Words to Know

This section provides the definitions of words commonly used when discussing long term care or long term care insurance.

A

Activities of Daily Living (ADLs) means the following self-care functions:

Bathing: Washing oneself by sponge bath, or in either a tub or shower, including the task of getting into or out of the tub or shower.
Dressing: Putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.
Toileting: Getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
Transferring: Moving into or out of a bed, chair or wheelchair.
Continence: The ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag.)
Eating: Feeding oneself by getting food into the body from a receptacle (such as a plate, cup, or table) or by a feeding tube or intravenously.

Adult Day Care means a program for six or more individuals of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside the Home.

Adult Day Care Center means a facility that is licensed or certified to provide a planned program of Adult Day Care services by the state in which it operates. If the state does not license or certify such facilities, then it must be operated pursuant to law and meet all of the following standards:

it provides Adult Day Care services in a protective setting and under appropriate supervision, including personal, social, and related supportive services that are designed to meet the needs of functionally or cognitively impaired adults through an individualized service plan;
it operates on less than a 24 hour basis;
it keeps written record of services for each person; and
it has established procedures for obtaining appropriate aid in the event of a medical emergency.

A.M. Best Rating: A.M. Best’s Financial Strength Rating is an independent opinion of an insurer's financial strength and ability to meet its ongoing insurance policy and contract obligations. It is based on a comprehensive quantitative and qualitative evaluation of a company's balance sheet strength, operating performance and business profile.

Application means the written application form provided by an insurance company and completed by an individual to apply for initial coverage, any increase in coverage, reinstatement or exchange.

Assessment means an evaluation done by a Licensed Health Care Practitioner designated by an insurance company to determine or verify that a policy holder is Chronically Ill. The Assessment uses generally accepted tests and instruments that use objective measures and produce verifiable results.

Assisted Living Facility means a facility that is engaged primarily in providing ongoing care and related services that: (a) has the appropriate state licensure or certification as an Assisted Living Facility where required; and (b) meets all of the following requirements:

it provides services and care on a continuous 24-hour basis sufficient to support the needs resulting from the inability to perform Activities of Daily Living or from a Severe Cognitive Impairment;
it has trained and ready-to-respond personnel actively on duty in the facility at all times to provide the services and care;
it makes and keeps records of all care and services provided to each resident;
it provides at least three meals a day and accommodates special dietary needs;
it provides residential services and Maintenance or Personal Care Services for at least six inpatients in one location;
it has formal arrangements with a Physician or Nurse to furnish medical care in case of an emergency; and
it has appropriate procedures to provide onsite assistance with prescription medications.

An Assisted Living Facility is not: a hospital; clinic; a place that operates primarily for the treatment of alcoholism, drug addiction or Mental or Nervous Disorder; a Nursing Home; an individual residence; an independent living unit; or a group living situation that fails to meet the above requirements.

If a facility has multiple licenses, a portion, wing, ward, or unit will qualify as an Assisted Living Facility only if it is engaged primarily in providing care and services that meet all of the above criteria.

B

Benefit Triggers is a term used by insurance companies to describe the criteria and methods they use to determine when a policy holder is eligible to receive benefits.

C

Care Coordinator means a Licensed Health Care Practitioner employed by or under contract to a Care Coordination Provider (see definition below) designated by an insurance company who is qualified by training and experience to assess and coordinate the overall care needs of a person who is Chronically Ill. This person can be a doctor, nurse, social worker or other similarly trained and licensed professional.

Care Coordination means identifying a person’s functional, cognitive, personal, and social needs for care and services and can help link the person to a full range of appropriate services. It may include but is not limited to the following:

the performance of comprehensive individualized Assessments, including reassessments as needed;
the development of Plans of Care, including an initial Plan of Care and subsequent Plans of Care as needed for changes in Your condition;
the coordination of appropriate services and ongoing monitoring of the delivery of such services, when desired by you or Your Representative and determined necessary by the Care Coordinator.

Care Coordination Provider means an agency, entity or person designated by an insurance company that provides Care Coordination and meets certain standards that pertain to staffing requirements, quality assurance, agency functions, reporting and records maintenance requirements.

Chronically Ill: The American General LTC Insurance policy considers a policy holder chronically ill when he or she is certified by a Licensed Health Care Practitioner as:

being unable to perform, without Substantial Assistance from another person, at least two Activities of Daily Living for a period that is expected to last at least 90 consecutive days due to a loss of functional capacity; or
requiring Substantial Supervision to protect Yourself from threats to health and safety due to a Severe Cognitive Impairment.

Confinement or Confined means you are a resident in a Nursing Home, an Assisted Living Facility or a Hospice Care Facility for a period for which a room and board charge is made.

Covered Expenses means costs you incur for Qualified Long Term Care Services and for which a benefit is payable under this Policy. Each benefit section defines its own Covered Expenses.

D

Daily Benefit Amount – The maximum amount a long term care insurance policy will pay in any single day. Not all long term care insurance policies include a daily benefit amount.

