NAC687B.095. Extension of benefits; continuation or conversion of coverage.

     1. Any termination of long-term care insurance must be without prejudice to any benefits payable for institutionalization if the institutionalization began while the long-term care insurance was in force and continues without interruption after termination.

     2. Such an extension of benefits beyond the period the long-term care insurance is in force may be limited to the duration of the benefit period, if any, or to payment of the maximum benefits, and may be subject to any waiting period contained in the long-term care insurance contract or any other applicable provision of the long-term care insurance contract.

     3. An insurer or similar organization issuing a group long-term care insurance contract shall include in the group long-term care insurance contract:

     (a) The basis for continuation of coverage; or

     (b) The basis for conversion of coverage.

     4. A group long-term care insurance contract which restricts the provision of benefits and services to certain providers or facilities or which contains incentives to use certain providers or facilities may comply with subsection 3 by containing a provision for the continuation of coverage under a long-term care insurance contract which provides benefits which are substantially equivalent to the benefits of the existing group long-term care insurance contract. The Commissioner shall make a determination as to the substantial equivalency of benefits, and in doing so, may take into consideration the differences between plans with and without managed care, including, but not limited to, the arrangement of providing benefits under the plans, the availability of service under the plans, the levels of benefits under the plans and the administrative complexity of the plans.

     5. As used in this section, “plan with managed care” means an arrangement for health care or assisted living designed to coordinate care of patients or to control costs through a system that provides, at a minimum, for review of the necessity and appropriateness of the allocation of health care resources and services provided or proposed to be provided to an insured, through management of cases or through use of specific networks of providers.

     (Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; R028-10, 12-16-2010, eff. 10-1-2011)