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Glossary
A
Accelerated Death BenefitSome life insurance companies offer life insurance policies with a special feature that allows payment of the death benefit when the insured person is still alive. Such payment usually is limited to situations in which the individual is terminally ill. The benefits are available to cover the costs of long term care services.
Activities of Daily Living (ADLs)The physical functions necessary for independent living. These usually include bathing, dressing, using the toilet, eating, and moving about (transferring). Some long term care policies pay benefits based on an individual's need for assistance to perform several ADLs.
Acute CareImmediate, short-term, medical treatment for a serious illness or injury, usually in a hospital or skilled nursing facility. May be contrasted with chronic care.
ADLs
Administration on AgingFederal agency for senior citizens, created by the Older Americans Act . Has nationwide organization of state and area agencies to provide support and resources to aid seniors in need.
Adult Day CareAlso known as day health centers. A non-residential setting for those who cannot safely remain at home alone due to physical or mental impairment or who may benefit from social interaction. Day centers also provide social, developmental, nutritional and therapeutic activities.
Aging in PlaceWhen an older individual continues to live at home or within the community, outside of an institutional environment.
Alternate CareA plan mutually agreeable to you, the insurance company of your long-term care policy, and those individuals preparing the plan. The alternate care you receive can include special treatment at home or in other facilities. Benefit levels may differ from your usual coverage. Definitions used in insurance policies may vary from policy to policy. Insurers may use this term to extend coverage to care in facilities of the future not yet identified or in use.
Alternate FacilityA licensed residence other than a skilled nursing facility where care services are delivered (i.e., hospice, assisted living, Alzheimer's etc.
Alzheimer's DiseaseA progressive and irreversible organic disease, typically occurring in the elderly and characterized by degeneration of the brain cells, leading to dementia, of which Alzheimer’s is the single most common cause. Progresses from forgetfulness to severe memory loss and disorientation, lack of concentration, loss of ability to calculate numbers and finally to increased severity of all symptoms and significant personality changes. Alzheimer’s is now typically covered by name in newer policies.
AntioxidantsSubstances that protect against cell damage by guarding the cell from oxygen free radicals. (Source : AMA)
AphasiaLoss of the ability to use or understand language.
Area Agency on AgingLocal representative of Administration on Aging provides resources and assistance to older Americans in legal matters, nutrition, counseling, day health care, in home services, and employment.
Asset ProtectionWillful, legal planning to achieve protection from Medicaid "spend-down" requirements, typically provided by irreversible trusts - recently outlawed by Congress except under specific conditions.
Assisted Living FacilityFacilities that allow independence. May provide congregate meals, housekeeping, transportation and preventative health services. They have 24-hour desk service and often a part-time health office.
B
Bed Reservation BenefitThe payment you receive for room charges in a Nursing Facility or Alternate Facility (to reserve your bed) when you are temporarily hospitalized while receiving benefits.
BeneficiaryThe recipient of the proceeds or benefits of an insurance policy.
Benefit PeriodPeriod of time that begins when the insured becomes eligible for benefits and ends when the insured has been out of claim status for a given period, such as 90 days.
Benefit TriggerCriteria used to determine eligibility for benefits. Triggers may be based on limitations in ADLs and/or degree of cognitive impairment.
C
Calendar YearA period of twelve months that begins on January 1 and ends on December 31.
Care CoordinatorA health care professional whose training includes managing and arranging for long term care services. This person can be a doctor, nurse, social worker or other similarly trained and licensed professional.
Caregiver AssistanceOften available from local offices for the aging through Caregiver Resource Centers which assist families and friends who provide care.
Case Coordination and AssistanceIn social adult day care, includes coordinating with and referring to other services providers and helping clients and their caregivers obtain public benefit information.
Case ManagementAssists older persons and their families in identifying what help is needed and in arranging for services. It helps the individual access appropriate services, benefits and entitlements.