Domestic Partner means a person who lives with you in a domestic partner relationship; the American General LTC insurance policy will treat a domestic partner as a spouse, provided that you have completed and returned a Declaration of Domestic Partnership in a form and manner required by the insurance company.

Durable Medical Equipment means equipment included in a Plan of Care which:

can enhance the policy holder’s abilities to perform Activities of Daily Living;
is functionally necessary and not just for the policy holder’s convenience;
is designed for repeated and prolonged use; and
is suited for use in the home.

Infusion pumps, special hospital-style beds, walkers or wheelchairs are examples of types of equipment that may be considered Durable Medical Equipment. Durable Medical Equipment does not include any drug, medicine or equipment implanted in the body, temporarily or permanently. Also not included is any Home Modification, motorized scooter, or sporting, protective, athletic or exercise equipment.

E

Elimination Period means the length of time between when a long term care insurance policy holder becomes eligible for benefits and when the policy holder begins receiving benefit payments from an insurance company. Some policies have calendar day elimination periods and some policies have service day elimination periods. It is important to know which an insurance company offers before you purchase a policy. American General LTC Insurance bases its elimination period on calendar days from the date you are eligible to receive benefits, meaning a policy holder need not receive covered services on a day in order for that day to count towards meeting the Elimination Period.

Exclusions are specific conditions or circumstances for which long term care insurance will not provide benefits.

F

Flexible Care Monthly Benefit means the total amount of monthly benefits payable under the American General LTC policy for the Flexible Care Benefit. It is equal to 40 percent of the Monthly Maximum benefit.

G

Guaranteed Renewable means an insurance company cannot cancel or fail to renew coverage because of a change in a person’s health or age. As long as premiums are paid and benefits have not been exhausted, coverage will continue. However, premiums can be changed if done so for all similar policies issued in the same state and on the same policy form with approval from the state insurance department.

H

Health Insurance Portability and Accountability Act (HIPAA) – HIPAA provides national standards to protect the privacy of personal health information. To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, included "Administrative Simplification" provisions that required Health and Human Services to adopt national standards for electronic health care transactions. Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.

Home means your domicile. Home does not include:

a Nursing Home, Assisted Living Facility or Hospice Care Facility;
a hospital; or
any other institutional setting.

Home Health Care Services means the following services provided in your Home:

part-time or intermittent skilled services provided by licensed nursing personnel;
home health aide services; and
physical therapy, respiratory therapy, occupational therapy, or speech therapy or medical social services.

Home Health Care Agency means an entity that is regularly engaged in providing Home Health Care Services or Maintenance or Personal Care Services for compensation and employs staff who are qualified by training or experience to provide such care. The entity must:

be supervised by a qualified professional such as a Registered Nurse (RN), a licensed social worker, or a Physician;
keep clinical records or care plans on all patients;
provide ongoing supervision and training to its employees appropriate to the services to be provided; and
have the appropriate state licensure or certification, where required or available.

Home Modification means the labor, equipment, and supplies used to make changes in a policy holder’s Home. These changes must be designed to:

enhance the policy holder’s ability to perform Activities of Daily Living; and
allow the policy holder to live safely and independently in his or her Home.

Examples include installation of a ramp in the Home or grab bars in the bathroom. It cannot include home repair, remodeling, or installation of a hot tub, swimming pool, or jacuzzi or other similar items or services.

Hospice Care means services designed to provide palliative care and alleviate an individual’s physical, emotional and social discomforts if he or she is Terminally Ill and in the last phases of life.

Hospice Care Facility means a facility which provides a formal hospice care program directed by a Physician on an inpatient basis. Hospice Care Facility does not mean a hospital or clinic, a community living center or a place that provides residential care only.

I

Inflation Protection – A feature or option of long term care insurance policies that increases the dollar amount of benefits over time to keep pace with rising costs of care.

Immediate Family means an individual’s Spouse, parents, brothers and sisters, and children by blood, adoption or marriage.

Informal Caregiver means the person who has responsibility for providing non-professional care on an unpaid basis for you in your Home, such as a family member or friend.

L

Lapse means the termination of a policy when a premium is not paid.

Licensed Health Care Practitioner means any of the following who is not an Immediate Family Member: a Physician (as defined in this section); a registered professional nurse; a licensed social worker; or any other individual who meets such requirements as may be prescribed by the Secretary of the Treasury of the United States.

Lifetime Maximum means the total amount of lifetime benefits payable under the American General LTC policy.

Long Term Care is the kind of help you would need should a chronic illness, unforeseen accident or disability leave you unable to care for yourself over an extended period of time. The care can take place in your home, an assisted-living facility, an adult day care center or a nursing home. Long term care includes help with daily activities such as eating, bathing or dressing. It encompasses services available in the community, such as visiting nurses, home health aides, home-delivered meals, housekeeping services and adult day care centers. It also covers respite care that provides support to the primary caregiver, who could be a family member, by enabling him or her to take a break. Unlike health (medical) care, the goal of long term care is not to provide a cure but to allow an individual to live with the highest level of independence.

