Does Medicare cover long-term care services?

Medicare provides only limited coverage for long-term care related primarily to recuperating from a sickness or injury. Medicare pays only for skilled nursing care and medically necessary services. You should not rely on Medicare to pay for your long-term care needs.

Can my premiums be increased?

Yes, premiums for all long-term care insurance policies may be increased. However, if premiums are based on issue age, they may only increase if premiums are increased for all individuals insured under the same type of policy. If premiums are based on attained age, premiums will increase as you age.

Can the insurance company cancel my long-term care policy?

No, your policy is guaranteed renewable for life. The policy may only terminate when you cease paying your insurance premiums or if you use the maximum amount of benefits available under the policy.

Are preexisting conditions covered under long-term care insurance policies?

Preexisting conditions must be covered by long-term care insurance policies. However, insurance companies may have a preexisting condition waiting period of up to six months. After your policy is in effect for six months, it will pay for covered benefits.

Are Alzheimer�s and other dementias covered by long-term care insurance?

Alzheimer�s disease and dementias are required to be covered.

What is an elimination period?

An elimination period is similar to a deductible. This means that when you begin using long-term care services there is a waiting period before the policy begins paying benefits. You are responsible for paying for all expenses during the elimination period.

Are benefits paid for all institutional settings such as CBRFs (community based residential facilities), assisted living facilities, and residential care facilities?

Long-term care policies pay only those benefits described or defined in the policy. Some policies pay for assisted living facilities, some do not. Most policies do not cover CBRFs or other placement. Read the definitions in your policy carefully.

How much does a stay in a nursing home cost?

The costs of nursing home care vary among facilities and locations. You should contact those facilities that you would consider acceptable and ask about their current daily charges. You can then determine the amount of coverage you will need.

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In general, the phrase "long-term care" refers to a broad range of services you may need for an extended period of time because of a chronic illness or disability. It usually does not include the type of care you receive on a short-term basis following a hospitalization or an acute illness.

Long-term care includes medical services, such as nursing care or therapies. It also includes supportive services, such as help in bathing, dressing, getting in and out of bed, taking medicines, or preparing meals. Long-term care can be provided in a variety of settings, including nursing homes, your home, an adult day care center, or a group living arrangement with supportive services. Community-based long-term care (provided outside of nursing homes) is often given by family and friends, but can also be provided by paid individuals or agencies, some of which are licensed by the state and/or certified by public funding programs like Medicare.

Nursing Home Care

Care in a nursing home includes several different levels of care:

Skilled Nursing Care

This is care furnished on a physician's order that requires the skills of professional personnel such as a registered nurse or a licensed practical nurse and is provided either directly by or under the supervision of these personnel.

Intermediate Nursing Care

This is basic care including physical, emotional, social, and other restorative services given under periodic medical supervision. This nursing care requires the skill of a registered nurse in administration, including observation and recording of reactions and symptoms, and supervision of nursing care.

Personal or Custodial Care

This is care that can be performed by persons without medical training and that is primarily for the purpose of meeting the personal needs of the patient, including feeding and personal hygiene.

Community Based Long-Term Care

Community-based long-term care can be provided in many settings and by many kinds of providers. If you are receiving several services from different providers, a professional case manager may be involved in arranging for and managing the services. A few of the specific kinds of services and agencies that provide community-based long-term care are:

Home Health Care

Home health care includes:

• Skilled nursing services such as providing therapy treatments or administering medication;

• Home health aide services such as checking temperature and blood pressure;

• Personal care such as help with bathing, dressing, walking, exercise; and

• Physical, occupational, respiratory, or speech therapy.

Assisted Living Facility

Assisted living facility care is care given in a residential facility and includes supportive, personal, or nursing services. Supportive services may involve assistance with meals, housekeeping, laundry, and arranging for transportation. Personal services means direct, hands-on help with activities of daily living.

Adult Day Care

Adult day care is care given in a nonresidential, community-based group program designed to meet the needs of functionally impaired adults. It is a structured, comprehensive program that may provide a variety of health, social, and related support services during any part of a day.

Respite Care

Respite care is the provision of personal care, supervision, or other services to a functionally impaired person in order to temporarily relieve a family member or other primary caregiver from caregiving duties. Respite care services are usually provided in the impaired person's home or in another home or homelike setting, but may also be provided in a nursing home.

