Using Your Benefits
For detailed information about your specific plan and coverage, refer to the most recent benefit booklet we sent to you, or login to your online account to download a copy of it.
Plan of care
Once you're eligible for benefits, our team of care coordinators will work with you to develop your plan of care based on your personal health information and care recommendations from your licensed health care practitioner.
Your plan of care identifies ways of meeting your needs for qualified long term care services. It will include details such as approved providers, dates of service, facility charges, hourly rates for caregivers, and quantified time for specific care services. It's also used to validate invoices we receive for reimbursement.
Identifying qualified caregivers
Our care coordinators have access to more than 200,000 providers of daily care, home modification, skilled nursing, and much more to help identify caregivers for you. Through this network, we can help you find care providers in your area; share the results of state survey reports about service availability, quality, costs, and licensing; and arrange for discounted services.
Care in your home
Depending on your coverage, you may elect to receive care at home. All providers must meet the qualifications established under the Federal Long Term Care Insurance Program (FLTCIP) and provide the required documentation to be certified and included in an approved plan of care.
An informal caregiver is a person providing maintenance or personal care whose services are not arranged or supervised by a home care agency. Typically their services are arranged by you, but in some instances an employment agency may offer support in locating someone. Informal caregivers may be your friend, relative, or private caregiver, as long as that person did not live in your home at the time you became eligible for benefits (and is not your spouse or domestic partner, depending on your coverage). Benefits for care provided by family members are limited under your specific plan.
A copy of a valid driver's license or passport, and a valid Social Security number.
A formal caregiver is a caregiver whose services are arranged and supervised by a home care agency (including visiting nurse associations and hospice agencies). Home care agencies must meet the laws of the jurisdiction in which they are located in order to be included in an approved plan of care.
A copy of the state-issued license for the appropriate type of home care agency and a Federal Employer Identification number.
Care in a facility
You may also elect to receive care in a facility. A facility may be an adult day care center, an assisted living facility, a nursing home, or a hospice facility. Facilities must meet the laws of the jurisdiction in which they are located and provide the required documentation to be included in an approved plan of care.
A copy of the state-issued license for the appropriate facility and a Federal Employer Identification number are required. The facility must also complete the appropriate facility form.
If you're eligible for benefits under another long term care insurance plan or other program, we'll determine which is the primary plan and coordinate the payment of your benefits. If the FLTCIP is your primary plan, we will pay first without coordinating with other plans.
When Medicare is the primary plan, the services they cover are not eligible for reimbursement under the FLTCIP. However, services covered by Medicare can be applied to the waiting period.
If another plan or program is primary, such as a Federal Employees Health Benefits (FEHB) plan, then it will pay first for the services they cover. In this case, we'll require you to submit the explanation of benefits you received from the other plan or program showing that you submitted a claim to it and how that claim was decided. We may also request a copy of the other plan, program booklet, or terms of coverage. We'll pay no more than the difference between the amount payable by your other coverage and your actual covered expenses.
Meeting your waiting period
Your waiting period is similar to a deductible in other insurance plans. The type of waiting period and length of your waiting period depends on your specific plan. You only have to satisfy your current plan's waiting period once in your lifetime.
To determine what waiting period you have, refer to your latest schedule of benefits or login to your online account.
A calendar day waiting period is the number of calendar days you must be eligible for benefits before we'll pay the benefits of your plan.
A service day waiting period is the number of days you must be eligible for benefits and receiving and paying for care (approved by your care coordinator) before we'll pay the benefits of your plan. We'll request the following information to help determine when your service day waiting period has been reached:
- itemized bills and an explanation of what services were provided
- a completed Informal Caregiver Invoice and proof of payment for services that were provided by an informal caregiver
- invoices from a formal provider
Services must be paid at the time rendered. Services paid for in cash cannot be validated to count toward the waiting period or be reimbursed.
Benefits immediately available
Once you're eligible for benefits, the waiting period does not apply while you are receiving hospice care, respite services, caregiver training, or the stay-at-home benefit. We'll pay for these services, however, they do not count toward meeting your waiting period (if you have a service day waiting period). If you're thinking about using the stay-at-home benefit, the charges you incur must be included in your approved plan of care.
Waiver of premium
You will not have to pay your premium once you have satisfied your waiting period. We'll also waive your premium if you're eligible for benefits and receiving hospice care.
Monitoring your claim
While you're receiving care, our care coordinators will review your benefit eligibility and plan of care at least once every 12 months and sometimes more frequently depending on your specific condition. We may request additional information by contacting you, your physician, or other persons familiar with your condition; accessing your medical records; having you examined, at our expense, by a licensed health care practitioner; or conducting an on-site assessment.
Notify us of changes
You must inform us of any anticipated or actual change in your condition, care, caregivers, or stay-at-home needs (such as home modifications and durable medical equipment), as soon as you know about or need to make a change. Any requested change to your plan of care must be reviewed and approved by our care coordination staff to avoid reimbursement denials or delays.
Closing a claim
If your benefit eligibility can no longer be documented, you are considered recovered and therefore no longer eligible for reimbursement of benefits for your current claim. The following are a few reasons why you may no longer be eligible for benefits:
- You no longer meet the benefit eligibility requirements
- You've used your entire maximum lifetime benefit
- We've been notified of your death