NY Ins L § 1117 (2021)
2021 New York Laws ISC - Insurance Article 11 - Licensing of Insurers 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;  (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; and  (F)  The  right  of the prospective insured, upon attaining the age of sixty-five years, to designate a third party who will receive a copy  of any  notices of nonpayment of premiums due or notice of cancellation for nonpayment of premiums that is sent to the prospective insured. 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.