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abbreviated underwriting: when the long term care insurance application asks few health-related questions designed to determine who may be immediately eligible for benefits or eligible for benefits within a short period of time. In the FLTCIP, the following groups are eligible for abbreviated underwriting:
act: the Long Term Care Security Act, 5 U.S.C. §§ 9001-9009. actively at work or active work:
activities of daily living (ADLs):
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. 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. adult day care center: means any facility operated, licensed and/or certified as an Adult Day Care Center under the laws of the jurisdiction in which it is located, or other facility that satisfies all of the following:
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. 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. annuitant: a person as defined by the Act at 5 U.S.C. § 9001 and the FLTCIP regulations (5 CFR Part 875), as amended. application: an application for insurance under the FLTCIP, whether submitted in connection with this Benefit Booklet or any prior Benefit Booklet issued to you under the FLTCIP. assisted living facility: a facility that satisfies all of the following:
Automatic Compound Inflation Option (ACIO): an inflation protection feature where benefits increase by a fixed percentage each year. Premiums do not increase annually as a result. (However, premiums are not guaranteed.) Under the FLTCIP, on each anniversary of your original effective date (or of the date you switch to the option), your daily benefit amount (DBA) and the remaining portion of your maximum lifetime benefit (MLB) will automatically increase at a rate of 4% or 5% compounded annually, depending on the option you select. [ Back to Top ] B bathing: an activity of daily living—getting into a tub or shower; and getting out of a tub or shower; and washing one's body in a tub, shower, or by sponge bath; and washing one's hair in a tub, shower, or sink. bed reservations: a benefit that pays a nursing home, assisted living facility, or hospice facility to hold an insured's bed during a temporary absence so that the insured may return to the facility. The FLTCIP bed reservation benefit covers up to 60 days per calendar year. benefit(s): payment an insurance company makes for a service covered under an insurance plan. benefit amount: the maximum we will pay for a covered service per day. Your benefit amounts are shown on your schedule of benefits. benefit booklet: a coverage booklet issued to your under the FLTCIP. This Benefit Booklet, together with your schedule of benefits, describes your coverage under the FLTCIP, and replaces any prior Benefit Booklet issued to you under the FLTCIP. benefit period: the length of time the insurance will last if the insured receives care every day that is reimbursed at a level equal to or more than the daily 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. 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. [ Back to Top ] C care coordination: services such as information, advice, and arranging of long term care by a professional care coordinator. In the FLTCIP, care coordination services are provided by registered nurses and are available to enrollees and their qualified relatives. 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. care planning visit: a visit by a provider acceptable to us who will:
caregiver training: training given to an informal provider who has not received formal training or has no experience providing this type of care. 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. certificate of insurance: a statement given to the insured stating the insurance benefits and terms. 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. 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. 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. 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. 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. 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. concealment: intentionally withholding information on an insurance application to hide facts from the insurance company. 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. continence: maintaining control of bowel and bladder function; or when unable to maintain control of bowel or bladder function, performing associated personal hygiene (including caring for catheter or colostomy bag). contingent nonforfeiture: a FLTCIP feature 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). covered services: those qualified long term care services listed in the covered services section for which coverage is provided under the FLTCIP. 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. [ Back to Top ] D daily benefit amount (DBA): this is the maximum amount the insurance will pay for a single day of long term care services. The FLTCIP offers daily benefit amounts from $100 to $450 in $50 increments. declination: the refusal of an insurer to issue a policy based on the review of the application for insurance and other relevant factors. domestic partnership: a committed relationship between two adults, of the same sex, in which the partners:
dressing: an activity of daily living—putting on any necessary item of clothing (including undergarments) and any necessary braces, fasteners, or artificial limbs; and taking off any necessary item of clothing (including undergarments) and any necessary braces, fasteners, or artificial limbs. durable medical equipment: equipment that you rent or purchase that is designed to be used in your home to treat a medical condition or assist you in performing the activities of daily living. Examples of durable medical equipment include walkers, hospital-style beds, crutches and wheelchairs. Durable medical equipment does not include prescription drugs, athletic equipment, equipment placed in your body or items commonly found in a household. [ Back to Top ] E eating: an activity of daily living—feeding yourself by getting food into your mouth from a container (such as a plate or cup), including use of utensils when appropriate (such as a spoon or fork); or when unable to feed yourself from a container, feeding yourself by a feeding tube or intravenously. 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. elimination period (deductible): see waiting period. emergency medical response system: a communication system that is installed in your home and used to call for assistance in the event of a medical emergency. It does not mean a home security system. employee: a person as defined by the Act at 5 U.S.C. § 9001 and the FLTCIP regulations (5 CFR Part 875), as amended. exclusions: specific conditions or circumstances for which the insurance will not provide benefits. existing enrollee: a person who first became insured under the FLTCIP by a "Benefit Booklet – Early Enrollment" or "Benefit Booklet - FO/Comp" that was issued prior to this Benefit Booklet. [ Back to Top ] F 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. family members: means spouse, child (natural, step-, or adopted), parent, sibling, in-law, or grandchild for purposes of determining whether benefits are payable for formal and informal caregivers. Federal Long Term Care Insurance Program (FLTCIP): was established by the Act at 5 U.S.C. § 9002. The rules for the administration of the FLTICP are set forth in the FLTCIP regulations (5 CFR Part 875), as amended. FLTCIP 1.0: the Federal Long Term Care Insurance Program's long term care insurance plan prior to October 1, 2009. FLTCIP 2.0: the Federal Long Term Care Insurance Program's long term care insurance plan introduced on October 1, 2009. formal care: care that is provided by a home health care aide or homemaker arranged or supervised by a home care agency or care that is provided by a nurse or therapist. formal caregiver: any of the following providers:
free look: a provision that allows the insured to return a policy to the company within 30 days of issue for a full refund. full underwriting: when applicants will have to answer numerous health-related questions designed to determine who may be immediately eligible for benefits or eligible for benefits within a short period of time. It may also include a review of medical records and/or an interview with a nurse. This is the type of underwriting that applicants would undergo if they applied for an individual policy in the private market. FLTCIP applicants undergo full underwriting with the exception of the following groups:
Future Purchase Option (FPO): the inflation protection feature that allows the insured to periodically purchase additional coverage without proof of good health. The FLTCIP Future Purchase Option increases benefits every other year with a corresponding increase in premiums. With FLTCIP 2.0, the insured may decline the Future Purchase Option an unlimited number of times. (However, premiums are not guaranteed.) [ Back to Top ] G grace period: the FLTCIP 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. group policy: group long term care insurance policy number 900-003 issued by John Hancock to the United States Office of Personnel Management under which you are insured. 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 for a class or classes of enrollees only. [ Back to Top ] H Health Insurance Portability and Accountability Act (HIPAA): a 1996 Federal law that specifies conditions under which certain long term care insurance policies qualify for Federal tax advantages. home: your place of residence. Home does not include a hospital, nursing home, hospice facility or assisted living facility. home care: services provided at home that may include nursing care; occupational, physical, respiratory, and speech therapy; personal care; and homemaker services. home care agency: an organization that:
home health aide: a person whose services are arranged and supervised by a home care agency and whose main function is to provide assistance with activities of daily living. The person must be appropriately licensed or certified in the jurisdiction where services are to be performed if that jurisdiction requires such licensure or certification. home modifications: minor modifications to your home that are primarily being made to improve your ability to perform the activities of daily living and allow you to live safely and independently in your home. Examples of home modifications include: installation of ramps for wheelchair access, installation of shower bars, widening of doorways and other similar accessibility modifications. Home modifications do not include: hot tubs, swimming pools, home repair or maintenance, bathroom or other room additions or other modifications that may increase the value of your home by more than a nominal amount. home safety check: a written evaluation of the safety of your home by a home health agency or other qualified professional agency or individual acceptable to us. Examples of the home items that may be evaluated include: cabinet and appliance height, furniture arrangement, doorway and hallway width and the need for safety bars in the bathroom. homemaker: a person who provides maintenance or personal care services that are necessary for you to stay at home. Such services may include light housekeeping, meal preparation, or shopping