CHAPTER 9
Long Term Care (LTC)
(LTC) policies are designed to help pay for the institutional nursing home and/or at-home care needed by persons with such "chronic" disabilities; those who are too sick to look after themselves, but not sick enough to need the "acute" care of hospitalization.
There are three standard levels of institutional and non-institutional care
1. Skilled Nursing Care. - 24 hour care 2. Intermediate Care. - not 24 hour care 3. Custodial Care.- part time, bathing, eating
3 ways to pay for LTC
1. Use of personal resources and assets or those of relatives 2. Qualification for Medicaid/Medi-Cal benefits. 3. Purchase a Long-Term Care policy that provides benefits on a daily basis if the individual is confined to a nursing home or requires care at home for an extended length of time.
what would be cheaper, a 30 day elimination period or a 180 day?
180 day
To meet the chronically ill trigger of a Long-Term Care Policy, an individual must be unable to perform a minimum of:
2 activities of daily living.
what does ADL stand for?
Activities and Daily living
Free-Look
All Medicare Supplement policies must have a prominent notice on the first page stating that the policyholder has the right to return the policy within 30 days of delivery and have the full premium refunded if the insured person is not satisfied for any reason.
HICAP
Health Insurance Counseling Advocacy Program falls under the department of aging
What does HICAP stand for?
Health Insurance Counseling and Programs
how much does HICAP cost?
ITS FREE, NO FEES
COMPREHENSIVE LONG-TERM CARE POLICY.
If coverage is provided for both institutional and non-institutional care CARE IN BOTH NURSING HOME AND HOME CARE
Which statement is true regarding Medicare supplement insurance plans?
Insurers may offer policies that contain only the core benefits.
Alzheimer's Coverage Requirement
Long-Term Care coverage is mandatory for care that results from an individual developing the symptoms of Alzheimer's disease or any other degenerative brain disease, except in the case of pre-existing conditions.
Loss Ratio Standards
Medicare Supplement policies are expected to return benefits to policyholders that are reasonable in relation to the premium charged
The law also requires Medicare Supplement policies to include the following basic or "core" benefits in addition to any other types of benefits provided:
Part A hospitalization benefits for days 61-90. Part A hospitalization benefits for the 60 lifetime reserve days and an additional 365 covered days after Part A benefits end. Part B coinsurance amounts (20% of Medicare-approved expenses). The first three pints of blood each year. 100% of Part A hospice care co-payments (Plan K pays 50%, Plan L pays 75%).
the adult day-care coverage of a LTC policy provides for:
Part-time community care for a person who lives at home.
Medicare Supplement Plans M & N
Plan M = only covers 50% of the Medicare Part A deducible and none of the Part B deductible Plan N = $20 co-payment for doctor's office visits and a $50 co-payment for visits to an emergency room that apply after the Medicare Part B deductible is paid. The cost of Plan N is expected to be about 30% less than that of Plan F.
What is the term used to apply to a break (rest) given to people caring full-time for an individual in their home?
RESPITE CARE
Unnecessary Replacement
Replacement is contingent upon the insurer's declaration that the replacement policy materially improves the position of the insured. This provision does not apply to replacement of group insurance. It is unlawful for an insurer, broker, agent or other person to cause a policyholder to replace a Long-Term Care policy unnecessarily or cause a policyholder to replace a Long-Term Care policy that will result in a decrease in benefits and an increase in premium. For the purposes of this section any third or greater policy sold to a policyholder in any 12-month period is considered an unnecessary replacement
ADL - activities of daily living
Self-care activities; Eating, bathing, dressing, and toileting. Assessment in the function in the ability to perform ADL's assesses their quality of life.
Medicare Supplement insurance
The core benefit plan without any additional benefits.
Medigap policies
Their primary function is to pay for some or all of Medicare's deductibles and co-payments and provide some benefits that are not covered by Medicare.
HHCAs
When an individual is in need of care but can function without being confined to a nursing home, care is usually provided through occasional visits to the person's home from registered nurses, vocational nurses or speech/physical therapists provided by Home Health Care Agencies (HHCAs)
Long-Term Care insurance application forms must include
a question asking if the applicant already has Long-Term Care insurance, or whether the proposed insurance is intended to replace any other LTC insurance presently in force.
Medicare SELECT
a type of Medigap insurance that requires enrollees to use a network network of providers (PPO NETWORK) this cut costs
Cold Lead Advertising
an illegal method of marketing which fails to disclose in a conspicuous manner that the purpose of the marketing is solicitation of insurance and that contact will be made by an agent or insurance company.
LTC coverage
an individual or group policy, or life insurance rider, which is designed to provide coverage for those suffering from chronic illnesses. Coverage is provided for at least 12 consecutive months for one or more necessary health or personal care services.
what is HICAP?
counseling service to the seniors that is free, helps them with how all of this works
Medicare Supplement Plans K & L
high ded, lower premiums, higher out of pocket costs Plan K covers the cost sharing for Part B preventive services, the Part A hospital co-insurance and an additional 365 days of hospitalization.
Nursing Facility Only Policy.
if LTC is provided only in a nursing home facility
Home care only policy
if coverage is only provided in the insured's home, a hospice or respite facility,
what does LTLC stand for?
long term care
Individuals who do not have the funds to pay these premiums may have few assets to protect, will often qualify for Medi-Cal benefits and are not good candidates for this type of insurance. Equally, the very wealthy may be considered self-insured against these types of potential losses.
perfect fit for someone in the middle of medical and self insured
what's the most expensive plan available?
plan J aka comprehensive medicare supplemental insurance
long-term care insurance
provides for long-term care expenses not covered by Medicare. you have a chronic diasbility and need supervision at all times
standard levels of LTC
skilled nursing care, intermediate nursing care, custodial care, home health care, home care and community- based care
hicap mission
stated mission is "to provide accurate and objective counseling, advocacy, and assistance with Medicare, health insurance, and related coverage plans for Medicare beneficiaries, their representatives, or persons imminent of Medicare eligibility, and to educate the public about Medicare and health insurance issues."
what do you have to do in order to sell long term care?
take an 8 hour course and get a certification
What long term care policy would be the most expensive?
the one with the shortest elimination period
