Abbreviated Underwriting
In this type of underwriting, the long term care insurance application asks few
health-related questions which are designed to determine who may be immediately
eligible for benefits, or eligible for benefits within a short period of time.
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Activities of Daily Living (ADLs)
The basic activities of caring for oneself:
- Eating
- Dressing
- Bathing
- Toileting (using the bathroom)
- Transferring (moving back and forth from a bed to a chair)
- Continence (the ability of the body to control
urination or bowel movements or both)
Insurance companies use the inability to perform a specified number of these
ADLs to help determine eligibility for long term care insurance benefits.
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Acute Care
Care provided by a doctor or other health care professional designed to treat or
cure an illness, wound, or condition. Long term care is not acute care.
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Adult Day Care
A program of activities and services provided to individuals in need of long
term care. It is a helpful option for individuals living at home whose family
caregivers work and who require someone to be with them throughout the day.
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Alternate Plan of Care
In certain circumstances, benefits for services that are not specifically
covered under a long term care insurance plan can be authorized. For example, if
the Comprehensive Option under the FLTCIP is chosen, services to make the
insured's home wheel-chair accessible may be approved.
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Alzheimer's Disease
A progressive neurological disease that affects brain functions, including
short-term memory loss, inability to reason, the deterioration of language,
and the inability to care for oneself.
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Annuitant
A person that receives or is qualified to receive an annuity. In the context of
the FLTCIP, it is a person as defined by the Act a 5 U.S.C. 9001(2), including
Federal annuitants, surviving spouses of deceased Federal or U.S. Postal Service
employees who are receiving a Federal survivor annuity, and individuals
receiving compensation from the Department of Labor who are separated from
Federal service.
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Assisted Living Facility
A licensed residential facility that provides room, board and 24 hour personal
care to individuals with long term care needs. It is an important care option for
individuals who are not able to manage at home but do not need the level of
skilled care provided in a nursing home.
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Automatic Compound Inflation (ACI)
An inflation protection feature that helps premiums remain constant while
benefits increase by a fixed percentage each year. Under the FLTCIP, benefits
increase automatically by 5% compounded annually with no corresponding increase in premium.
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Bed Reservations
A benefit which pays the nursing home, assisted living facility or hospice
facility to hold the insured's bed during a temporary absence so that the
insured may return to the facility.
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Benefit(s)
Payment an insurance company makes for a service covered under an insurance
plan.
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Benefit Amount
The maximum an insurance company will pay for covered service per a designated
unit of time (usually per day, per week, or per month).
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Benefit Booklet
The document
you receive from Long Term Care Partners if you apply for coverage and your application
is approved. This Booklet, together with your schedule of benefits,
describes your coverage under the Federal Program.
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Benefit Period
The length of time the insurance will last if the insured receives care every
day which is reimbursed at a level equal to or more than the daily (or weekly)
benefit amount (DBA). If the reimbursement is less than the DBA, the insurance
will last longer than the benefit period. The benefit period is used together
with the DBA to calculate the maximum lifetime benefit.
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Benefit Trigger
A term used by insurance companies for the requirements you must meet in order
to become eligible for benefits. Benefits would actually be payable after you
meet the benefit trigger and satisfy the required waiting period.
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Care Coordination Services
Services such as information, advice, and arranging of long term care by a
professional care coordinator.
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Care Coordinator
A person, sometimes a registered nurse (RN), working on behalf of the insurance company
to perform care coordination services. This often includes, but is not limited
to, selecting physicians, specialists, care centers, etc.
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Caregiver
A caregiver is the person who helps you accomplish the basic everyday activities
you can no longer manage without assistance, due to illness, injury,
cognitive impairment, or the natural aging process.
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Caregiver Training
Training given to an informal provider who has not received formal training or
has no experience providing this type of care.
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Catastrophic Event
An event or
series of events affecting such a significant number of enrollees that it
threatens to undermine the financial stability of the FLTCIP.
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Certificate of Insurance
A statement given to the insured stating the insurance benefits and terms.
