N.Y. Comp. Codes R. & Regs. tit. 11 § 52.12

Current through Register Vol. 46, No. 45, November 2, 2024

Section 52.12 - Long term care insurance

(a) Long term care insurance is an insurance policy, rider, or certificate advertised, marketed, offered or designed to provide coverage, subject to eligibility requirements, for not less than 24 consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis and provides at least the benefits set forth in either paragraph (1), (2) or (3) of this subdivision or a combination of the benefits set forth in paragraphs (1), (2) and (3) as approved by the superintendent:

(1) Option I:

(i) Coverage of all levels of care in a nursing home of at least $100 per day; except that such $100 may be reduced to at least $70 per day for policies or certificates issued for delivery outside the metropolitan area.

(ii) Coverage of home care of at least 50 percent of the daily indemnity amount provided for care in a nursing home.

(2) Option II:

(i) Coverage of all levels of care in a nursing home at no less than 60 percent of reasonable charges.

(ii) Coverage of home care at no less than 60 percent of reasonable charges.

(3) Option III:

(i) Coverage of all levels of care in a nursing home which has contracted with an insurer to provide services to their policyholders or certificateholders, at no less than 75 percent of the negotiated rate. For noncontracting nursing homes, payment may be made at no less than 50 percent of the reasonable charge or $55 per day, whichever is less.

(ii) Coverage of home care by a home care provider which has contracted with an insurer to provide services to their policyholders or certificateholders, at no less than 75 percent of the negotiated rate. For noncontracting home care providers, payment may be made at no less than 50 percent of the reasonable charge or $30 per day, whichever is less.

(b) A group policy which offers options, one of which includes at least the benefits set forth in subdivision (a) of this section, may be labelled long term care insurance, however, certificates providing coverage that does not comply with subdivision (a) of this section must be labelled nursing home insurance only, home care insurance only or nursing home and home care insurance, as applicable.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.12