Catastrophic IllnessIllness resulting in sudden temporary or permanent change or significant disruption to a person's normal lifestyle.
Chronic CareContinuous, long-term care for persons suffering from chronic conditions. May be contrasted with acute care.
Cognitive ImpairmentA diminished mental capacity, such as difficulty with short-term memory, attention or any other loss of intellectual capacity that requires supervision to help or protect the impaired person.
Continuing Care Retirement Community (CCRC)A combination of residential and nursing home facilities that might also include a broad variety of recreational, social, medical and other services. Requires a significant entrance fee followed by monthly payments to retain residency and services. As one option for obtaining and paying for long-term care, CCRCs are currently considered affordable for fewer than 10% of retirees. Also called life care community.
Convalescent CareAnother term often used for short-term custodial care and refers to a "recovery" period after an illness or injury when some assistance may be needed that does not require skilled care.
Custodial CareBoard, room, and other personal assistance services (including assistance with ADLs, taking medicine, and other similar personal needs), that do not include a health care component and may be provided by people without medical skills or training.
D
Daily Benefit AmountIn a long-term care policy the specific amount of insurance the policy pays for each covered day of long-term care as defined in the policy. The insured may choose from a wide range of daily benefit amounts and, under some policies, different amounts for different types of care, such as a higher daily benefit for nursing home care and a somewhat lower benefit for home care. Options available vary widely among insurers and policies.
Death BenefitIn some long-term care policies, a benefit payable to the insured’s survivors or estate if the insured dies before a specified age. Often 65 or 70. The benefit amount is a refund of premiums the insured paid minus the amount of any benefits the insured received while living.
DeductibleThe amount you must pay before your insurance policy will start paying. May have to be satisfied on an annual basis or once in the lifetime of the policy. Under a long-term care insurance policy the elimination period serves as the deductible.
DementiaProgressive mental disorder that affects memory, judgment, and cognitive powers. One type of dementia is Alzheimer's disease.
Diagnostic Related Group (DRG)A classification based upon an individual’s medical diagnosis at the time the individual is admitted to a hospital for treatment that is funded by Medicare and which determines in advance how much Medicare will reimburse the hospital for treatment regardless of the length of the hospital stay. This has resulted in shorter hospital stays and an increase in nursing home admissions since its implementation in 1984.
E
Elimination PeriodThese terms refer to the waiting period, the initial number of days before the benefits are paid by the insurance company. Most policies offer a choice of waiting periods, ranging from 0 to 365 days, during which policyholders pay for needed services out of their own pockets.
ExclusionAny condition or expense for which a policy will not pay.
Explanation of Medicare Benefits (EOMB)The statement of payment from Medicare; it shows the amount charged by the medical provider, the amount approved by Medicare and the amount actually paid by Medicare. It is this statement that is submitted to the insurance company for payment under the Medigap policy.
F
Facility CareHealth services rendered to an individual in his or her facility. Facility care includes a wide range of services, such as part-time skilled nursing care, speech therapy, physical or occupational therapy, facility health aides, or facility makers.
Free-Look PeriodAn insurance policy provision required by most states, allowing the policy owner to inspect the policy for a specified period of time, often ten, 15, 20 or 30 days and to return the policy to the insurer, if desired, for a refund of the entire premium.
Friendly VisitingProvides person-to-person social contact which prevents isolation and loneliness for older people who live alone.
G
Guaranteed RenewableWith this policy provision, an insurance company cannot cancel a policy unless you fail to pay premiums when due. Premiums cannot be raised unless there is a rate increase for all policyholders in a particular group.
H
Health Care Financing Administration (HCFA)The branch of the U.S. Department of Health and Human Services that administers the Medicare program and provides information about long-term care and other health services.
Health Insurance Association of America (HIAA)An insurance trade group, comprised primarily of private health insurers, that represents the U.S. health insurance industry on public policy and other issues related to health insurance. It also compiles and disseminates data reported by insurance companies, government agencies, and hospital and medical associations. Visit website.
