Insurance Test Chapter 10
LTC facilities
1) Skilled Nursing facilities 2) Custodial Care 3) Intermediate care facility
Levels of Care (LTC)
1) skilled care 2) Intermediate care 3) Custodial care 4) Home health care 5) Adult day care
Long term care policies must provide coverage for at least (?) months of care in a setting other than an acute care unit of a hospital. 1) 6 2) 12 3) 30 4)24
24
An insured must be confined to a nursing home facility before the start of their benefit period. This statement refers to. 1) Excluded period 2) Elimination period 3) Benefit period 4) An intermediate period
Elimination period: an elimination period is the time an insured must be confined to a nursing home before the start of their benefit payments
Which of the following is not a Long Term Care facility? 1) injury 2) skilled nursing 3) intermediate 4) custodial
Injury
What kind of program provides assistance to impoverished people taht are unable to provide for themselves?
Medicaid
What kind of program provides assistance to impoverished people that are unable to provide for themselves?
Medicaid
Long term disability benefits stated in a policy are the maximum benefits that the policy will pay. (T/F)
True
Medicaid is a government insurance program that was designed for those people who are in need of public financial assistance (T/F)
True
The benefits of a LTC policy would be triggered by an insured being unable to perform two activities of daily living. (T/F)
True
Optional benefits (inflation rate)
a. inflation protection b. Nonforfeiture
cognative impairment
an organic brain disorder. Ex) Alzheimers, dementia and parkinson disease.
skilled care
daily nursing and rehabilitative care that can only be provided by medical personnel, under the direction of a physician. includes the administration of medication, medical diagnosis, and minor surgery in an institutional setting
ADLs (activities of daily living)
personal daily care tasks, including bathing, skin, nail, and hair care, walking, eating and drinking, mouth care, dressing, transferring, and toileting
LTC free look period
30 days. 30 days from the policy's delivery, the policy can be returned for a refund
What are the most common LTC elimination periods?
30, 60, 90, or 180 days
LTC partnership
A LTC partnership allows for those insured who have exhausted or at lease used some of their private LTC benefits, to make applications to Medicaid for coverage, without having to meet the same means testing.
LTC qualified vs. Non-Qualified
A LTC policy meets the definition of being qualified if it contains the following five requirements. 1. Qualified LTC services are only provided 2. The contract does not pay for or reimburse expenses incurred that would otherwise be reimbursed under Title XVII of the social security act 3. Policy must be guaranteed renewable 4. Any refunds or dividends must be used to reduce costs of the policy (premiums) or increase the benefits in the future 5. An insurance contract is required to satisfy consumer protection provisions that concern model regulations, model act provisions, full disclosure and nonforfeiture
Medicaid
A federal and state government-funded needs program, designed to provide medical assistance to impoverished people that are unable to provide for themselves. In addition to being poor, applicants must also satisfy one of the following additional requirements, blind, disabled, care for children receiving welfare benefits, pregnant, over 65 years old, a U.S. citizen, and in need of nursing home care. ex) a person that would qualify for Medicaid would be a 70-year-old impoverished man that is in need of nursing home care.
What kind of program is medicaid?
A needs based program
LTC exclusions
Acts of war, drug addiction, injuries from committing a felony, nervous disorders, and organic based mental illnesses
Medicaid would most likely be for which of the following? 1) an injured person 2) a person over 65 3) an impoverished person 4) a person recovering from a drug addiction
An impoverished person
Medical Insurance
An insured must keep their medical insurance in force as an LTC only pays for care while in a facility. It does not pay for doctor visits, hospitalization, prescriptions and other medical treatments.
When selling LTC policies, the agent must make sure the client gets a Buyer's guide and an outline of coverage at the time of (?)
Application; Both items should be given to the client when they are presented with an application.
How many consecutive months of care in a setting other than in a hospital must a LTC policy provide?
At least 24 consecutive months of care in a setting other than an acute unit of a hospital
Inflation protection
Guarantee of insurability allows for an insured to periodically increase their benefit levels without providing evidence of insurability to an insurer. LTC policies are guaranteed renewable. Every policy must offer optional inflation protection to offset increases in the cost of care. A guaranteed Renewal provision must be on the first page of the LTC policy.