Hospice Care

Hospice care is a specially designed package of social and medical services that primarily provides pain relief, symptom management, and supportive services to terminally ill people and their families.

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Whether you require long-term care depends on your level of disability. The chances of needing long-term care usually increase as you age, but long-term care may be needed at any age.

It is important to recognize that at some time in your life you may require long-term care services. Therefore, you should think about how to pay for this care.

In Wisconsin, 3% of all people age 65 to 84 reside in a nursing home. That number increases to 25% for persons above age 85.

The longer a person lives, the more likely it is that he or she will need some kind of long-term care. Some people who have acute illnesses may need nursing home or home health care for only short periods. Others may need care for many months or years. Many people who need long-term care receive that care in their own homes through services provided by home health agencies, relatives, or friends. Others receive care through nursing homes, group homes, or assisted living facilities.

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The costs for long-term care vary depending on the service. For example, in 1998, the average cost for a day in a nursing home was approximately $117 (Wisconsin Department of Health and Family Services). Home health care can also be costly. A home health visit by a registered nurse can cost approximately $96, depending on the length of the visit. Home health aide personal care services provided by a home health agency can cost $53 per hour.

Other types of long-term care services can also be expensive if they are provided frequently or for a long period of time.

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Private Individuals

Most long-term care is paid for by the people receiving the care or by their families. Other sources of payment include Medical Assistance (Medicaid), Medicare, veterans� payments, and private insurance. Many persons who require extensive long-term care eventually "spend-down" their savings and other resources and become eligible for Medical Assistance.

Medicare

Medicare is the federal program that helps pay hospital and medical costs for those who are 65 or older and some disabled persons. It provides very limited coverage for short periods of time for nursing home and home health care but does not cover any long-term care services for extended periods of time.

Nursing Home Care

If a nursing home stay is approved by Medicare, the program pays in full for up to 20 days of skilled nursing care in a skilled nursing facility approved by Medicare. However, Medicare will pay for your stay only if it follows a hospitalization of at least three days and you enter a Medicare-certified nursing home within 30 days after hospital discharge. From the 21st to the 100th day, Medicare pays part of the cost. Medicare pays nothing beyond the 100th day. Very few nursing home stays are covered by Medicare. This is both because many nursing homes do not participate in the Medicare program and because Medicare defines "skilled care" in a very restrictive way.

Home Health Care

Medicare covers only those home health care visits that Medicare considers to be medically necessary. Medically necessary care is defined quite narrowly and you must meet certain other criteria before Medicare will pay for the care. For example:

• The care must include part-time skilled nursing care, physical therapy, or speech therapy;

• You must be confined to home;

• Your doctor must set up a home health plan; and

• The agency providing services must participate in Medicare.

Most home health care visits do not meet Medicare's definition of medically necessary care. Therefore, Medicare will not pay for them.

Medical Assistance

Medical Assistance, also known as Medicaid, is a government health care program paid for by state and federal governments. To be eligible for Medical Assistance:

• You must be 65 or over, disabled, or in a family with dependent children;

  and

• You must have low income and few assets; or

• You must be paying so much money for health care that you have very little income left.

For eligible persons, Medical Assistance pays for most health care costs, including nursing home and community-based care.

Nursing Home Care

Medical Assistance is a major source of payment for nursing home care. About 74% of all nursing home residents in Wisconsin receive help with their nursing home costs. To qualify for Medical Assistance nursing home benefits, an eligible nursing home resident must require medical, nursing, and/or therapeutic care on a daily basis, and be under a doctor�s plan of treatment. Even after a person becomes eligible for Medical Assistance, most of his or her income must be used to pay nursing home bills, with Medical Assistance paying remaining costs (Wisconsin Department of Health and Family Services).

Many residents of nursing homes who receive Medical Assistance are able to pay for their care themselves when they are first admitted to the nursing home. In 1998, in Wisconsin 15% of all nursing home admissions for the elderly were private pay. Over the course of a long nursing home stay, many people use most of their savings to pay for their care, and then become eligible for Medical Assistance (Wisconsin Department of Health and Family Services).

Home Health Care

Home health care can, in many cases, substitute for care provided in hospitals and nursing homes. Medical Assistance pays for home health aide and personal care services for eligible persons who have medical care needs and are under a doctor�s plan of treatment. The services must be received from an agency certified by Medical Assistance.