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Chronic Care
Care provided to help maintain daily function. There is no expectation that the
care recipient will improve or recover. Long term care is chronic care.
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Chronically Ill
A condition that is verified by a physician that renders the individual
unable to perform at least two of the activities of daily living or the person
has a severe cognitive impairment from which the
person is not expected to improve or recover.
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Claim
A submitted request to the insurance company by the claimant to receive payment
and/or reimbursement for expenses covered under the claimant's policy.
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Cognitive Impairment
A deterioration or loss in intellectual capacity that results in impairment in
some or all of the following: short and long-term memory, orientation to people,
place, and time, deductive or abstract reasoning (including judgment), and
ability to perform activities of daily living.
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Commission
A part of the premium that is paid to the insurance agent or
broker. The Federal Long Term Care Insurance Program does NOT pay commissions to
insurance agents or brokers.
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Community-Based Services
Locally-based services (such as meals on wheels and adult day care) that allow a
person to
remain independent and in their own homes.
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Comprehensive Option
A plan feature which covers both facilities-based and home-based care. Under the FLTCIP,
this option covers services provided in a nursing home, assisted
living facility, adult day care center, care at home, hospice care (in a
facility or at home), respite services (in a facility or at home), bed
reservations and caregiver training.
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Concealment
Intentionally withholding information on an insurance application to hide facts
from the insurance company.
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Contest the Validity
When an insurance company can cancel your coverage as if it had never been
issued and return all the premiums paid due to falsification of information by
the certificate holder.
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Continence
An activity of daily living - the ability of the body to control urination or
bowel movements or both.
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Contingent Non-forfeiture
A feature of
the FLTCIP that provides paid-up long term care insurance coverage for a
shortened benefit period if coverage lapses after an increase in premiums beyond a certain level as specified by the National
Association of Insurance Commissioners (NAIC).
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Covered Services
The qualified long term care services covered under the contract of insurance.
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Custodial Care
Services aimed at maintaining your health and/or preventing deterioration in
your functional status, provided on an extended basis. Long term care includes
custodial care.
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Daily Benefit Amount
This is the maximum amount your insurance will pay in any single day.
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Declination
The refusal of an insurer to issue a policy based on the review of the
application for insurance and other relevant factors.
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Effective Date
The date on which insurance coverage begins.
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Eligible Group
Individuals
who are eligible to apply for long term care insurance coverage under the FLTCIP
- also called the Federal Family. It includes Federal and U.S. Postal Service
employees and annuitants, members and retired members of the uniformed services
and qualified relatives.
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Elimination Period
The number of days that you have to pay for services before your coverage begins to
pay benefits. See waiting period.
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Exclusions
Specific conditions or circumstances for which your insurance will not provide
benefits.
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Facilities-Only Option
A plan feature which covers facilities-based care only. Under the FLTCIP, this
option covers services provided in a nursing home, assisted living facility, hospice care in a facility, respite services in a
facility, bed reservations and caregiver training.
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Family Member
Means spouse, child (natural, step or adopted), parent, sibling, in-laws, or
grandchild for purposes of determining whether benefits are payable for formal
caregivers and informal caregivers.
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FLTCIP
Refers to the Federal Long Term Care Insurance Program.
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Federal Program
Refers to the Federal Long Term Care Insurance Program (FLTCIP).
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Formal Care
Care which is provided by a home health aide or homemaker arranged or supervised by a
home care agency, or provided by a nurse or therapist.
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Free-Look Period
A provision which allows the insured to return a policy to the company within 30
days of issue for a full refund. This protection is included in the FLTCIP.
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Full Underwriting
Means that applicants will have to answer numerous health-related
questions. It may also include a review of medical records and/or an interview
with a nurse.
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Future Purchase Option
An inflation protection feature that allows the insured to periodically purchase
additional coverage without proof of good health. The FLTCIP offers a future
purchase option that increases your benefits every other year with an increase
in premiums.
