1117 - Health insurance plans for long term care.
§ 1117. Health insurance plans for long term care. (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 theselection 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 thischapter 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.