Personal Care

Medical Assistance also pays for personal care, such as assistance with bathing, dressing, eating, or getting in and out of bed. To be paid by Medical Assistance, services must be received by eligible persons under a doctor's plan of care and provided by a personal care agency certified by Medical Assistance. Persons receiving this care may also be eligible for a limited amount of necessary household help such as grocery shopping, meal preparation, or laundry.

Community Options Program

In Wisconsin, the Community Options Program provides community-based long-term care services to some people who would otherwise need nursing home care. For those with limited income and assets, all or part of the cost of the care can be paid by a special state funding program or, in some cases, Medical Assistance. The Community Options Program offers a wide range of services including personal care, respite care, adult day care, transportation, and even necessary help with household chores. Information on eligibility for the Community Options Program may be obtained from your local county aging unit or your local county social or human services department.

Estate Recovery Program

Wisconsin has an estate recovery program through which the state seeks repayment of Medical Assistance payments for care received while the recipient resided in a nursing home. The program also seeks recovery of certain noninstitutional medical assistance benefits for recipients over age 55. The recovery is made from the estate of a recipient or the estate of the recipient's spouse. An estate includes all assets owned by a person at the time of death.

More information about the Estate Recovery Program is available from your local county social or human services department and tribal agencies.

Medicare Supplement Insurance

Medicare supplement insurance policies do not provide coverage for long-term care. They are designed to supplement Medicare and provide very limited coverage for nursing home and home health care.

For more information on the benefits included in Medicare supplement insurance policies, consult the booklet, "Wisconsin Guide to Health Insurance for People with Medicare" which is available from the Insurance Commissioner's Office.

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There are three types of insurance policies currently on the market in Wisconsin to cover long-term care expenses. They are:

1. Long-Term Care Insurance Policies

   These policies cover both institutional (nursing home or other facility) care and care in the community (home health care or other community-based services).

2. Nursing Home Insurance Policies

   These policies cover only institutional (nursing home or other facility) care.

3. Home Health Care Insurance Policies

   These policies cover only care received in the community (home health care or other community-based services).

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The Wisconsin Insurance Commissioner�s Office has set minimum standards for each of the three types of policies.

All three types of policies must:

• Provide at least one year of benefits.

• Provide benefits based on the level of care only if the lowest limit of daily benefits is not less than 50% of the highest limit of daily benefits. For example, benefits provided for home health care would have to be at least 50% of those provided for nursing home care.

• Policies cannot provide an elimination period longer than 365 days. They may offer a policy with an elimination period of more than 180 days, but the policy must also offer you the opportunity to choose an elimination period of less than 180 days. An elimination period is like a deductible. It is the number of days you would have to wait before the insurance company would make any payments.

• Provide coverage regardless of whether care is medically necessary. However, the policy may require the care to be provided in accordance with a plan of care or that the activities of daily living (ADLs) and cognitive impairment assessment be performed by licensed or certified professionals, such as physicians, nurses, or social workers.

• Pay benefits without requiring you to be in a hospital before getting the covered service.

• Pay benefits if you are unable to perform three or more ADLs or if you have a cognitive impairment.

• Pay benefits if you have "irreversible dementia" (Alzheimer�s disease) provided you have met the waiting periods under the policy and need the type of care covered by the policy. This does not prevent an insurance company from refusing to accept an application from you if you have Alzheimer�s or a similar disease.

• Offer and, if selected, provide an inflation protection option that increases the maximum daily benefit and lifetime benefit amounts, if applicable, in an amount at least equal to 5% compounded annually.

• Offer and, if selected, provide a nonforfeiture benefits option that provides paid-up insurance if the policy lapses.

• Describe the benefit appeal procedure. This procedure requires the company to review the appeal and make a decision within 30 days.

Policies that include home health care benefits must pay for community-based (home health) care:

• Whether or not you have an acute medical problem.

• Even if the services are not provided by a Medicare-certified agency or provider.

• Even if you were not previously in a hospital or nursing home.