Hodgkin's DiseaseA cancer of lymphoid tissue (found in lymph nodes and the spleen) that causes the lymph nodes to enlarge and function improperly; may cause illness, fever, loss of appetite, and weight loss. (Source: AMA)
Home CareCare provided to a person in his or her home which is mainly for the purpose of meeting the Activities of Daily Living. It may be rendered by persons without professional skills or training working under the supervision of a Home Care Agency or a Home Health Care Agency; however, this does not include a member of your Immediate Family.
Home Delivered MealsProvide at least one home-delivered meal 5 to 7 days a week to homebound elderly persons (and spouses and disabled dependents of any age). Allied services include nutrition education, nutrition counseling and shopping assistance.
Homemaker ServicesA variety of non-skilled at-home services, including shopping, meal preparation, laundry services, housekeeping and similar activities provided either by employees of private home health agencies or state agencies. Some long-term care policies pay a benefit for such services.
HospiceAn organization which primarily provides pain relief, symptom management, and support services for terminally ill patients and their families.
Hospice CareCare for the terminally ill. Includes some medical assistance primarily for pain control and making the ill person comfortable, as well as counseling services for the ill and their families. May occur at home or in an institutionalized setting.
I
Indemnity BenefitA flat payment made directly to the policyholder, rather than to the nursing facility or facility care agency for services rendered.
Inflation ProtectionAn option offered on some long-term care policies which can increase the maximum daily and lifetime benefits to combat inflation. The protection is generally 5% per year, but varies from policy to policy as to whether the increase is calculated at simple or compound interest.
In-Home CareBroad term describing services ranging from light housekeeping to intensive medical care. Can require several different types of health care professionals. Allows elders to remain in their own homes.
Intermediate CareIn the context of long-term care and Medicare, refers to a level of nursing services performed intermittently, rather than around the clock, by professional medical personnel, usually a registered or licensed practical nurse or other medical practitioners such as licensed therapists.
Intermediate Care Facility (ICF)A care facility providing skilled nursing care on an as-needed basis rather than on a 24-hour basis, as well as custodial care associated with the intermediate level care. An Intermediate facility may not provide Skilled Care and, therefore, may not be certified by Medicare since that is the only level of care for which they will pay.
J-K
L
LapseTo allow insurance coverage to expire by not paying premiums.
Level PremiumsThe company cannot raise the premiums due to age or medical condition. The company may raise the premium rates for an entire class of people with permission from the state insurance commission.
Lifetime Maximum BenefitMaximum amount of benefits payable under a long-term care insurance policy. This is determined by the daily benefit and the benefit period chosen at the time of policy purchase. If an unlimited benefit period is chosen, there is no lifetime maximum benefit.
Long Term CareServices that are provided in a setting other than an acute care unit of a Hospital. Long-term Care may include Skilled Nursing Care, Intermediate Care, Custodial Care, Nursing Facility Care, Alternate Facility Care, Home Care, Home Health Care, Adult Day Care, and Respite Care.
Long Term Care Ombudsman ProgramProtects the health, welfare, safety, and rights of residents of long term care facilities, primarily nursing homes and adult homes. Trained and certified volunteers and professional staff visit long term care facilities, receive and investigate complaints, advocate for residents and mediate disputes.
M
Maintenance and Enhancement of Daily Living SkillsIn social adult day care, means activities which supplement, maintain and/or enhance the individual's daily living skills. These skills are wide ranging and include shopping, doing laundry, cooking, using a telephone, grooming and dental hygiene.
Maintenance Nursing CareAlso called simply Maintenance Care or Custodial Care; it is care which is primarily done for the purpose of meeting an individual’s personal needs (activities of daily living) such as bathing, eating, dressing or taking medications. It may be provided by persons without professional training or skills. Even so, this type of care is usually given under a doctor’s orders.