Long Term Care Insurance helps cover the cost of long term care services. If you meet the criteria for claiming benefits, it enables you to receive care at a facility or – under policies like American General LTC – to receive care at your home, if you prefer. Generally, long term care services are not covered by health insurance; health insurance may cover the cost of treatment for illnesses but not the cost of services considered custodial or that support the activities of daily living.

M

Maintenance or Personal Care Services means any care that provides needed assistance with any of the disabilities of a Chronically Ill individual. This includes protection from threats to health and safety due to Severe Cognitive Impairment.

Medicaid is a program that provides medical benefits to low-income individuals. Medicaid is operated and administered by the state government and is subsidized by the federal government. Medicaid is the only program currently in place to pay for nursing home care for people who cannot afford it and who do not have private insurance.

Medicare: The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 is a nationwide health insurance program for people who are 65 or older or who are eligible for Social Security disability payments. The Medicare program has two separate parts. Part A covers inpatient hospitalization and skilled nursing care. Part B covers physician services and certain medical equipment and services. Medicare pays for only a small percentage of nursing home care. Medicare will only cover 100 days of treatment in a skilled nursing facility after a hospital stay of at least three days.

Mental or Nervous Disorder means neurosis, psychoneurosis, psychopathology, psychosis, or mental or emotional disease or disorder, as classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association.

Monthly Maximum means the total amount of monthly benefits payable under the American General LTC Insurance policy for either the Facility Care Benefit or the Home and Community Care Benefit. The Monthly Maximum will increase in accordance with the terms of any Inflation Protection Rider in force.

N

The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate.

Nurse means someone who is licensed as a Registered Graduate Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Vocational Nurse (LVN) and is operating within the scope of that license.

Nursing Home means a facility or distinctly separate part of a hospital or other institution that is appropriately licensed or certified or complies with the state’s facility licensing requirements to engage primarily in providing nursing care to inpatients under a planned program supervised by a Physician. It also:

provides 24 hour-a-day nursing care by a Nurse under the supervision of a Registered Nurse (R.N.) or a Physician;
maintains a daily medical record of each inpatient; and
provides nursing care at skilled, intermediate, or custodial levels.

Nursing Home also means a facility that is licensed as a specialized Alzheimer’s Unit in all states where such licensure exists.

P

Partnership Programs – Partnership between states and private long term care insurance companies which allows long term care insurance policy holders to keep some or all of their assets if they apply for Medicaid after exhausting their long term care insurance policy’s benefits. Not all states have partnership programs. Generally, under a partnership policy the amount of spend-down protection you receive is equal to the amount of benefits paid to a policy holder under their private partnership policy.

Physician (as defined in section 1861(r)(1) of the Social Security Act) means a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the state in which he or she performs such function or action.

Plan of Care means a written individualized plan of services prescribed by a Licensed Health Care Practitioner. It specifies an individual’s long term care needs and the type, frequency, and providers of the services appropriate to meet those needs and the costs, if any, of those services. The Plan of Care will be modified as required to reflect changes in:

an individual’s functional or cognitive abilities;
an individual’s social situation; and
an individual’s care service needs.

Policy means the contract between you and an insurance company.

Q

Qualified Long Term Care Services means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating, and rehabilitative services and Maintenance or Personal Care Services which are required by a Chronically Ill individual and are provided pursuant to a Plan of Care prescribed by a Licensed Health Care Practitioner.

R

Respite Care means supervision and care an individual receives while the family or other individuals who normally provide substantial amounts of care on a daily basis take short-term leave or rest that provides them with temporary relief from the responsibilities of providing care.

S

Severe Cognitive Impairment means a loss or deterioration in intellectual capacity that is comparable to (and includes) Alzheimer’s disease and similar forms of irreversible dementia; and is measured by clinical evidence and standardized tests that reliably measure impairment in the person’s:

short-term or long-term memory;
orientation as to people, places or time; and
deductive or abstract reasoning.

Spouse means the person to whom an individual is legally married, or a Domestic Partner.

Stay At Home Support Lifetime Maximum means the maximum benefit payable under American General LTC Insurance policy’s Stay at Home Support Benefit, which is not to exceed 10 percent of either the Lifetime Maximum or, if an inflation protection rider applies, the Inflated Lifetime Maximum as shown on Your Policy Schedule.

Substantial Assistance means either Hands-on Assistance or Standby Assistance. Hands-on Assistance is the physical assistance of another person without which you would be unable to perform the Activities of Daily Living. Standby Assistance means the presence of another person, within Your arm’s reach, that is necessary to prevent, by physical intervention, Your injury while you are performing the Activity of Daily Living.

Substantial Supervision means continual supervision (which may include cueing by verbal prompting, gestures, or other demonstrations) by another person that is necessary to protect you from threats to Your health or safety (including, but not limited to, such threats as may result from wandering.)

T

Terminally Ill means having six months or less to live, as certified by a Physician.

U

Underwriting is the process of examining, accepting or rejecting insurance risks and classifying those selected, to charge the proper premium for each.

W

Waiver of Premium is a provision of long term care insurance plans that allows the policy holder to stop paying premiums while receiving benefits.