FAQs
FAQs
What is Long Term Care?
What is Long Term Care?
Long term care (or LTC) refers to the services that help you with basic Activities of Daily Living (ADLs), which include:
Bathing
- washing yourself by sponge bath or in either a tub or shower
- getting into or out of the tub or shower
Dressing
- putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs
- you will be considered able to dress yourself even if these tasks can only be performed by using modified clothing or adaptive devices such as tape fasteners or zipper pulls
Continence
- maintaining control of bowel and bladder function
- when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene, including caring for a catheter or colostomy bag
Toileting
- getting to and from the toilet
- getting on and off the toilet
- performing associated personal hygiene
Eating
- feeding yourself by getting food into the body from a receptacle (such as a plate, cup, or table)
- when unable to feed yourself from a receptacle, feeding yourself by a feeding tube or intravenously
Transferring
- getting into or out of a bed, chair, or wheelchair
- you will be considered able to transfer even if you use or require equipment such as canes, quad canes, walkers, crutches, grab bars, or other support devices, including mechanical or motorized devices, in order to transfer or ambulate
Long term care can also refer to services needed to protect your health when you have a severe cognitive impairment, like advanced Alzheimer's. These services can be received at home or in a facility.
When do I need Long Term Care?
When do I need Long Term Care?
You need long term care when you can no longer perform basic Activities of Daily Living (ADLs) on your own, or when you or loved ones can no longer be confident that you can keep yourself healthy or safe due to severe cognitive impairment.
How do I qualify for benefits?
How do I qualify for benefits?
You can qualify for benefits in one of two ways:
- You need substantial assistance from another person to perform three of six basic ADLs: bathing, dressing, toileting, eating, getting in and out of bed or a chair (also called transferring), or managing bowel and bladder continence (peeing and pooping), and these limitations are expected to last at least 90 days
- You have a severe cognitive impairment (like Alzheimer’s) and need constant supervision to be safe.
How do I apply for benefits?
How do I apply for benefits?
If you need to start using your LTC benefits, contact us immediately. We will provide you with an Application for you to complete, along with a Provider Certification and Plan of Care forms to be completed by your doctor.
Your elimination period can only start once we have received the doctor forms and medical records. Once we receive your completed application, the forms from your doctor, and substantiating medical records, we will review your claim to determine if you are eligible for benefits. Call us if you need assistance completing your Application.
What Is Covered
What Is Covered
- Nursing Facility Care including room, board
- Assisted Living Facility including room, board
- Limited Bed Reservation at a Nursing or Assisted Living Facility
- Home Health Care
- Adult Day Care as part of an approved plan of care
- Hospice Care, excluding drugs, supplies, equipment or doctor visits
- Respite Care
- Alternate Care as approved
What Is Not Covered - Group Plan
What Is Not Covered - Group Plan
We do not reimburse expenses for the following:
- Services received outside the United States or its territories or possessions.
- Any costs incurred if you already have a Functional Incapacity or Severe Cognitive Impairment on the effective date of this policy.
- Any costs incurred while you are not covered by this policy, except as specifically described in “Extension of Benefits” in Section 5.
- Services provided to you by a member of your Immediate Family, except as specifically described in “Respite Care Benefit” in Section 6.
- Services provided to you by any person other than an employee of a licensed provider of Long Term Care services, or a provider specifically approved by us, except as specifically described in “Respite Care Benefit” in Section 6.
- Any costs incurred by your dependent child or any dependent other than your covered spouse.
- Services or items furnished or paid for by a governmental entity, facility, or program other than Medicaid unless we are required to do so by specific law.
- Services or items furnished free of charge or for which you are not legally obligated to pay in the absence of insurance.
- Any personal care items. Personal care items are those articles or supplies that are used for the personal care, grooming, hygiene, entertainment, enjoyment, refreshment, or convenience of an individual and that are not necessary, as determined by us, to assist or enable the individual to successfully perform the Activities of Daily Living.
- Costs of mechanical assistance, machinery, or devices, including installation.
- Care for a condition that arises from, or originates during, services in the armed forces.
- Care for a condition resulting from participation in a felony or illegal occupation.
- Prescription and over-the-counter drugs and medications, supplies and equipment (e.g., needles, oxygen, gloves, etc), and physician visits.
- Transportation, including ambulance transfer.
- Services that fall outside the established plan of care that we have approved.
What Is Not Covered - Individual LTC Plan
What Is Not Covered - Individual LTC Plan
We do not reimburse expenses for the following:
- Care resulting, directly or indirectly, from attempted suicide or an intentionally self-inflicted injury while sane or insane.
- Care resulting from your alcoholism or addiction to drugs or narcotics. This does not include addiction that results from drugs or narcotics taken as prescribed by a physician.
- Care for a condition that results from war or an act of war, whether declared or undeclared.
- Care for a condition resulting from participation in a felony or illegal occupation.
- Services received outside the United States or its territories or possessions.
- Services provided to you by a member of your Immediate Family, except as specifically described in “Respite Care Benefit” in Section 5.
- Services provided to you by any person other than an employee of a licensed provider of Long Term Care services, or a provider specifically approved by us, except as specifically described in “Respite Care Benefit” in Section 5.
- Services or items furnished by or in a Veteran’s Administration or federal government facility, unless otherwise required by law.
- Services or items furnished free of charge or for which you are not legally obligated to pay in the absence of insurance.
- Services that fall outside the established Plan of Care that we have approved.
- Any personal care items. Personal care items are those articles or supplies that are used for the personal care, grooming, hygiene, entertainment, enjoyment, refreshment, or convenience of an individual and that are not necessary, as determined by us, to assist or enable the individual to successfully perform the Activities of Daily Living.
- Costs of mechanical assistance, machinery, or devices, including installation.
- Transportation, including ambulance transfer.
- Prescription and over-the-counter drugs and medications and physician visits.
- Services received while your coverage is not in force except as provided under “Extension of Benefits” in Section 4.
