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

L

Levels of Care can include these three levels of long-term care:

Skilled Care: 24 hour a day prescribed care provided by licensed medical professionals who are under the direct supervision of a physician.

Intermediate Care: Prescribed care that can be provided on an intermittent, rather than continuous basis - for example, physical therapy.

Custodial Care: Care that assists people with daily living requirements, such as dressing, eating and personal hygiene.

Lifetime Maximum: A set benefit amount payable under a contract or policy. In some types of contracts, benefits that have been used are renewable, but usually only up to a specific figure. That specific figure is the lifetime max­imum. It is the total amount of benefits payable during the lifetime of the policy.

Lifetime Reserve Days: Hospitalization (Part A) under Medicare from the 91st day of confinement through the 150th day. This period of consecutive hospitalization is not re­newable; once used, the benefit is gone.

Limiting Charge: Also called Limiting Physician Charge. This refers to the OBRA 1989 and 1990 legislation which, among other things, attempts to put a cap or ceiling on the amount medical providers charge for their services under Part B of Medicare.

Long-Term Care (LTC): A wide range of medical and non-medical services ranging from custodial help with activities of daily living to occasional nursing care to skilled nursing services provided to people who are physically or mentally unable to provide independent care for themselves. Usually used to describe care for the elderly although younger disabled persons also utilize long-term care services. Care may be needed while recovering from an accident or illness, during an extended period of disability, or simply as a result of the normal aging process. Home health care, adult day care, respite care and nursing home stays fall into the category of long-term care.

Long-Term Care (LTC) Insurance: Insurance that covers expenses incurred when the insured receives specified services associated with extended care in a variety of settings including the individual’s home, nursing homes and community-based facilities such as assisted living facilities and adult day care centers. Also called Nursing Home Insurance.

Long-Term Care Partnerships: See State/Private Insurer Long-Term Care Partnerships.

Long-Term Care Rider: An attachment that may be added to some life insurance and other types of insurance policies to allow some or all of the death benefit or other primary benefit to be used to help pay for long-term care costs under situations defined in the policy.

M

Maintenance Nursing Care: Also 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: A limit on the amount that a plan will pay. It may be expressed as a dollar amount or as a time limit.

Maximum Daily Benefit: The 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.

Medicaid: A joint federal-state welfare program that pays for medical care for those with very low incomes. It will cover nursing home costs and some very limited home health care but only after most assets and income have been exhausted. Being on Medicaid may reduce or limit the choice of nursing homes. Called Medi-Cal in California.

Medical Insurance (Part B): That part of Medicare which helps pay for medically necessary physicians’ services, outpatient hospital services, home health care services, and a number of other medical services and supplies that are not covered by Medicare Part A. Part B is also called Supplementary Medical Insurance.

Medicare: The Federal government-sponsored health care program funded and operated by the Social Security Administration, providing medical benefits for individuals over the age of 65, some disabled persons and those with end-stage renal disease. Automatically includes Part A Hospital Insurance. Part B Supplementary Medical Insurance covers physicians services and other outpatient care and is optionally available for a monthly charge. There are some co-payments and deductibles on both Parts A and B. The dollar amounts of these may change each year (check with your local Social Security office for current details).  Medicare does not provide benefits for custodial or intermediate nursing home care, or long-term care.

Medicare Supplement Insurance: Private insurance policies that “supplement” the benefits provided by Medicare. A Medicare supplement policy is sometimes called a  “Medigap” policy supplement because it fills in the “gaps” left by Medicare benefits. Generally speaking, Medicare supplements will pay only if Medicare approves some portion of the services provided. The general rule of thumb is: Medicare supplements supplement Medicare. Therefore, if Medicare totally denies the claim, the supplement policy will deny the claim also. Medicare supplements do not provide long-term care benefits.

Model Policy (NAIC): Any insurance policy prototype, including a long-term care policy, developed and recommended by the National Association of Insurance Commissioners (NAIC) and offered to insurance companies and to the individual states as a minimum standard for approval purposes. Neither insurers nor states are required to accept or adopt NAIC models, although many do. NAIC’s model long-term care policy is more liberal than the first generation of private LTC policies, but less liberal than many private LTC policies currently available.

N

National Association of Insurance Commissioners (NAIC): An 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.

Nonforfeiture Feature: A provision in some long-term care policies offering a guarantee that certain policy benefits will remain available even if the insured stops paying premiums. One type of nonforfeiture is a paid-up policy providing the same benefits for a shorter period or lower benefits for the same period as the original policy. Return of premium benefits are another form of nonforfeiture.

Nursing Home: A non-specific term that refers to any of several types of facilities designed to provide one or more levels of care for persons who need assistance. May include skilled, intermediate, and/or custodial care facilities.

Nursing Home Care is care provided in a skilled nursing facility where all three levels of care (skilled, intermediate and custodial) are provided. In order to be licensed, nursing homes must meet appropriate standards for the state in which they operate. They may or may not be Medicare approved.

O

Organic Disorder: An 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.

P

Paid-Up Policy: In 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 Disease: An 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.

Part A: That part of Medicare that covers inpatient hospital care, skilled nursing facility care, home health care, and hospice care.  Also called Part A Hospital Insurance.