Maximum Daily BenefitThe amount designated in a long-term care policy up to which it will pay benefits per day for nursing home care. It also determines the amount per visit payable for home health care.
MedicaidThe federally supported, state operated and administered public assistance program that pays for health care services to low-income people, including elderly or disabled persons. Medicaid pays for long term nursing facility care and some limited facility health services.
Medical NecessitySome policies also allow medical necessity as a qualifying criteria. This usually means that your doctor has certified that your medical condition will deteriorate if you do not receive needed services in a setting such as a nursing home or your own home. In this instance needed services are identified by your doctor in a Plan of Care.
MedicareThe federal program providing hospital and medical insurance for people aged 65 and older, some disabled persons, and those with end-stage renal disease. Medicare provides only very limited benefits for skilled care, and under specific conditions, for nursing facility and facility health care.
Medicare Supplement InsurancePrivate insurance policies that "supplement" the benefits provided by Medicare. A Medicare supplement policy is sometimes called a "Medigap" policy. Medicare supplements do not provide long-term care benefits.
Medigap InsurancePrivate insurance that supplements Medicare. While Medigap policies typically cover Medicare's deductibles and coinsurance amounts, they do not provide benefits for long term care. Like Medicare, Medigap policies primarily cover hospital and doctor bills.
N
National Association of Insurance CommissionersAn organization of insurance commissioners and superintendents that promotes communication about insurance regulation and practices and recommends model laws related to insurance in all states for the purpose of helping standardize laws and practices, and promoting consumer protection. Visit website.
National Institute on AgingOne of the National Institutes of Health, the principal biomedical research agency of the United States Government. The NIA promotes healthy aging by conducting and supporting biomedical, social and behavioral research and public education.
Nonforfeiture BenefitA policy feature that provides for some return on premiums paid or reduced benefits, even if the policyholder quits paying the premium after a minimum period of time. This feature makes the insurance purchase more of an investment than true insurance, and raises the basic policy price.
Nursing FacilityA facility or part of a facility that is licensed or certified in the state in which it is operating to provide Skilled Nursing Care, Intermediate Care, or Custodial Care.
O
Occupational TherapistHealth and rehabilitation professional that helps people regain, develop, and build skills that are important for independent functioning, health, well-being, security, and happiness. Occupational therapy practitioners work with people of all ages who, because of illness, injury, or developmental or psychological impairment, need specialized assistance in learning skills to enable them to lead independent, productive, and satisfying lives. (Source : American Occupational Therapy Association, Inc.)
Organic DisorderAn alteration in the structure of an organ caused by disease as opposed to psychosomatic or functional disorders in which no evidence of organic problems exist even though some impairment exists. In long-term care policies, often referred to as demonstrable organic disease and should specifically include Alzheimer’s and Parkinson’s diseases, both of which have organic origins. Other associated terms are dementia and organic dementia.
Outline of CoverageA description of policy benefits, exclusions, and provisions that makes it easier to understand a particular policy and compare it with others.
P
Paid-up PolicyIn long-term care insurance, it is generally the operation of a nonforfeiture feature under which the insured’s coverage continues for some period based on the amount of premiums paid when the policy lapses. Methods for providing the paid-up policy may include full benefits for a shorter benefit period or partial benefits for the full original benefit period. Some policies also have a provision which pays up the policy under specified conditions upon the death of an insured spouse. Some companies offer limited or single payment premium modes that result in paid up policies when a specified number of annual premiums have been paid.
Parkinson's DiseaseAn organic brain disease caused by degeneration of or damage to the basal nerve cells of the brain, usually in elderly people and characterized by tremors, muscle rigidity and a shuffling walk. About a third of diagnosed patients progress to dementia after ten or more years if untreated. Symptoms are less severe with drug treatment. It is often covered by name in newer policies.
Period of ConfinementThe time during which you receive care for a covered illness. The period ends when you have been discharged from care for a specified period of time, usually six months.
