The Federal Long Term Care Insurance Program (FLTCIP) is a qualified long term care insurance plan. This means you must meet certain benefit triggers to be eligible for benefits.
You may be eligible to receive the benefits under your plan if a licensed health care practitioner has certified in the last 12 months that you are unable to perform, without substantial assistance from another person, at least two activities of daily living for an expected period of at least 90 days due to a loss of functional capacity, or you require substantial supervision due to your severe cognitive impairment.
Activities of daily living
Bathing means getting into and out of a tub or shower; washing your body in a tub, shower, or by sponge bath; and washing your hair in a tub, shower, or sink.
Dressing means putting on and taking off all clothing items and any necessary braces, fasteners, or artificial limbs.
Transferring means getting into and out of a bed, chair, or wheelchair.
Eating means feeding yourself by getting food into your mouth from a container (such as a plate or cup), including the use of utensils when appropriate (such as a spoon or fork) and when unable to feed yourself from a container, feeding yourself by a feeding tube or intravenously.
Continence means maintaining control of bowel and bladder function and when unable to maintain control of bowel or bladder function, performing associated personal hygiene (including caring for a catheter or colostomy bag).
Toileting means getting on and off the toilet and performing associated personal hygiene.
Severe cognitive impairment
A severe cognitive impairment is a deterioration or loss in intellectual capacity (such as Alzheimer's disease) that places you in jeopardy of harming yourself or others and, therefore, you require substantial supervision by another person. It is measured by clinical evidence and standardized tests that reliably measure impairment in short or long term memory; orientation to people, places, or time; and deductive or abstract reasoning.
Filing a claim
The first step in the claims process is to call and speak to one of our customer service consultants. They will explain the process and review the initial information we need from you, including the required forms you must complete and submit to begin your claim.
As part of determining if you're eligible for benefits, we may also:
your physician, or other persons familiar with your condition.
Request to have you examined
by a licensed health care practitioner (at our expense).
Access your medical records
to get information about your condition or the services provided to you (we cannot approve a claim if we are not given access to your medical records).
Conduct an on-site assessment
at your residence, by a registered nurse, who is local to your geographic area and employed by our contracted national vendor; the nurse will observe your ability to perform activities of daily living and administer a brief mental status exam.
Authorizing others to speak for you
We are only authorized to speak with you, the insured. If you'd like to authorize us to speak with a designated person about your coverage, complete and return the Authorization for Disclosure of Information form. You don't have to wait until you're eligible for benefits to do this. The sooner we have it on file, the better.
If you have a legal representative that is authorized to make decisions on your behalf, please submit a copy of your durable power of attorney or guardianship papers (as determined by your state of residence).
Determining benefit eligibility
This process can take several weeks, depending on the amount of information needed to determine your claims benefit eligibility date. This is the date when you started needing long term care assistance, according to the policy. We'll send you a written notice of our decision on whether or not you're eligible for benefits no later than 10 business days after we receive all of the requested information. A care coordinator will also call you to discuss our decision.
We'll include instructions and the forms necessary for submitting invoices and providing proof of payment in our decision letter. We'll also assign a team of care coordinators to work with you and your family to develop a plan of care that best meets your long term care needs.
If you feel that you are eligible for benefits, you may request a review of the denial by sending a written request to us no later than 60 days after the date of the denial.