431:10-116
Insurance Code
[§431:10H-116] Nonforfeiture benefits. (a) Except as provided in subsection (b), a long-term care insurance policy shall not be delivered or issued for delivery in this State unless the policyholder or certificate holder has been offered an option to purchase a policy or certificate that includes a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. If the policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates.
(b) For a group long-term care insurance policy, the offer of a nonforfeiture benefit under subsection (a) shall be made to the group policyholder. However, if the policy is issued as a group long-term care insurance, other than to a continuing care retirement community or other similar entity, the offering shall be made to each proposed certificate holder.
© The commissioner shall adopt rules to specify the type of nonforfeiture benefits to be offered as part of long-term care insurance policies or certificates, the standards for nonforfeiture benefits, and the rules for contingent benefit upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse shall be available and the substantial premium rate increase that triggers a contingent benefit upon lapse as provided in subsection (a). [L 1999, c 93, pt of §2] whenever the policy provides reimbursement or payment for any service, which is within the lawful scope of practice of a psychologist licensed in this State, the person entitled to benefits or performing the service shall be entitled to reimbursement or payment, whether the service is performed by a licensed physician or licensed psychologist;
(4) Notwithstanding any provision to the contrary, each policy, contract, plan, or agreement issued on or after February 1, 1991, except for policies that only provide coverage for specified diseases or other limited benefit coverage, but including policies issued by companies subject to chapter 431, article 10A, part II and chapter 432, article 1 shall provide coverage for screening by low-dose mammography for occult breast cancer as follows:
(A) For women forty years of age and older, an annual mammogram; and
(B) For a woman of any age with a history of breast cancer or whose mother or sister has had a history of breast cancer, a mammogram upon the recommendation of the woman’s physician.
The services provided in this paragraph are subject to any coinsurance provisions that may be in force in these policies, contracts, plans, or agreements.
For the purpose of this paragraph, the term “low-dose mammography” means the x-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast. An insurer may provide the services required by this paragraph through contracts with providers; provided that the contract is determined to be a cost-effective means of delivering the services without sacrifice of quality and meets the approval of the director of health;
(5) (A) (i) Notwithstanding any provision to the contrary, whenever a policy, contract, plan, or agreement provides coverage for the children of the insured, that coverage shall also extend to the date of birth of any newborn child to be adopted by the insured; provided that the insured gives written notice to the insurer of the insured’s intent to adopt the child prior to the child’s date of birth or within thirty days after the child’s birth or within the time period required for enrollment of a natural born child under the policy, contract, plan, or agreement of the insured, whichever period is longer; provided further that if the adoption proceedings are not successful, the insured shall reimburse the insurer for any expenses paid for the child; and
(ii) Where notification has not been received by the insurer prior to the child’s birth or within the specified period following the child’s birth, insurance coverage shall be effective from the first day following the insurer’s receipt of legal notification of the insured’s ability to consent for treatment of the infant for whom coverage is sought; and
(B) When the insured is a member of a health maintenance organization (HMO), coverage of an adopted newborn is effective:
(i) From the date of birth of the adopted newborn when the newborn is treated from birth pursuant to a provider contract with the health maintenance organization, and written notice of enrollment in accord with the health maintenance organization’s usual enrollment process is provided within thirty days of the date the insured notifies the health maintenance organization of the insured’s intent to adopt the infant for whom coverage is sought; or
(ii) From the first day following receipt by the health maintenance organization of written notice of the insured’s ability to consent for treatment of the infant for whom coverage is sought and enrollment of the adopted newborn in accord with the health maintenance organization’s usual enrollment process if the newborn has been treated from birth by a provider not contracting or affiliated with the health maintenance organization; and
(6) Notwithstanding any provision to the contrary, any policy, contract, plan, or agreement issued or renewed in this State shall provide reimbursement for services provided by advanced practice registered nurses licensed pursuant to chapter 457. Services rendered by advanced practice registered nurses are subject to the same policy limitations generally applicable to health care providers within the policy, contract, plan, or agreement. [L 1987, c 347, pt of §2; am L 1990, c 112, §2; am L 1991, c 268, §§1, 5; am L 1994, c 279, §3; am L 1995, c 47, §1; am L 1999, c 13, §2 and c 222, §3; am L 2002, c 155, §55; am L 2015, c 35, §45]
Note
Director of health to monitor mammogram screening services to assure that the demand for screening does not exceed the ability of the medical community to safely provide the services. L 1990, c 112, §5.
Sunset evaluations modified, see §§26H-4, 5.
Civil relief for state military forces, see chapter 657D.
Federally funded programs, see §431:10A-602.
Newborn adopted children, see §432:1-602.6.
Risk-based capital for insurers, see §§431:3-401 to 414.