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Grace Period
The Federal
Program includes a 30 day grace period. This means that payment of your premium
must be received by the 30th day after the date it is due. If your premium is
not received by the end of the grace period, a written notice of termination of
coverage will be sent to you by first class mail. You will have 35 days from the
date of the termination letter to pay your premium, otherwise your coverage will
end.
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Group Policy
Specific to the Federal Long Term Care Insurance Program (FLTCIP): The group
long term care insurance policy issued to the United States Office of Personnel
Management (OPM) under which participants of the FLTCIP are insured.
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Guaranteed Renewable
A feature of tax-qualified long term care insurance plans whereby an insurance
company cannot cancel or fail to renew coverage because of a change in a
person's health or age. As long as premiums are paid and benefits have not been
exhausted, coverage will continue. When a plan is guaranteed renewable, premiums
may be changed on a group basis only.
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Hands-On Assistance
When you require physical help by another person without whom you would not be
able to perform the activities of daily living. Some insurance companies measure
the inability to perform activities of daily living based on the need for
hands-on assistance only.
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Health Insurance Portability and Accountability Act (HIPAA)
Federal health insurance legislation passed in 1996 that specifies conditions
under which certain long term care insurance policies qualify for Federal tax
advantages.
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Home Care
Services provided at home which may include nursing care; occupational,
physical, respiratory and speech therapy; personal care; and homemaker services.
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Home Health Aides
Individuals who provide care to older adults or people with disabilities at
home. Training or certification may vary for home health aides, but typical
services they provide include assistance with activities of daily living,
managing medications, and some household tasks.
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Homemaker Services
Household chores performed for someone unable to do them on their own.
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Hospice Care
Services provided by a hospice provider for the care or management of a
terminal illness.
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Inflation Protection
A feature or option of long term care insurance coverage that increases the
value of benefits over time to keep pace with increasing costs of care.
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Inflation Rate
The rate at which the cost of long term care is expected to increase in the
future.
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Informal Care
Care provided by an unlicensed caregiver whose services are not arranged and
supervised by a home care agency.
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Informal Caregiver
A person providing maintenance or personal care who is not a formal caregiver.
This includes a homemaker whose services are not arranged and supervised by a
home care agency.
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Insured
A person covered under an insurance policy.
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Insurer
The insurance company that agrees to pay losses of benefits. Also, the insurer
can be any company whose primary business is selling insurance to the public.
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International Benefits
Benefits for covered services received outside the United States.
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Lapse
The termination of insurance coverage when premium is not paid.
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Licensed Health Care Practitioner
A physician, any registered professional nurse, or a licensed social worker.
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Life Expectancy
The average number of years of life remaining for a group of persons given age
according to a particular mortality table.
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Long Term Care
Personal care and other related services provided on an extended basis to people
who need help with activities of daily living or who need supervision due to a
severe cognitive impairment.
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Long Term Care Insurance
Insurance that helps defray the costs of assistance with the activities of daily
living or the costs of supervision due to a severe cognitive impairment.
Depending on the coverage selected, care can be received at home or in an
assisted living facility or nursing home.
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Long Term Care Partners
Specific to the Federal Long Term Care Insurance Program (FLTCIP): Administrator
of the Federal Long Term Care Insurance Program.
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Maintenance or Personal Care
Any care with the primary purpose of providing needed assistance that results in
or from:
- Inability to perform, without substantial assistance from another person, at
least 2 activities of daily living for an expected period of at least 90 days
due to a loss of functional capacity; or
- A severe cognitive impairment
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Material to Your Insurability
Generally, means coverage would not have been issued had the facts, as shown in an individual's
medical records, been disclosed to the insurer before the original effective date.
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Maximum Lifetime Benefit
This is the maximum amount of benefits that the insurance coverage could pay. The maximum lifetime benefit can
also be referred to as a "pool of money". For the FLTCIP, your maximum lifetime
benefit is calculated by multiplying your daily benefit amount times the number
of days in the benefit period you selected.
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Medicaid (Medi-Cal)
The joint Federal-state program that pays for health care services for
individuals who meet their state's poverty guidelines. Medicaid can be accessed
only when all prior assets and funds are depleted to state required levels.