Long term care policies must carry the (?) renewal clause in this state?
Guaranteed Renewable
What type of policies are long term care? 1) provisionally renewable 2) guaranteed renewable 3) Optionally renewable 4) interactive
Guaranteed renewable
Mr. John receives physical therapy. Which category of care does he receive? 1) custodial 2) respite 3) skilled 4) home health
Home Health
Which of the following is specialized care that includes occupational therapy? 1) intermediate care 2) respite care 3) home health care 4) skilled care
Home Health Care
What kind of care is most likely at one's residence on a part time basis? 1) intermediate 2) Hospice 3) respite 4) home health
Home health, Home health care is received at home on a part time basis
When is nursing home care covered by medicare?
If it is part of the treatment for a covered injury or illness
Eligibility for benefits
In order to qualify for LTC benefits from a Long-Term care policy, an insured must not be able to perform some "activities of daily living". If an insured is unable to perform 2 or more ADLs and/or have a cognitive impairment they are considered to be chronically ill.
(?) care is daily care, but not 24 hour care
Intermediate
What kind of care is daily care, but not 24 hour care?
Intermediate care
Adult day care
Is on less than 24-hour continual basis for the care of functionally impaired adults. the care provided included transportation to and from a daycare center, a variety of health and social-related activities with meals being included as part of service. specialized care for alzheimer's victims is included in adult day care benefits
What allows for insureds who have exhausted their LTC benefits to apply for medicaid coverage, without having to meet the same testing standards? 1) LTC partnership 2) Benefit period provision 3) inflation rate provision 4) return of premium
LTC partnership
Benefit amounts (LTC)
LTC policies pay the benefit amount in a fixed dollar per day charge, regardless of the actual cost of the care.
Benefit periods
LTC policies usually vary as to the maximum period for which benefits will be paid; most often from 3 to 5 years, but no less than 24 months. A longer benefit period results in the insured paying a higher premium. A qualified LTC policy must pay benefits when an individual is diagnosed as chronically ill.
Sally needs custodial care at home, what kind of coverage will satisfy her need? 1) accidental health 2) disability income 3) long term care 4) Medical in-hospital
Long Term Care
What kind of care is provided for at least 24 months in a setting other than an acute unit of a hospital? 1) medicaid 2) long term care 3) assisted living 4) medicare
Long Term Care
What program provides assistance to people that have only limited financial resources and need help? 1) Medicaid 2) part c 3) part d 4) social disability
Medicaid
How is medicaid funded?
Medicaid is a federal and state funded program
When is a LTC outline of coverage delivered?
Must be delivered to a LTC applicant upon their initial solicitation and prior to the presentation of their application form
Intermediate care
Occasional nursing and rehabilitative care provided by medical personnel. The care is daily care, but not for 24-hour care
Gina desires to obtain a Long Term Care Policy. What would not be a factor to determine the cost of her policy? 1) age 2) health 3) benefit amount 4) personal income
Personal Income
In regard to a LTC policy, what factor is not considered? 1) personal Income 2)provided benefits 3) health 4) age
Personal Income
Custodial Care
Primarily for meeting personal needs, such as helping with the activites of daily living. it can be provided by someone without professional medical skills or training, but must be in accordance with a physician's order
LTC Policies
Provide coverage for various levels of care to suit one's lifestyle, and their degree of necessary care. LTC policies must provide coverage for at least 24 consecutive months of care in a setting other than in an acute unit of a hospital. All long term care insurance policies must also offer policyholders the option of purchasing coverage that would raise their benefit levels to account for reasonably anticipated increases in the costs of their Long Term Care services covered by their policy.
LTC policies are guaranteed (?)