Federally Tax-Qualified Long-Term Care Insurance Policies

Congress passed a new law in 1996 called the Health Insurance Portability and Accountability Act (HIPAA). HIPAA allows for certain federal income tax advantages for long-term care insurance policies that are designated as "tax-qualified" or "qualified." If you have a tax-qualified policy, you may be able to deduct part or all of the premium you pay for the policy. You can include the premiums with other annual uncompensated medical expenses in excess of 7.5% of your adjusted gross income. The amount of the premium that you can claim as a deduction depends upon your age.

Long-term care insurance policies sold on or after January 1, 1997, as tax-qualified policies must meet certain standards. These policies must contain a caption on the face page of the policy, similar to:

This policy is intended to be a tax-qualified long-term care insurance contract under Section 7702B (b) of the Internal Revenue Code.

You must receive at the time you apply for coverage an Outline of Coverage that also contains a notice on the face page that it is intended to be a tax-qualified policy.

Tax-qualified long-term care insurance policies are required to cover services for a chronically ill individual that are given according to a plan of care prescribed by a licensed health care practitioner. You are considered chronically ill if you are unable to perform a certain number of activities of daily living without substantial help from another person for at least 90 days. You also may be considered chronically ill if you need substantial supervision to protect your health and safety because you have a cognitive impairment.

The benefits paid by a tax-qualified long-term care insurance policy are generally not taxable as income. Benefits you receive from a nontax-qualified long-term care insurance policy may or may not be taxable as income. The U.S. Department of the Treasury has not yet ruled on this issue.

State Income Tax Deduction

Beginning in the January 1998 taxable year, you can deduct the amount paid for long-term care insurance from your Wisconsin income tax. This deduction applies to both policies designated for federal income tax purposes as tax-qualified and policies that are nontax-qualified.

Life Insurance - Long-Term Care Policies

Another way to cover long-term care services is through a rider attached to a life insurance policy. Long-term care riders attached to life insurance policies are different from long-term care policies in several respects. For example, monthly benefits for a stay in a covered nursing home are typically based on a percentage of the life insurance amount. On a $100,000 policy, a 2% benefit would give you $2,000 a month. A monthly benefit for home health care, when covered under the rider, is usually half of the nursing home benefit.

Long-term care benefits under these riders are tied directly to the amount of life insurance in force. Such benefits will be reduced by any loans or withdrawals against the policy. Using the long-term care benefits will also reduce life insurance coverage under the policy.

A long-term care rider has a separate insurance charge that usually increases each year in a manner similar to the cost of the life insurance under the basic policy. The annual charge for the rider will not exceed the guaranteed cost and will normally be less.

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Many people are interested in long-term care insurance to help pay for a stay in a nursing home or other long-term care services. However, long-term care insurance is not for everyone. For some individuals, long-term care insurance is an affordable and attractive form of insurance. For others, the cost is too high and the benefits are insufficient. The purchase of long-term care insurance should not cause a financial hardship by making you neglect other more pressing financial needs. Each person must examine his or her needs and resources to decide whether long-term care insurance is appropriate.

Whether you should buy a policy will depend on your age, financial status (including your assets and annual income), health, marital status, and overall retirement objectives. For example, if your only source of income is a minimum Social Security benefit or Supplemental Security Income (SSI), or if your assets and income make you close to Medical Assistance eligibility you should carefully consider whether you can afford a long-term care, nursing home, or home health care policy. It makes no sense to buy a policy if you can't afford to pay the premiums year after year.

Remember, if you have existing health problems that are likely to result in the need for long-term care, such as Alzheimer's disease, you probably will not qualify for a policy.

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Type of Coverage

Look at how the policy pays benefits. Policies pay benefits in different ways. For example, some policies pay a fixed amount for each day you are confined in a nursing home or each day you receive community-based care, regardless of the actual cost of the care. Other policies pay according to the provider's actual charges up to a fixed daily amount or a percent of the charges. Policies paying benefits based on a usual and customary charge basis or prevailing charge basis contain a notice to this effect on the face page of the policy.

You should also examine for what period of time benefits are paid. Benefits may last for only one year or for the rest of your life, depending on the policy. In general, plans that provide payments for longer periods of time are more expensive. You may select from several options when you first buy the policy. You may not be able to increase the benefit amounts at a later date without proving insurability.

In comparing insurance policies, be sure to look at the type of coverage contained in the policies. Compare similar policies. For instance, compare nursing home only policies to nursing home only policies.

