2023 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
* NB Effective until January 1, 2024
* (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;
* NB Effective January 1, 2024
* (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.
* NB Effective until January 1, 2024
* (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;
* NB Effective January 1, 2024
* (G)   (i)  A  written  statement  indicating  that  such  policy  or
certificate may be subject to future premium  rate  increases  and  that
such  rate increases shall be subject to the approval or modification of
the superintendent; and
(ii) A list  of  past  premium  rate  increases  for  such  policy  or
certificate   over  the  previous  ten  years,  or  if  such  policy  or
certificate was not offered over the previous ten  years,  past  premium
rate  increased for policies or certificates that offer similar benefits
over the previous ten years;
* NB Effective January 1, 2024
* (H) Directions on how to obtain information about  the  department's
review  of  any  rate filing or application, contact information for the
department, and information on how to contact  the  authorized  insurer,
corporation,   health  maintenance  organization  or  fraternal  benefit
society for more information;
* NB Effective January 1, 2024
* (I) Whether or not there is a period in which rates will not change,
and if so, when that time period expires;
* NB Effective January 1, 2024
* (J) A description of whether or not the premium may change,  and  if
so,  the circumstances under which any such premium changes could occur,
including whether the department must approve such changes;
* NB Effective January 1, 2024
* (K) Whether the policy contains provisions providing for a refund or
partial refund of premium upon the cancellation of the  policy,  and  if
such provisions exist, provide a description of their terms;
* NB Effective January 1, 2024
* (L) A description of the options policyholders will have to mitigate
any premium increases;
* NB Effective January 1, 2024
* (M)  A description of the options policyholders will have should the
premiums increase, and the policyholder deems it in their best  interest
to cancel the policy;
* NB Effective January 1, 2024
* (N)  A statement that the policyholder will be given at least ninety
days notice before any premium change takes effect;
* NB Effective January 1, 2024
* (O) A statement that if the authorized insurer, corporation,  health
maintenance  organization or fraternal benefit society seeks to increase

the premium rate, the department will post notice of the rate filing  on
its website prior to any determination by the department; and
* NB Effective January 1, 2024
* (P)  The  right of the prospective insured to submit public comments
on any rate  filing  or  application  regarding  premium  rates  on  the
department's website.
* NB Effective January 1, 2024
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.
* (h) The department shall post on its website information  describing
the  process  that  it uses in reviewing and approving premium rates for
policies or contracts of long term care insurance.
* NB Effective January 1, 2024
* (i) Whenever an authorized insurer, corporation, health  maintenance
organization  or  fraternal  benefit  society  submits  a rate filing or
application to the superintendent to increase or decrease premium  rates
for   any   policy   or   certificate   subject  to  this  section,  the
superintendent shall  post  a  public  notice  of  the  rate  filing  or
application  on  the  department's  website  within  fourteen  days. The
superintendent shall provide for a process for  the  public  to  provide
comments on such rate filing or application electronically or in writing

for  a  period  of thirty days after such public notice is posted on the
department's website.
* NB Effective January 1, 2024
* (j)   The   superintendent,  upon  rendering  a  decision  regarding
approval, disapproval or modification of a rate filing  or  application,
shall  issue a public notice of such decision. Such written decision and
notice shall be made publicly available on the department's  website  no
later than the date on which the rate filing or application is approved,
disapproved, or modified. Such notification shall include:
(1)  a  summary  of the determinations made and considerations used by
the department regarding the approval, disapproval  or  modification  of
such rate filing or application, and
(2)  a  statement  with  relevant  detail  as  to  why  the  approval,
disapproval or modification of the proposal is consistent with paragraph
three of subsection (f) of this section.
* NB Effective January 1, 2024
* (k) Upon receipt  by  an  authorized  insurer,  corporation,  health
maintenance  organization  or  fraternal  benefit society covered by the
provisions of this section of an approval or  modification  decision  by
the  superintendent  with  respect to a rate filing application with the
department, such authorized  insurer,  corporation,  health  maintenance
organization or fraternal benefit society shall notify policyholders and
certificate  holders of such decision no later than ninety days prior to
the effective date of the premium rate increase. Such notification shall
include:
(1) a description of such decision; and
(2) a written statement conforming to the requirements  set  forth  in
subparagraph (G) of paragraph six of subsection (b) of this section.
* NB Effective January 1, 2024
* (l)  The  provisions  set forth in subparagraphs (G), (H), (I), (J),
(K), (L), (M), (N), (O), and (P) of paragraph six of subsection  (b)  of
this section shall not apply to policies or certificates that are exempt
from premium rate increases.
* NB Effective January 1, 2024