for items needed to provide maintenance or personal care. homemaker services: household chores performed for someone unable to do them on their own. hospice: a facility, unit of a facility, public or private agency or unit of a public or private agency that meets Federal certification requirements as a hospice, or is comparably licensed under applicable laws to provide care or management of the terminally ill. hospice care: services provided by a hospice for the care or management of a terminal illness. hospital: a facility that is licensed as a hospital which provides a broad range of 24-hour-a-day medical and surgical services for sick and injured persons by, or under the supervision of, a staff of physicians, and provides nursing care 24 hours a day. [ Back to Top ] I inflation protection: a feature or option that increases the value of benefits over time to keep pace with increasing costs of care. inflation rate: the rate at which the cost of long term care is expected to increase in the future. informal care: care provided by an unlicensed caregiver whose services are not arranged and supervised by a home care agency. informal caregiver: a person providing maintenance or personal care who is not a formal caregiver. The term includes a homemaker whose services are not arranged and supervised by a home care agency. The term does not include anyone who normally lived in your home at the time you became eligible for benefits. For example, if your child or your housekeeper is living with you at the time you become eligible for benefits, care they provide to you would not be covered as informal caregiver services. insured: a person covered under an insurance policy. 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. intermediate care: occasional or part-time skilled care. international benefits: benefits for covered services received outside the United States. [ Back to Top ] L lapse: the termination of insurance coverage when premium is not paid. licensed health care practitioner: a physician, registered professional nurse, or licensed social worker. life expectancy: the average number of years of life remaining for a group of persons given age according to a particular mortality table. 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. It can be provided at home or in an adult day care center, assisted living facility, or nursing home. 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. Long Term Care Partners: specific to the Federal Long Term Care Insurance Program (FLTCIP): Administrator of the Federal Long Term Care Insurance Program. [ Back to Top ] M maintenance or personal care: any care with the primary purpose of providing needed assistance that results in or from:
material to your insurability: we would not have issued your coverage had the facts, as shown in your medical records, been disclosed to us before your original effective date. maximum lifetime benefit (MLB): means the total amount of money that we may pay for charges you incur for covered services. Your maximum lifetime benefit is equal to your Benefit Period (in days) multiplied by your daily benefit amount and is shown in your Schedule of Benefits. It may increase or decrease, as described in this Benefit Booklet, and is reduced as benefits are paid. If you have an unlimited benefit period, your maximum lifetime benefit is also unlimited. Medicaid (Medi-Cal in California): the joint Federal-state program that pays for health care services for individuals who meet their state's poverty guidelines. medical underwriting: the process of reviewing an individual's health status to determine eligibility for coverage under a long term care insurance plan. 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. 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. Member of the Uniformed Services: a person as defined by the Act at 5 U.S.C. § 9001 and the FLTCIP regulations (5 CFR Part 875), as amended. misrepresentation: 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. [ Back to Top ] N 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. new enrollee: a person who first becomes insured under the FLTCIP by this Benefit Booklet, FLTCIP 2.0. nonforfeiture: a feature that provides paid-up long term care insurance coverage for a shortened benefit period if coverage lapses. Contingent nonforfeiture is one type of nonforfeiture benefit and the type that is included in the FLTCIP. nurse: 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. nursing care: services requiring the professional skills of a nurse, which are provided by a nurse under the orders of a physician for the purpose of improving or maintaining your health. 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. [ Back to Top ] O OPM: the United States Office of Personnel Management. original effective date: the date that your coverage first became effective under this Benefit Booklet or a prior Benefit Booklet issued to you under the FLTCIP. Your original effective date is shown on your schedule of benefits, but may be changed to a later date according to the effective date of coverage section. [ Back to Top ] P personal care: care to help you meet personal needs such as bathing, dressing and eating. physician: a person licensed as a medical doctor (M.D.) or doctor of osteopathy (D.O.) practicing within the scope of his or her license issued by the jurisdiction in which the services are provided. plan of care: a plan that is prescribed by a licensed health care practitioner that identifies ways of meeting your needs for qualified long term care services if:
