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Program Details and Rates
This book provides a detailed overview of what's covered under the FLTCIP and includes the FLTCIP 3.0 Outline of Coverage and FLTCIP Privacy Notice.
This book answers common questions about the FLTCIP. It includes a worksheet to compare the FLTCIP with other plans and a glossary of terms.
and Lapse History
This is an important notice that details the FLTCIP's and John Hancock's premium rate increase and lapse history.
Long-Term Care Insurance
The National Association of Insurance Commissioners (NAIC) created this guide to help educate and protect consumers thinking of purchasing long term care insurance.
The full application is for all applicants except newly eligible employees and spouses. Full underwriting means we ask comprehensive questions about your health.
The abbreviated application is for newly eligible employees and spouses applying within 60 days of becoming eligible. Abbreviated underwriting means we ask fewer questions about your health.
FLTCIP 3.0 Full Application
If your answers to Part C-Medical Information and Part D-Lifestyle Information on the full application are longer than what can fit on the application, use this form to provide additional information.
The FLTCIP 3.0 Benefit Booklet is the governing contractual document for enrollees who have coverage under the FLTCIP 3.0 plan.
This brochure explains what long term care is and the value of long term care insurance. It also provides an overview of coverage under the FLTCIP and who's eligible.
This guide was developed jointly by the Centers for Medicare and Medicaid Services (CMS) and the NAIC. It describes ways to help you cover health care costs and explains what a Medigap policy is.
Disclosure of Information
Use this form to authorize us to speak with a designated person about your coverage.
If a legal representative is authorized to make decisions on your behalf, we require a legal copy of your durable power of attorney or guardianship papers.
Use this form to change your billing method. The FLTCIP offers payroll or retirement pay deductions, automatic bank withdrawals, and direct billing as options to pay for your coverage.
Domestic partners must submit this form to the employee's or retiree's agency, annuity office, or branch of service before you apply.
Use this worksheet to compare long term care insurance policies you may be considering side-by-side.
This brochure explains the key steps in the claims process, such as determining if you're eligible for benefits and educating you on what to expect if you are approved.
This kit contains the required forms you, or your legal representative, must complete and return to us before we can process your claim.
Use this form to initiate the claims process. Completing the form does not guarantee a claim approval and/or benefit reimbursement.
This authorization permits a licensed health care practitioner, medical facility, or other entity that has health documentation, to disclose information about you that we need to determine if you're eligible for benefits.
By completing this form, you are certifying that the Tax Identification Number (TIN) provided is correct. This TIN is used in our required reporting to you and the IRS for benefits paid during the year.
FLTCIP 1.0 Benefits
This brochure is for claimants who have FLTCIP 1.0 coverage. It includes important forms and instructions to assist you in the reimbursement of approved care expenses.
FLTCIP 2.0 Benefits
This brochure is for claimants who have FLTCIP 2.0 coverage. It includes important forms and instructions to assist you in the reimbursement of approved care expenses.
FLTCIP 3.0 Benefits
This brochure is for claimants who have FLTCIP 3.0 coverage. It includes important forms and instructions to assist you in the reimbursement of approved care expenses.
If you use an informal caregiver, you must submit this form along with proof of payment. The payment must be made after the services are rendered. Payments made by cash or checks made out to cash are not reimbursable.
You have the option to request direct payment to certain home care agencies or facilities. This form is used to assign benefits directly to your provider. It also includes an IRS Form W-9 that your provider must complete.
Claims Payments via EFT
This form is for claimants to authorize direct deposit of claims payments via electronic funds transfer (EFT) to a bank account or to change bank account information for an existing authorization.
Claims Payments via EFT
This form is for providers to authorize direct deposit of claims payments via electronic funds transfer (EFT) to a bank account or to change bank account information for an existing authorization. You must assign benefits to the provider first.
Not Covered Services
This brochure summarizes what services are covered and not covered for reimbursement under the FLTCIP 3.0 plan for each provider type.
This brochure explains common claims topics and terms that we use in our materials and communications with claimants.
for Faxed Documentation
Use this cover sheet when you fax claims documentation to us. Examples include invoices, proofs of payment, claims initiation and legal documents, and aide notes. Make sure to include your claim number on each page that you are faxing.