A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

Activities of Daily Living (ADLs): Routine actions such as eating bathing, transferring (bed to chair), dressing, toileting and continence. The inability to perform 2 or 3 of these activities is generally used to determine level and kind of home health or nursing home care needed and to qualify for benefits under long-term care insurance.

Acute Care: Immediate, short-term, medical treatment for a serious illness or injury, usually in a hospital or skilled nursing facility. May be contrasted with chronic care.

Adult Day Care: Care inside or outside the home provided for adults who require assistance with the activities of daily living or other largely non-medical supervision. But possibly including minimal medical-related services such as supervising the taking of medicine. Often includes social and recreational programs and, sometimes, occupational and physical therapy. Primarily intended for care during the hours that family members or other informal caregivers are at work, rather than care on a 24-hour basis.

Adult Day Care Facilities: Community based centers that provide comprehensive services ranging from health assessment and care to social programs for older persons who need some supervision. They may be operated by hospitals, nursing homes, local governments or private groups. Out of pocket costs vary. Medicare does not cover adult day care.

Alternate Care: A 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.

Alzheimer’s Disease: A 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.

Assisted Living Facility: A non-specific term referring to any setting that provides living arrangements and assistance for the elderly and/or disabled. Also called Adult Foster Care.

B

Bed Reservation Benefit: In some long-term care policies, a benefit paid to maintain the insured’s space in a nursing home facility when the insured must be hospitalized temporarily.

Benefit Amount or Limits: In general, the maximum amount payable by an insurer to an insured for the specific benefits contracted for under an insurance policy. In long-term care insurance, generally refers to the daily benefit amount for which the insured has contracted and which is payable for each day of long-term care the insured receives in accordance with the policy’s provisions.

Benefit Cap: The lifetime dollar limitation of a long-term care policy.

Benefit Maximum: Either a certain number of days or a dollar amount expressing what a policy will pay for a given service. This is the “most” that the policy will pay.  It may pay less due to other policy limitations.

Benefit Period: In a long-term care insurance policy, the maximum length of time specified in the contract during which benefits will be paid. Periods available vary considerably from policy to policy and insurer to insurer, ranging from as short as one year to a lifetime. In some cases, especially for longer benefit periods, a maximum dollar limit may also apply. For example, the policy might provide for a lifetime benefit period capped at $500,000 maximum benefits. When $500,000 in benefits have been paid, benefits cease even if the insured is still living and receiving long-term care.

C

Care Coordination Benefit: A benefit in newer long-term care policies that pays consultation fees for a professional, such as a registered visiting nurse or a medical social worker, to periodically assess and make recommendations about the insured’s care program. For example, consultation might begin at a specified time after the insured has been confined to a skilled nursing facility. The purpose is to adjust services when and if the individual’s care needs change. Also called personal care adviser and personal care advocate benefit.

Caregiver: A non-specific term describing either a skilled or nonskilled person who provides some type of care for another. In long-term care policies, types of care and types of caregivers are generally defined for purposes of identifying covered services.

Case Management: A professional service which arranges and coordinates health and/or social services through assessment, service plan development and modification, monitoring, and quality assurance.

Chronic Care: Continuous, long-term care for persons suffering from chronic conditions. May be contrasted with acute care.

Cognitive Impairment: A defect in or loss of all or part of an individual’s memory, judgment, perception, reasoning or other intellectual functioning as medically diagnosed. Often one of the triggers for benefit payments under a long-term care insurance policy.

Cognitive Impairment Reinstatement Provision: A provision in some long-term care policies that allows a policy that has lapsed because the insured did not pay the premium to be reinstated for full benefits if the premiums are paid within six months after the lapse. Typically, the insured’s physician must certify that the insured suffered a cognitive impairment that presumably caused the individual to fail to pay the premium on time.

Coinsurance: A cost-sharing requirement which provides that a Medicare beneficiary must assume a portion or percentage of the costs of covered services. Medicare coinsurance amounts are usually stated either in dollars or as a percentage of the reasonable charge for services.

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 Care is another 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.

Co-Payment: Used interchangeably with coinsurance. Co-payment is usually a set dollar amount rather than a percentage.

Custodial Care: In the context of long-term care or Medicare, refers to assistance requiring the lowest level of skills, helping with activities of daily living, but not with medical care. Can be provided by people who have no medical training, sometimes by aides trained in caregiving skills and frequently provided informally by family members or other unpaid volunteers. Custodial care services, which may be performed in a nursing home, the individual’s home, or some other setting, are the most common type of services required by the elderly and the disabled.

Custodial Care Facility: A care facility providing the lowest skill level of care, primarily assistance with activities of daily living and minimal skilled nursing care, the latter usually limited to supervision of medicine-taking.

