membership organizations and not-for-profit
      groups, or by a subsidiary or affiliated entity of any of the foregoing,
      to the members of the association, society, organization or  group,  and
      (b) by employers to their employees.