Peripheral Vascular DiseaseThe narrowing of blood vessels in the legs or arms, causing pain and possibly tissue death (gangrene) as a result of a reduced flow of blood to areas supplied by the narrowed vessels. (Source: AMA)
Personal CareIn general, provides assistance to an impaired individual with toileting, mobility, transfer, eating, dressing, bathing, grooming, personal hygiene, self-administering medication, cooking and other everyday personal tasks. Assistance can range from "some assistance" to "total assistance," and the amount of assistance varies depending in the particular provider, program and funding source.
Personal Care AdvisorA benefit offered by some long-term care policies. Also called Care Coordination Benefit.
Pre-existing ConditionsMedical conditions that existed, were diagnosed, or were under treatment before you took out a policy. Long term care insurance policies may limit the benefits payable for such conditions.
Post Claims UnderwritingA practice whereby a claim is denied on the basis of the individual's health status at the time the policy was purchased. Most reputable companies do medical underwriting at the time a policy is sold, rather than at the time a claim is submitted.
Rehabilitative (Restorative) CareSkilled care provided by a trained medical person (physical therapist, R.N., speech therapist). Its purpose is to restore health following an accident, injury or illness. Medicare pays for a limited amount of this type of care.
Q-R
Rehabilitative (Restorative) CareSkilled care provided by a trained medical person (physical therapist, R.N., speech therapist). Its purpose is to restore health following an accident, injury or illness. Medicare pays for a limited amount of this type of care.
Respite ServicesOnce you are benefit-free (as defined in your particular policy) for a specified length of time, usually six months, those benefits already paid out are restored. Not all long-term care policies offer this benefit.
Return of Premium BenefitA type of nonforfeiture benefit included in some long-term care policies that provides a cash value accumulation and return of premiums in the future to insureds who receive no policy benefits or minimal benefits while the policy is in force. Exact provisions vary from policy to policy, but generally provide a greater return the longer the policy is in force and usually deduct the amount of any claims paid before returning premiums to the insured.
RiderAn attachment to an insurance policy that changes or adds provisions not included in the original policy There is an additional charge for riders added at the insured’s option to provide additional benefits for the insured. Also called an endorsement.
S
Skilled Nursing CareNursing and rehabilitative care that can be performed only by, or under the supervision of, skilled medical personnel.
Skilled Nursing FacilityUnder Medicare, an institution (or a distinct part of an institution) that provides daily skilled nursing care and related services for patients who require medical, nursing, or rehabilitative services.
SocializationIncludes social, intellectual, cultural, educational and physical activities to promote the individual's use of his or her socialization skills and encourage him or her to interact with others.
Spousal DiscountA premium reduction, usually from 10% to 25% of the premium, that some insurers provide when both a wife and husband purchase long-term care policies. Insurers offering such discounts sometimes do so for two people who permanently reside together whether or not they are spouses.
Supervision & MonitoringProtects the safety and welfare of the individual and provides ongoing encouragement by observing the individual and knowing his or her whereabouts and current needs.
Supplemental Nutrition Assistance Program (SNAP)Provides home-delivered meals and other nutrition-related services to the nutritionally at-risk elderly.
T
Telephone ReassuranceFor older people who live alone and need a regular telephone contact to check on their well-being and safety.
U-V
UnderwritingThe process of examining and investigating an applicant for insurance to determine whether or not the insurance company is willing to provide insurance coverage and on what basis.
United Seniors Health Council (USHC)NCOA is the nation's first association of organizations and professionals dedicated to promoting the dignity, self-determination, well being, and contributions of older persons. Visit website.
W-Z
Waiting PeriodIn some health insurance policies, a period during which no benefits are paid immediately after the policy goes into effect. Sometimes used incorrectly as a synonym for an insurance policy’s elimination period.
Waiver of Premium BenefitAny provision included within or as a rider to an insurance policy providing that, when specified conditions exist, the policy will continue in force without further premium payment. When the specified conditions no longer exist. the insured person resumes paying premiums.
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