Custodial Nursing Care: Also called Maintenance Nursing Care or simply Maintenance Care; it is care which is primarily done for the purpose of meeting an individual’s daily personal needs such as bathing, eating or taking medications. It may be provided by persons without special training or skills. If given in a hospital or nursing home, the care will usually be under the direction of a doctor. Also called custodial care.

D

Daily Benefit Amount: In 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 Benefit: In 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.

Deductible: The amount of health care expense that a Medicare beneficiary must first incur and pay out-of-pocket annually before Medicare will begin payment for covered services. Medicare deductibles include the Part A hospital deductible; the Part B deductible for all covered services under Part B; and the blood deductible.

Dementia: Deterioration of mental ability, generally caused by organic brain disease, less often by psychological factors. Characterized by disorientation and loss of memory and intellect. Also called organic dementia.

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. The DRG classification is part of Medicare’s Prospective Payment System (PPS), designed to help contain costs. This has resulted in shorter hospital stays and an increase in nursing home admissions since its implementation in 1984. Also called Diagnosis Related Groups.

E

Elimination Period: In insurance policies, a period after the onset of an illness or injury during which no benefits are paid, effectively providing for a deductible. Common in long-term care policies, although some insurers offer policies with no elimination period. Sometimes called a waiting period, which is technically incorrect from the viewpoint of the insurance industry, in which a waiting period is a different phenomenon. See waiting period.

Employer-Sponsored LTC Insurance: Long-term care insurance made available by an employer to its employees, similar to other types of group insurance. Many employer -sponsored LTC plans may also be offered to employee family members including spouses, parents, parents of spouses and children, depending on the particular plan and the insurer.

Excess Charge: Also called Balance Billing, it relates to Medicare Part B charges. It is the amount of the medical bill which is above the dollar figure allowed by Medicare.

Exclusion: A condition not covered under the policy.

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.

Extended Care Facility: An institutionalized setting outside of a hospital that provides 24-hour skilled nursing care as prescribed by a physician.

F

Free Look Provision: An insurance policy provision required by most states, allowing the policyowner 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.

Fraud: The outright misrepresentation of facts with the direct intent to defraud either Medicare and/or an insurance company.

G

Gatekeepers: In long-term care Insurance, refers to policy provisions, restrictions or limitations that qualify the insured to begin receiving benefits, such as being referred for care by a physician, being unable to perform a specified number of activities of daily living, having a prior hospital confinement, or others. Technically, these are the coverage triggers in long -term care policies. Also called safety nets.

Guaranteed Renewable Policy: A policy that guarantees the insured may renew the policy up to a specified age, or for life, as long as the insured pays the premiums. The insurance company may increase the premiums on guaranteed renewable policies for all policies of that particular type, but may not increase the premium for any individual policy.

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.

Health Insurance Claim Number: The number listed on the beneficiary’s Medicare card; it will consist of nine digits followed by one or more letters. The nine digits represent the Social Security number of either the beneficiary or their spouse depending upon whose income it is based upon.

Health Maintenance Organization (HMO): A type of service provider that arranges for both health care services and payment for those services. Requires members to pay a pre -set monthly fee covering a broad range of services rather than payment for individual services. Members must use medical practitioners and facilities approved by the HMO, usually at a location the HMO owns and operates and using medical personnel employed by the HMO. HMOs may contract with Medicare to offer Medicare beneficiaries all services covered by fee-for-service Medicare. When a Medicare beneficiary joins an HMO, he or she must usually “sign over” their Medicare benefits to that HMO.

Home Health Care: A type of medical care that is gaining popularity as people attempt to stay out of nursing homes. It is growing rapidly as technology provides equipment that is more portable and personnel receive additional training. As the name implies, services are performed at an individual’s home, as opposed to an outside facility. Generally may refer to any level of care and a wide range of skilled and non-skilled services, including part-time nursing care, various types of therapy, assistance with activities of daily living and homemaker services such as cleaning and meal preparation. For Medicare purposes, this term refers specifically to intermittent, physician-ordered medical services or treatment and should not be confused with definitions contained in long-term care policies. Also called Home Care.

Home Health Care Agency: Either a private commercial venture or a state-operated organization that is licensed to provide health care and/or homemaker services to individuals who need assistance but need not be institutionalized. Those who actually provide the services are commonly referred to as home health aides who may or may not have to be specifically trained and licensed or certified in particular states. Newer long-term care policies often pay for such services performed in an insured’s home.

Homemaker Services: A 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.

Hospice: An organization which primarily provides pain relief, symptom management, and support services for terminally ill patients and their families.

Hospice Care: Care 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. Medicare provides benefits under Part A for this type of care; there are restrictions and qualifications that apply.

Hospital Insurance (Part A): That part of the Medicare program which helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care.

I

Inflation Protection is an 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.

Intermediate Care: In 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 which they will pay for.

Glossary J-Z (cont)