LTC DISCLOSURE FORM |
1. INSTITUTIONAL CARE | | |
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What levels of care are covered by the policy? | YES | | NO |
Does the policy provide benefits for these levels of care? | | | |
Skilled Nursing Care? | | | |
Intermediate Nursing Care? | | | |
Custodial/Personal Care? | | | |
(By state law, all long-term care policies in Washington State must cover all three of the above levels of care.) | | |
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Where can care be received and be covered under the policy? | | |
Does the policy pay for care in any licensed facility? | | | |
If no, define the restrictions on where care can be obtained: | |
Is the alternative plan of care benefit available with institutional part of policy? | | If yes, see section 2 | |
Does the alternative plan of care benefit include home care? | | If yes, see section 2 | |
Does the alternative plan of care benefit include structural home improvements? | | | |
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2. HOME/COMMUNITY BASED CARE | | |
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What types of care are covered by the policy? | | |
Does the policy provide home care benefit for: | | |
Check all that apply | | |
Adult day care | | | |
Adult day health care | | | |
Chore services | | | |
Home health aides | | | |
Homemaker services | | | |
Hospice | | | |
Hygiene/personal care | | | |
Laboratory services | | | |
Meals/nutrition services | | | |
Medical equipment/supplies | | | |
Prescription drugs | | | |
Physician/nursing services | | | |
Respite care | | | |
Social workers | | | |
Therapies (List) | | | |
Transportation | | | |
Other: | | | |
Are these separate or post-confinement benefits? | Separate | | Post - Confinement | |
Where can home/community-based care be received? | | | |
Check all that apply | | | |
Adult day care centers | | | |
Alternative care facilities | | | |
Assisted living facilities | | | |
Boarding homes | | | |
Community centers | | | |
Congregate care facilities | | | |
Multiple family residences | | | |
Single family residences | | | |
Other: | | | |
Does the alternative plan of care benefit include home care? | | | |
Does the alternative plan of care benefit include structural improvements? | | | |
Must the alternative plan of care be pre-certified? If yes, by whom? | | | |
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3. BOTH INSTITUTIONAL AND COMMUNITY-BASED CARE | | | |
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What is the maximum daily benefit amount for: | YES/NO/COMMENTS |
Institutional/nursing home care? | |
Home/Community Based Care? | |
Are there limits on the number of days (or visits) per year for which benefits will be paid for: | | | |
Institutional/nursing home care? | |
Home/Community based care? | |
What are the dollar limits the policy will pay during the policyholder's lifetime for: | |
Institutional/Nursing home care? | |
Home/Community based care? | |
Total lifetime limit? | |
What basic features and benefits does the policy offer? | | | |
Is the policy guaranteed renewable? | | | |
Can you purchase additional increments of coverage? If yes: | |
When can additional coverage be purchased? | |
How much can be purchased? | |
When is additional coverage no longer available for purchase? | |
Does the policy have inflation protection? | | | |
If yes, what is the % amount of the increase? | |
Is the rate of increase simple or compound? | |
When do increases stop? | |
If policy includes inflation coverage, what is the daily benefit for: | | | |
Institutional/nursing home care. | | | |
5 years from policy effective date? | |
10 years from policy effective date? | |
Home/Community based care. | | | |
5 years from policy effective date? | |
10 years from policy effective date? | |
After the limits have been reached for inflation adjustments, what is the maximum daily benefit for: | |
Institutional/nursing home care | |
Home/community based care | |
After the limits have been reached for inflation adjustments, what is the maximum lifetime benefit for: | | | |
Institutional/nursing home care | |
Home/community based care | |
Is there a waiver of premium provision for: | | | |
Institutional/nursing home care? | | | |
Home/community based care? | | | |
How many days of confinement in an institution are required before the waiver of premium benefit is available? | |
How many days of confinement at home are required before the waiver of premium benefit is available? | |
How many days of benefits must be paid before waiver is effective? | |
Does the policy have a nonforfeiture benefit? | | | |
If yes, how many years must policy be in effect before the insured benefits from nonforfeiture values? | |
What would the benefit value be in terms of dollars after 20 years? | |
What does the nonforfeiture benefit promise? (give an appropriate example showing dollars and time limits) | |
Does the policy have a death benefit? | | | |
If yes, specify value (in dollars of %) | |
What conditions or limitations apply, if any? | |
Does the policy have a restoration of benefits provision? | | | |
If yes, give amount of benefit and minimum required # of days between benefits. | |
If disability recurs, is there a new elimination or waiting period before benefits begin again? | | | |
If yes, after how long? | |
How long is the waiting period for preexisting conditions? | |
How is the preexisting condition defined? | |
When do benefits begin? | | | |
How long is the elimination or waiting period before benefits begin for: | | | |
Institutional/nursing home care? | |
Home/community based care? | |
What gatekeepers are required before benefits start? | | | |
Doctor certification | | | |
Case management | | | |
If yes, by whom? | |
Medical necessity | | | |
Plan of treatment | | | |
If yes, by whom? | |
Inability to perform activities of daily living (ADLs) | | | |
If yes, how many ADLs must fail before benefits begin? | |
If the policy uses an ADL gatekeeper(s), define "inability to perform ADL." | | |
Is there a separate benefit qualification requirement if there is a cognitive impairment? | | | |
Who determines a qualifying event? | |
Define any separate benefit qualification requirement if there is a cognitive impairment: | |
What does the policy cost? | | | |
How often can the premium increase? | |
By how much annually can the premium increase? | |
Is there a discount if both spouses buy policies? | | | |
If so, how much? | |
Do you lose the discount if one spouse dies? | | | |
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4. ADDITIONAL POLICY INFORMATION | | | |
Use this space to outline additional benefits, further explanations or clarifications | | | |
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5. POLICY DEFINITIONS | | | |
(Include definitions of policy provisions) | | | |