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Medicare
A Federal health care program for most adults age 65 and older and certain
disabled individuals. It pays for long term care under limited circumstances and
for limited periods of time.
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Member of the Uniformed Services
A person as defined by the Act at 5 U.S.C. 9001(3), including a member of the
uniformed services, other than a retired member of the uniformed services, who
is:
- On active duty or full-time National Guard duty for a period of more than 30
days; or
- A member of the Selected Reserve
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Medicare Supplement Insurance (Medigap)
Private insurance to help pay hospital and medical costs Medicare does not
cover. It pays for long term care under limited circumstances and for limited
periods of time.
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Misrepresentation
Means a statement or omission of information material to your insurability that
occurred with or without your knowledge of the facts as shown in your medical
records.
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National Association of Insurance Commissioners (NAIC)
An association of the chief insurance regulators in all 50 states, Washington
D.C., and four U.S. territories. The NAIC's primary responsibility is to set
guidelines to protect the interests of insurance consumers.
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Non-forfeiture
A feature that provides paid-up long term care insurance coverage for a
shortened benefit period if coverage lapses.
Contingent non-forfeiture is one type of non-forfeiture benefit and the type
that is included in the FLTCIP.
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Nurse
Means a registered professional nurse (R.N.), licensed practical nurse (L.P.N.)
or licensed vocational nurse (L.V.N.) who is currently licensed in the
jurisdiction in which the services are provided.
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Nursing Care
Services requiring the professional skills of a nurse (R.N.), licensed practical
nurse (L.P.N.) or licensed vocational nurse (L.V.N.).
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Nursing Home
A licensed facility that provides 24-hour-a-day room and board, nursing care and
personal care services. Nursing homes also provide medical care, therapy, and
other health related services.
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OPM
Refers to the United States Office of Personnel Management.
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Original Effective Date
The date that an individual's coverage under the Federal Program becomes effective.
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Personal Care
Care to help you meet personal needs such as bathing, dressing and eating.
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Plan of Care
A plan prescribed by a licensed health care practitioner that identifies ways of
meeting your need for long term care services.
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Policy
A written legal contract of insurance issued by the insurance company to the
policyholder or group sponsor, which outlines the terms of the insurance.
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Policy Holder
An individual or group sponsor that has a written and signed policy agreement with their insurance
provider. The U.S. Office of Personnel Management is the policyholder for the
Federal Long Term Care Insurance Program.
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Pool of Money
See maximum lifetime benefit.
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Portable Coverage
Even if the insured is no longer a member of an eligible group, once the insured
has long term care insurance coverage, he/she can keep it, as long as the
required premium has been paid and the maximum lifetime benefit has not been
exhausted.
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Premium
The money paid to an insurance company for coverage.
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Qualified Long Term Care Services
Necessary, diagnostic, preventative, therapeutic, curing, treating, mitigating
or rehabilitative or maintenance or personal care services, which are required
by a person who is eligible for benefits. Services that are primarily for
companionship are not qualified long term care services.
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Qualified Relative
A person as
defined by the Act at 5 U.S.C. 9001(5) and the FLTCIP regulations, including:
- The spouse of an employee, annuitant, member of the uniformed services or
retired member of the uniformed services
- A parent, stepparent or parent in-law of an employee or member of the uniformed
services
- An adult child (natural, step or adopted) of an employee, annuitant, member of
the uniformed services or retired member of the uniformed services if such a
child is at least age 18
- A person receiving an annuity as the surviving spouse of a deceased member of
the uniformed services or a deceased retired member of the uniformed services
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Rate
The pricing factor on which an insurance company bases their insurance premium.
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Renewal
The continuance of the coverage of a policy beyond the original length of time
set in the original policy based on the acceptance of the new policy's premium.
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Respite Services
Services by a substitute caregiver, from a few hours to a few days, to give time
off to the regular caregiver.