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. 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. pool of money: see maximum lifetime benefit. 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. preexisting condition: an illness or disability for which the insured was treated or advised within a stated time period before applying for a long term care insurance policy. Under the FLTCIP, once a person is insured, benefits are not denied for a preexisting condition provided that the condition was not misrepresented during the process of applying for insurance. premium: the money paid to an insurance company for coverage. [ Back to Top ] Q 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. qualified relative: a person as defined by the Act at 5 U.S.C. § 9001 and the FLTCIP regulations (5 CFR Part 875), as amended. [ Back to Top ] R rate: the pricing factor on which an insurance company bases their insurance premium. 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. respite care: services by a substitute caregiver, from a few hours to a few days, to give time off to the regular caregiver. respite services: services that provide your primary caregiver with temporary relief from his/her caregiving responsibilities. Retired Member of the Uniformed Services: a person as defined by the Act at 5 U.S.C. § 9001 and the FLTCIP regulations (5 CFR Part 875), as amended. rider: a written contract agreement between insurer and insured which changes the policy or certificate. [ Back to Top ] S schedule of benefits: the customized listing of your coverage under the FLTCIP. severe cognitive impairment: a deterioration or loss in intellectual capacity that (a) places a person in jeopardy of harming him/herself or others and, therefore, the person requires Substantial Supervision by another person; and (b) is measured by clinical evidence and standardized tests which reliably measure impairment in: (1) short or long term memory; (2) orientation to people, places or time; and (3) deductive or abstract reasoning. signed: any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media and is consistent with applicable law. skilled care: care provided by a medical professional. 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. social worker: a person who has been issued a license, certificate, or similar authorization to act as a social worker by a jurisdiction or a body authorized by a jurisdiction to issue such authorization. spend down: depletion of income and assets to meet eligibility requirements for Medicaid (Medi-Cal in California). 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. substantial assistance: Hands-On Assistance or Standby Assistance. Hands-on assistance means physical help by another person without which you would not be able to perform the Activities of Daily Living. Standby assistance means that you require the presence of another person within arm's reach of you to prevent, by physical intervention or cueing, injury to you while you are performing the Activities of Daily Living. substantial supervision: that you require continual monitoring by another person (which may include cueing by verbal prompting, gesture, or other demonstrations) to protect you from threats to your health and safety, for instance, while wandering. 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. [ Back to Top ] T tax-qualified: conforming to Federal standards that enable the enrollee in a long term care insurance plan to receive Federal tax advantages. The FLTCIP is designed to be a tax-qualified plan. terminal illness or terminally ill: an illness or injury determined by a physician to be likely to result in your death within 6 months. therapist: a person who is licensed or certified to provide Therapy Services in the jurisdiction in which the services are provided. therapy services: physical, respiratory, speech, or occupational therapy services provided by a Therapist. toileting: an activity of daily living — getting to and from the toilet; and getting on and off the toilet; and performing associated personal hygiene. transferring: an activity of daily living — getting into a bed, chair, or wheelchair; and getting out of a bed, chair, or wheelchair. [ Back to Top ] U underwriting: the process of reviewing an individual's health status to determine eligibility for coverage under a long term care insurance plan. United States: the United States of America and its territories and possessions. unlimited benefit period: an option under some insurance plans that pays benefits for as long as the insured needs care, subject to the daily benefit amount. An unlimited benefit period is sometimes called a lifetime benefit in other plans. [ Back to Top ] V void or voided: to retroactively cancel your coverage as if it had never been issued, in which case we will return all the premiums you paid. [ Back to Top ] W
waiting period: the time between becoming eligible for benefits and when long term care insurance actually begins paying 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. FLTCIP 2.0 offers a 90-calendar day waiting period. waiver of premium: a provision of long term care insurance plans that allows the insured to stop paying premiums while receiving benefits. weekly benefit amount: benefit amounts for covered services calculated on a weekly basis (7 times the daily benefit amount). Available with the Comprehensive option under FLTCIP 1.0 only, 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. workforce: collectively, employees, annuitants, Members of the Uniformed Services, and Retired Members of the Uniformed Services. written or writing: a record which is on or transmitted by paper or electronic media, and which is consistent with applicable law.
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