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Long-term care provides services that help people with chronic conditions overcome limitations that keep them from being independent. It helps individuals maintain their level of functioning, rather than improving or correcting medical conditions. If individuals have physical illnesses or disabilities, they often need help with activities of daily living (ADLs). These ADLs include bathing, continence, dressing, eating, toileting and transferring. Individuals with cognitive impairments usually need supervision, protection, or verbal reminders to do everyday activities. Skilled care and custodial care are the terms most often used to describe long-term care and the type or level of care needed.

The eligibility for benefits shall not be more restrictive than the inability to perform at least three of the following ADL s: 1.) bathing, 2.) continence, 3.) dressing, 4.) eating, 5.) toileting, 6.) transferring (ability to move into or out of a bed, chair, or wheelchair). Insurers may use ADLs to trigger benefits in addition to these listed, provided they are listed in the policy. However, an issuer of a qualified long-term care contract (discussed in LTCPP below) is limited to considering only the activities of daily living listed in this paragraph.

Long-term care insurance is designed to help pay for an individual’s long-term care expenses. Depending on the plan you choose, it may pay part or all of your care.

Coverage

Long-term care insurance policies are not standardized. Instead, insurers sell policies providing a variety of benefits and the contracts can be complicated. Every insurer must define its terms, benefits, and exclusions in the policy. Insurers must also deliver an “Outline of Coverage” which helps to explain these terms to a prospective buyer.

You should verify the policy provides the services you need. Some policies only provide benefits if the insured resides in a nursing home. Others only cover benefits received at home. Other policies may provide both nursing home and home health care. Many policies also include coverage for adult day care centers, assisted living centers, or other community facilities.

Home health care coverage also varies. Some policies pay benefits only for skilled nursing care performed in your home by registered nurses, licensed practical nurses, and occupational, speech, and/or physical therapists.

When you apply for a long-term care policy you should choose the following:

  • the daily benefit amount;

  • the maximum benefit period, and

  • the elimination period that would best suit your needs.

The insurance benefit may be a set dollar amount or may be stated as a number of years, months, or days. You must satisfy an elimination period (waiting period), which is the length of time you must wait after entering a nursing home or using home care before benefits from your policy will begin. The maximum elimination period is 180 days.

Prior Hospitalization Requirement

Insurers that issue Long Term Care policies may condition eligibility for benefits on a prior hospital stay ONLY for waiver of premium, post confinement, post acute care, or recuperative benefits. They cannot condition eligibility for benefits provided in an institutional (psychiatric) care setting on the receipt of a higher level of institutional (psychiatric) care.

Also, a long-term care insurance policy containing post-confinement, post-acute care, or recuperative benefits must clearly specify, in a separate paragraph of the policy entitled “Limitations or Conditions on Eligibility for Benefits”, the applicable limitations and any required number of days confinement.

Policies sold prior to 1992 may contain a hospitalization requirement. However, a long-term care policy or rider that conditions eligibility for non-institutional benefits on the prior receipt of institutional care may not require a prior institutional stay of more than 30 days.

Tax Benefits

Federally tax-qualified long-term care insurance contracts provide certain federal income tax advantages. If you are paying a premium for a qualified long-term care contract, you may deduct part or the entire premium.

Low Income

Seniors who do not have the financial resources to pay their long-term health care expenses may qualify for Medicaid. To qualify for Medicaid, your monthly income must be less than the federal poverty level, and your assets cannot exceed certain limits.

Medicaid will cover you only in Medicaid approved nursing homes that provide the level of care needed. Under certain circumstances, Medicaid will pay for home health care. The rules governing Medicaid are complex. For more information about Medicaid, contact the Florida Department of Children and Families at 1-866-762-2237.

Long-Term Partnership Program (LTCPP)

The Long Term Care Partnership Program (LTCPP) is designed to help protect the assets of long-term care insurance policyholders who subsequently seek Medicaid benefits.