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Retired Member of the Uniformed Services
Specific to the Federal Long Term Care Insurance Program (FLTCIP): A person as
defined by the Act at 5 U.S.C. 9001(4), including a member or former member of
the uniformed services entitled to retired or retainer pay. This includes
military reservists at the time they qualify for an annuity (also known as grey
reservists).
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Rider
A written contract agreement between insurer and insured which changes the
policy or certificate.
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Schedule of Benefits
Specific to the Federal Long Term Care Insurance Program (FLTCIP): The
customized listing of your coverage under the FLTCIP. You will receive a copy of
your schedule of benefits from Long Term Care Partners if you apply for coverage
and they approve your application. This schedule, together with your Benefit
Booklet, describes your coverage under the FLTCIP.
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Severe Cognitive Impairment
A deterioration or loss in intellectual capacity that results in impairment of
some or all of the following: short and long term memory; orientation to people,
place, and time; deductive and abstract reasoning (including judgement); and
ability to perform activities of daily living.
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Skilled Nursing Care
The highest level of care provided by a Registered Nurse (R.N) or a Licensed
Practical Nurse (L.P.N) 24 hours a day. It is prescribed by a physician.
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Spend Down
Depletion of income and assets to meet eligibility requirements for Medicaid.
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Spousal Benefits
Options offered by some insurance programs to spouses. The options may include
allowing spouses who both qualify for the insurance to pay premiums that are
less than if each person had purchased individual coverage and/or allowing
spouses to use each other's benefits.
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Standby Assistance
When you require the presence of another person, within arms reach of you, to
help you perform the activities of daily living. Some insurance companies
measure the inability to perform activities of daily living based on the need
for standby assistance, rather than or in addition to hands-on assistance. The
FLTCIP measures such inability based on either the need for hands-on assistance
or standby assistance.
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Substantial Assistance
Hands-on or standby assistance required to perform activities of daily living.
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Substantial Supervision
Continual monitoring of a cognitively impaired person.
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Supplemental
Security Income (SSI)
A Federal income supplement program funded by general tax revenues (not
Social Security
taxes). It is designed to help aged, blind, and disabled people, who
have little or no income. It provides cash to meet basic needs for food,
clothing, and shelter.
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Tax-Qualified
Conforming to Federal standards that enable the enrollee in a long term care
insurance plan to receive Federal tax advantages.
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Terminal Illness or Terminally Ill
An illness or injury determined by a physician or other licensed healthcare
professional to be likely to result in your death within 6 months.
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Therapist
A person who is licensed or certified to provide therapy services.
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Therapy Services
Physical, respiratory, speech, or occupational therapy services provided by a
therapist.
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Toileting
An activity of daily living - getting to and from the toilet, getting on and off
the toilet, and performing associated personal hygiene related tasks.
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Transferring
An activity of daily living -- the ability to move in or out of a bed, chair or
wheelchair.
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Underwriting
The process of reviewing an individual's health status to determine eligibility
for coverage under a long term care insurance plan.
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Unlimited Benefit Period
An option under some insurance plans, including the FLTCIP, that pays benefits
for as long as the insured needs care, subject to your daily, weekly, or monthly benefit amount. An unlimited benefit period is sometimes called a "lifetime
benefit".
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Waiting Period
The time between becoming eligible for benefits and when your long term care
insurance actually begins paying those benefits. Sometimes known as an
elimination period or a deductible, it helps keep premiums affordable. The
longer the waiting period, the lower the premiums. The waiting period can be
measured in calendar days or days-of-service. A days-of-service waiting period is the number of days you must be eligible for benefits and receiving covered
services before your benefits begin. The FLTCIP includes a days-of-service waiting period.
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Waiver of Premium
A provision of long term care insurance plans, including the FLTCIP, that allows
the insured to stop paying premiums while receiving benefits.
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Weekly Benefit Amount
Benefit amounts for covered services calculated on a weekly basis (seven times
the daily benefit amount). Available with the Comprehensive option under the
FLTCIP, the insured may exceed the daily benefit amount on any one day and may
be fully reimbursed, as long as the total of that week's qualified long term
care expenses does not exceed the weekly benefit amount.
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