Part B: That part of Medicare that covers physicians’ services, the cost of medical equipment and supplies, outpatient hospital services, and a variety of other medical services not covered by Medicare Part A. Also called Part B Medical Insurance.

Participating Medical Provider: A Participating Physician is one who accepts as payment for his or her services, the portion of the bill that Medicare approves. Medicare will then pay 80 percent of that amount approved and either the patient or their insurance company must pay the other 20 percent remaining.

Peer Review Organization (PRO): A group of practicing doctors and other health care professionals under contract to the federal government to review the care provided to Medicare patients. Also known as a Quality Review Organization (QRO).

Personal Care Advisor: A benefit offered by some long-term care policies.  Also called Care Coordination Benefit.

Pre-Existing Condition: Health conditions diagnosed or treated prior to the effective date of a health care or long-term care policy. Precise definitions differ widely among health insurers and policy types. Policies vary in whether or not they exclude coverage for these conditions and, if so, for how long.

Policy Form Number: Legal designation used by an insurance company when filing a specific policy form with the state insurance department.

Policy Summary: A summation of selected features of an insurance policy prepared and attached to the policy by the insurer for delivery to the policyowner/insured.

Primary Care Physician: Generally refers to HMOs or other types of member organizations; the doctor selected by the enrollee is called the Primary Care Physician since that doctor is in charge of managing that member’s health care needs.

Primary Care Services: Under Medicare, they are designated to include consultation services, hospital in-patient services and psychiatric services. These services are often referred to as “Evaluation and Management Services.”

Prospective Payment System (PPS): Federally mandated method intended to control Medicare costs under which Medicare pays a fixed reimbursement to hospitals based on the individual’s diagnosis rather than on the actual cost of treatment. Costs are determined in advance-prospectively-rather than after the fact or retrospectively. Implemented by classifying patients into diagnostic related groups (DRGs) that dictate the amount Medicare pays for treatment.

R

Registered Nurse (RN): An individual who provides nursing services after completing a course of study that results in a baccalaureate degree and who has been legally authorized or registered to practice as an RN and use the RN designation after passing examination by a state board of nurse examiners or similar state authority.

Rehabilitative (Restorative) Care is skilled 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.

Reinstated Benefits: When a policy has lapsed due to nonpayment of premiums, benefits may be reinstated at the company’s option. It is common for the company to determine proof of insurability before it will do so.

Renewable at the option of the Insurance Company: This refers to policy contract renewability. The insurance company can choose to cancel the policy on an individual basis.

Respite Care: A few hours to several days of assistance to give a temporary rest or break from caregiving for the individual’s usual caretaker, often a family member or friend. The service can be provided at home or in a facility setting such as a nursing home. Benefits for respite care are included in most long-term care insurance policies. Medicare covers respite care only for the terminally ill under their hospice program.

Restoration of Benefits means once 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 Benefit: A 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.

Rider: An 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

Safety Nets: See Gatekeepers

Senile Dementia: Outdated term referring to organic dementia associated with old age. Dementia was formerly divided by age of onset into senile (over age 65) and pre-senile (under age 65). But this division is now considered artificial since symptoms are identical regardless of age.

Skilled Nursing Care: In the context of long-term care or Medicare, refers to the highest level of professional medical care, characterized by 24-hour supervision by a registered or licensed practical nurse as ordered by a physician. For Medicare, must be performed in a skilled nursing facility as specifically defined by Medicare, a requirement that may or may not apply under a long-term care policy depending on the insurer.

Skilled Nursing Facility (SNF): A facility licensed by the individual state, and one that may be certified by Medicare, providing care that requires the highest level of medical skills with continuous, 24-hour attention from a registered or licensed practical nurse, under a physician’s orders and/or supervision. May also provide Intermediate or Custodial care and makes care available from other medical practitioners and for emergency services.

Spell of Illness: A period of time that begins on or with the first day of confinement in either a hospital or nursing home and ends at a specific point. As an example, Medicare’s first 60 days of hospitalization begins on the first day admitted to the hospital and ends when the beneficiary has gone 60 days without being re-admitted to the facility.

Spousal Discount: A 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.

State/Private Insurer Long-Term Care Partnerships: Arrangements between some states and certain private insurance companies to provide long-term care insurance. Subject to the specific legal requirements for each state, these partnerships help protect the assets of insureds who typically must become nearly impoverished before qualifying for Medicaid (Medi-Cal in California) assistance for long-term care costs. In general, the state approves the long-term care policies offered by insurers who agree to include state -mandated provisions. Insureds who purchase the approved policies may protect one dollar in assets for every one dollar in benefits paid by the private insurance coverage. The purpose of these plans is to shift some of the burden for long-term care from Medicaid programs to private insurance while at the same time allowing insurance purchasers to keep assets they would otherwise have to spend in order to qualify for Medicaid when the private insurance benefits are exhausted.

T

Therapeutic Devices may include hospital beds, crutches, wheelchairs, ramps, intravenous pumps and respirators.

U

Underwriting: The 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.

W

Waiting Period: In 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. See Elimination Period.

Waiver of Premium Provision: Any 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.