Policies frequently limit benefits to specific types of services provided by specific types of facilities or agencies. For example, services provided in the home may be limited to those provided by a licensed home health agency. Other types of personal care, help with household chores, or other services may not be covered. Your policy may cover ambulance service to and from the hospital, but the same type of policy offered by another company may not. In other words, it is important to check each policy to be sure you know exactly what services are covered. The kind of long-term care services you may need or want may not be covered under the policy.

You should determine whether premium payments are based on issue age or attained age. Attained age premiums automatically increase as one ages. Issue age premiums will increase only if premiums are increased for everyone insured under the policy form. Some policies limit premium payments to a given payment period, such as 10 or 20 years.

Standards for Benefit Triggers

Policies are required to pay benefits based on benefit triggers called activities of daily living (ADLs). Policies must base benefits on at least six ADLs. They are:

• 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.

• 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 a catheter or colostomy bag.

• Dressing--Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.

• 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.

• 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.

Policies must pay benefits when the insured requires assistance to perform any three of the six activities of daily living, or you have a cognitive impairment. Cognitive impairment means a deficiency in short-term or long-term memory, orientation as to person, place, and time, deductive or abstract reasoning, or judgment as it relates to safety awareness. Assessment of ADLs and cognitive impairment can be performed by licensed or certified professionals, such as physicians, nurses, or social workers. You would be considered unable to perform an activity of daily living if you need hands-on assistance to perform the activity or, in the case of a cognitive impairment, must have supervision or verbal cueing to protect yourself and others.

Preexisting Condition Waiting Period

If you are sick, or under a doctor�s care for a particular condition when you purchase the policy, you may not be eligible for benefits for that condition until a certain period of time has passed. This is called a preexisting condition waiting period. Preexisting condition waiting periods vary from company to company. The longest waiting period permitted in Wisconsin is six months. This waiting period can be applied only to conditions that you have not been asked about on the application and for which you have seen or been treated by a doctor in the six months before you take out the policy.

Elimination Period

Policies frequently have elimination periods. This is the number of days you must be in a nursing home or other facility receiving the care covered by the policy or the number of home care visits that must be received before benefits are paid. You will pay all of the cost of care during the elimination period. The longest elimination period permitted under Wisconsin law is 365 days. Usually, the longer the elimination period, the lower the premium. The longer the elimination period, the less chance there is that you will collect benefits. You may select from several options when you buy a policy. Elimination periods do not begin until the preexisting condition waiting period has been satisfied. Wisconsin law allows insurance companies to offer elimination periods up to 365 days, but the company must also sell the same type of policy that offers elimination periods for 180 days or less.

Inflation Protection

Unless your long-term care policy provides a way for benefits to increase as long-term care costs increase, you may have a benefit that is too low by the time you need care. For example, a nursing home that costs $100 a day in 1995 could cost $150 or more in the year 2010. All policies must offer the option to purchase inflation protection at 5% compounded annually. Some policies may allow you to purchase additional coverage at a later date. The benefit option may cease if you do not agree to accept the 5% increase in a given year. For those policies that express the maximum benefits as a dollar amount, that amount must also increase at the rate of 5% compounded annually. Adding these riders to a policy will increase the cost of the policy.

Waiver of Premium

Many policies provide for a waiver of premium. This means that after a specified period of time of receiving benefits under the policy you may apply to have your premiums waived until you are no longer receiving covered care or the lifetime maximum benefit has been paid.

Nonforfeiture Benefits

All policies must offer the option to purchase a shortened benefit period nonforfeiture benefit option. The nonforfeiture benefit must provide paid-up long-term care, nursing home only, or home care only insurance coverage when you do not pay the premiums on your policy. The maximum benefit under the paid-up policy is the greater of 100% of the sum of all premiums paid for the policy, including premiums paid prior to any change in benefits, or 30 times the daily benefit amount in effect on the lapse date. As with the inflation protection option, such a rider adds to the cost of the policy.

Policy Exclusions

Long-term care policies may have certain exclusions. The most common are for mental and nervous disorders, preexisting conditions, care received outside the USA, and care needed as a result of self-inflicted injury.