The Federal Deficit Reduction Act of 2005 allowed states to establish Qualified State Long Term Care Partnership Programs. However, having a qualified LTCPP policy does not guarantee that the insured will be eligible for Medicaid. The Department of Children and Families determines Medicaid eligibility in Florida. They can be reached at 1-866-762-2237. Click here to visit the FL Medicaid Web site for information on the Long Term Care Partnership Program overseen by the Agency for Health Care Administration (AHCA).

While Florida participates in the LTCPP, not all states do. If a consumer plans to move to another state, check with its Medicaid eligibility agency to find out if they participate in the program. Also, while not all states recognize policies purchased in other states, Florida does honor LTCPP insurance policies purchased in other reciprocal states.

The advantage of a Long Term Care Partnership Program Policy or Certificate is the asset disregard. In return for purchasing a partnership policy or certificate, a portion of a policyholder’s assets will be disregarded when determining their eligibility for Medicaid long term care services, if and when they apply for such services.

Traditionally, to be eligible for Medicaid, applicants’ assets cannot exceed certain financial eligibility thresholds. When applying for Medicaid long term care benefits, the program allows individuals who purchase these policies to retain one dollar in assets for each dollar of long term care insurance benefits paid by the policy. For example, the typical asset limit for an individual applying for Medicaid nursing home services is $2,000. If an applicant received $100,000 in benefits through a partnership program insurance policy or certificate, they may retain up to $102,000 in assets.

Home Health Policy

A Home Health Care policy is a limited benefit policy which provides coverage at the insured person's home, sometimes after an earlier hospital release, due to sickness or injury. This is not to be confused with Home Health Care Benefits which are available under a Long Term Care Policy.

Home Health Care benefits on a Home Health Care Policy are restricted to cases of medical necessity or where activities of daily living are limited. The insured person must be under the care of a physician. The physician determines the need for home health care and sets the daily benefits required. The policy schedule will specify a maximum time period of care and a maximum benefit per hour of care.

Continuing Care Retirement Community

Continuing Care Retirement Communities (CCRCs) are retirement facilities that contract to furnish a resident with shelter and health care in return for an entrance fee and periodic monthly fees. They are also known as “life-care facilities.” Continuing care at-home contracts may also be offered. These are contracts for services rendered by CCRCs and are designed to provide assistance with activities of daily living for individuals that do not live in the CCRC. These contracts provide the option of allowing the consumer to move to the CCRC at a later date.

These facilities are licensed by the Office of Insurance Regulation (OIR). The information on continuing care communities begins on page 18 of a booklet, published by the Department of Financial Services, entitled "Long Term Care: a Guide for Consumers." The information includes a list of the responsibilities of the facilities, the services they provide, and the variety of ways they are financed. The OIR also provides a map of CCRCs located by county at the following link: http://www.floir.com/siteDocuments/CCRCHyperlinkMap.pdf

In addition to the CCRC information, the guide provides a list questions to consider when purchasing a long term care policy and standards by which to judge providers.

Long Term Care Insurance Tips

Verify before you buy!!!! Contact us to verify the license of the agent and the insurance company before you sign the application for a policy.

Long Term Care Insurance Guide: The guide is an excellent tool if you are shopping for an insurance policy. It will help you understand the coverage and your rights and responsibilities.

Review your policy carefully!!!! Understand your coverage, where the care is to be provided, when it starts, and how long it lasts.

Individuals have a 30-day free look provision. You have the right to take up to 30 days to review your policy and decide if you want to keep it or return it for a full refund.

An individual policy must include a grace period provision. The grace period for premium payment is 30 days for a Long-Term Care Insurance Policy.

Homemaker service contracts are not insurance. Since these plans are not insurance, there is no protection if the company goes out of business.

Contact Us or File a Complaint

Should you need additional information, you may speak with an insurance specialist between the hours of 8am–5:00pm at one of the telephone numbers listed below:

1-877-MY-FL-CFO (1-877-693-5236)

Out of State Callers: (850) 413-3089

You can also contact us for assistance anytime by email at Consumer.Services@MyFloridaCFO.com. or file a complaint through our “Consumer Help Online” website.