Renewable
Medicare and Medigap with LTC policies
While providing an elderly insured with protection against medical care and no costs, do not provide for the coverage of long-term custodial or nursing home care. Nursing home care is only covered by medicare if it is part of the treatment for a covered injury or illness. it does not cover an insured's care that is needed directly as a result of aging. An outline of coverage must be delivered to an LTC applicant upon their initial solicitation and prior to the presentation of their application form
Medicare
pays in full for the first 20 days of skilled nursing home care in a medicare approved facility after one has been hospitalized for 3 days. From the 21st to the 100th day, the patient may pay a daily copayment, to receive benefits. No benefits will be provided after the 100th day in a skilled nursing home facility
home health care
received at home as part-time skilled nursing care, speech therapy, physical or occupational therapy, part time services from home health aides or help from homemakers and/or companion services
In regard to state law, what is the right to return time for a Long Term Care Policy? 1) 25 days 2) 15 days 3)60 days 4)30 days
30 Days
What is the LTC free look time? 1) 30 days 2) 10 days 3) 20 days 4) 15 days
30 days
What best describes activities of daily living? 1) activities performed without assistance 2) activities performed on a regular basis 3) activities performed at home 4) activities assigned by a medical professional
Activities performed without assistance. aActivities of daily living are functions performed without assistance
LTC underwriting considerations
All LTC applications, with the exception of those that cannot be denied based on answers in an application must contain clear and unambigous results questions designed to ascertain the health conditions of the prospective insured. In order for a LTC policy to be issued to an 80 yr old applicant, the company must obtain a physical exam, assesment of their functional capacity, an attending physician's statement, and copies of their medical records
Treatments not covered under a LTC policy are called? 1) exclusions 2) interactions 3) options 4) considerations
Exclusions
What is the general way in which long term policy will pay for eligible benefits? 1) fee for indemnity 2) home health 3) expense incurred 4) activities of daily living fees
Expense Incurred
Medicaid will not provide Family Planning services to impoverished qualified recipients. (T/F)
False
Medicaid is only state funded (T/F)
False, federal and state funded
Mrs. Jones was given a break from taking care of her husband. Which type of care gave her this relief? 1) skilled care 2) respite care 3) adult day care 4) benefit care
Respite Care
Respite care
Normally associated with hospice care and is most often considered a benefit to family members of a patient whereby the family is provided with a break or relief from caring for their patient. Respite care provides a break for an unpaid caregiver by hiring a outside caregiver to provide their services.
(?) care is considered a benefit to family members
Respite
Long term care policies offer many types of coverages. Which of the following would be considered an optional coverage? 1) home health 2) respite 3) perscription 4) intermediate
Respite
Nonforfeiture
Return of premium is offered by insurers that write LTC policies. If in the event of death of an insured or if the policy lapses, an insurer will return a portion of the premiums paid to a beneficiary, or to an insured if they are alive. A long term care policy may not be issued or delivered unless non-forfeiture (default or lapse) benefits have been offered to an applicant.
Jackson has a LTC policy. What 3 levels of care can he expect from his policy?
Skilled Nursing, Intermediate, and Custodial Care
What type of care is Daily Nursing Rehabilitative care, under the supervision of a skilled professional? 1) custodial care 2) respite care 3) skilled care 4) intermediate care
Skilled care
Which of the following descriptions is incorrect? 1) Adult daycare is the care of functionally impaired adults 2) Intermediate care is daily care, but not 24-hour care 3) Respite care provides caregiver relief 4) Skilled care is received at home by medical Personnel
Skilled care is received at home by medical personnel
Which of the following is not an Activity of Daily Living? 1) eating a meal 2) sleeping 3) putting on clothes 4) taking a shower
Sleeping
Which of the following would NOT be included as an activity of daily living in a long term care policy? 1) sleeping 2) transferring 3) walking 4) maintaining continence
Sleeping
Juan receives medicaid. How is her assistance program funded? 1) state and federal government funded 2) State funded 3) federal government funded 4) FICA funded
State and federal government funded
LTC Elimination Period
The LTC elimination period is most often 30, 60, 90, or 180 days during which an insured must be confined to a nursing home facility before the start of their benefit periods. A short elimination period results in one paying a higher premium.
Which of the following is not covered under nursing home care? 1) when it is treatment for a covered injury 2) when it is treatment for a covered illness 3) when it is needed as a direct result of aging 4) when it is associated with skilled care
when it is needed as a direct result of aging