Renewability

The renewal provision of a policy is on the first page of the policy and in the Outline of Coverage. All policies currently on the market are "guaranteed renewable for life." This means that your coverage will continue as long as you pay the premium. The insurance company may raise premiums, but only if it raises them for all individuals who have the same policy. This does not mean that your coverage will continue if you have exhausted the benefits in the policy. If you buy a policy with a one-year benefit period, your benefits will end after one year of receiving care. You will not be able to renew these benefits.

Reinstatement

Policies also include reinstatement provisions. If you fail to pay premiums, the insurance company is required to give notice to you and your designee that the policy will lapse in 30 days. However, if your policy lapses and you provide proof of cognitive impairment or inability to perform activities of daily living, your policy can be reinstated if you request reinstatement within at least five months after lapse and pay the past due premiums.

Cost of Policy

The premium may vary according to many factors, including the policy benefits, your age, sex, and place of residence. The conditions under which the premium can be raised and the actual premium charged are discussed in the Outline of Coverage. Policies purchased at younger ages are generally less expensive than those bought at older ages.

Policies include rate stabilization requirements, which prohibit increases in the premium rate schedule during the initial three years a policy is in force. After the initial three-year period, any rate increase is guaranteed for at least two years after its effective date. For insured individuals age 75 or above and whose coverage has been in force for at least ten years, no rate increase may exceed 10%. Premium increases may not be based on your age beyond 65 or on the length of time you have been covered under the policy.

Compare prices when you compare policies. Ask questions if the policy you are considering is a lot less or a lot more expensive than other policies with similar benefits.

Cancellation

You have the right to request cancellation of the policy at any time and the insurance company must issue a prorated premium refund. If you die while the policy is in force, the insurance company will issue a refund of premiums to your estate.

Health Questions

When you apply for long-term care insurance, you may be asked questions relating to your health status, including any prior hospitalization and nursing home confinements. Each insurance company has its own standards for deciding who is eligible for a policy. If the questions are not answered accurately, the insurance company may refuse to pay benefits, terminate the contract, and return your premium at the time you make a claim. If the application is part of the policy, check it again when you receive the policy to make sure all questions have been answered accurately.

Using the Long-Term Care Insurance Checklist included in this guide will give you a more accurate idea of the actual policy premium.

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• Check on the agent selling the policy. You can check with the Insurance Commissioner�s Office to see if an agent is licensed. It is a good idea to work with a local agent who will be available to help file claims and answer questions. Feel free to ask the agent how long he or she has been an agent, and the names of other companies the agent represents. Check with friends and neighbors for the name of a good agent and try to schedule an appointment in the agent�s office.

• Try to compare several policies. A list of all long-term care insurance policies currently being sold in Wisconsin is available from the Insurance Commissioner�s Office.

• Call the Medigap Helpline at 1-800-242-1060. This is a statewide toll-free number that has been set up by the state to answer questions for the elderly concerning health insurance.

• Check with the Insurance Commissioner�s Office to find out whether there have been any administrative actions taken against the company or the agent.

Questions to Ask the Selling Agent:

• What type of policy is it, and what coverage does it provide? Is the policy considered a long-term care, nursing home only, or home health care only policy?

• What types of facilities or providers are eligible to provide the care covered by the policy? Are these facilities and providers available in my community?

• How long will the benefits last?

• How much will the policy pay each day?

• Does the policy have elimination periods before benefits begin? How long are they?

• Are there any preexisting condition limitations?

• What is the cost of nonforfeiture benefits? Inflation protection? Waiver of premium?

• What happens if you don�t pay your premium?

• What conditions are not covered by the policy?

• What number of ADLs must be deficient?

• Is the policy considered a "tax-qualified" policy?

• Who do you contact if you have questions about coverage or if you need help filing a claim?

Free-Look Periods

Take advantage of "free-look" periods. You will have at least 30 days from the time you receive the policy to look it over and decide if you want to keep it. If you decide to return the policy to the company within the "free-look" period, you will receive a full refund.

Do not be misled by advertising.

Don't be misled by the endorsements of celebrities. Most of these people are professional actors who are paid to advertise insurance policies. They are not insurance experts.

Be wary of cards received in the mail that look as if they were sent by the federal government.

They may actually have been sent by insurance companies trying to find potential buyers. Be skeptical if you are asked questions over the phone about Medicare or your insurance. Any information you give may be sold to insurance agents who will call you or come to your home.

Don't overinsure.

It is not necessary to buy several policies. One good long-term care insurance policy, which covers both institutional and community-based care, is enough.

Be careful about dropping one policy to buy another.

Before you buy a new policy be absolutely sure that it is better than the one you already have. Even if your agent has changed companies and wants you to change also, consider it carefully. If you do decide to switch policies, be sure that your new application is accepted before you cancel the old policy.

If you switch policies you may be subject to new preexisting condition waiting periods or have other restrictions placed on your benefits. However, if you replace your policy and there is no lapse in coverage, the time you were covered under one policy counts toward meeting the preexisting condition waiting period under the new policy.

Never pay an agent in cash.

Pay by a check made payable to the insurance company.

Be sure to get the name, address, and telephone number of the agent and the company.

Obtain a local or toll-free number (if the company has one) so you can contact the company.

If you don't receive your policy within 45 to 60 days, contact the company or agent.

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Activities of Daily Living (ADLs)

Activities that are a normal part of everyday life, such as bathing, continence, dressing, eating, toileting, and transferring.

Adult Day Care

Care given in a nonresidential, community-based group program designed to meet the needs of functionally impaired adults. It is a structured, comprehensive program that provides a variety of health, social, and related support services during any part of a day.

Alternative Plan of Care

If you otherwise qualify for benefits, this provision allows you to qualify for benefits not specifically listed in the policy upon the agreement of you, your physician, and the company.

Assisted Living Facility

A place certified or registered by the Department of Health and Family Services. These facilities exist to bridge the gap between independent living and nursing homes and provide a variety of services depending on the residents' needs.

Bed Reservation

This benefit is payable if you are receiving nursing home care and need to spend time in a hospital. The company will cover any charge made by the nursing home for reserving your bed during your hospitalization.

Benefit Triggers

A term used to describe when to pay benefits. One type of benefit trigger is an activity of daily living (ADL). Insurance companies may use different events or types of benefit triggers to determine when benefits will begin to be paid. The triggers are described in the eligibility criteria of the policy.

Care Coordination

Services provided by a licensed or certified health care professional designated by the insurance company to perform an assessment and develop a plan to meet your long-term care needs.

Case Management

Services provided by a licensed or certified health care professional to assist in arranging, monitoring, or coordinating long-term care services.

Caregiver Training

Training provided in order to assist an informal and unpaid caregiver to care for you at home.

Cognitive Impairment

A deficiency in your short-term or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.

Elimination Period

The number of days you must wait after receiving long-term care before receiving insurance benefits.

Exclusion

Any condition or expense that the policy will not pay.

Guaranteed Purchase

A rider to a policy that allows you to increase the benefits during specific periods of time without proof of insurability.

Home Health Care

Care including skilled nursing services such as providing therapy treatments or administering medication; home health aide services such as checking temperature and blood pressure; personal care such as help with bathing, dressing, walking, exercise; and physical, occupational, respiratory, or speech therapy.

Hospice Care

A specially designed package of social and medical services that primarily provides pain relief, symptom management, and supportive services to terminally ill people and their families.

Instrumental Activities of Daily Living

Basic functional activities necessary for you to remain in your home such as meal preparation, shopping, light housekeeping, laundry, telephoning, and handling money and paying bills.

Paid-up Survivor

A rider that, in the event of the death of your spouse, waives the premiums for life if both you and your spouse had coverage for a specified time with the same company.

Plan of Care

A plan outlining the care you need and the length of time the care will be needed.

Respite Care

The provision of personal care, supervision, or other services to a functionally impaired person to relieve a family member or other primary caregiver from caregiving duties. Respite care services are usually provided in the impaired person's home or in another home or homelike setting.

Return of Premium

A rider that provides that if you die after being insured for a specified period or if you have paid premiums for a specified period, the insurance company will return premiums paid minus any benefits paid.

Waiver of Premium

The suspension of premium payments after you have been receiving benefits from the policy for the period of time specified in the policy.

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If you have questions or complaints about:

Medicare

Contact your local Social Security office or your county agency on aging or you may contact the Social Security Administration by calling toll-free 1-800-772-1213.

Medical Assistance

Contact the county Social Service Agency or the recipient hotline. In Madison the recipient hotline number is (608) 266-4279. In other parts of the state the number is 1-800-362-3002.

Insurance

Contact the agent or company involved. If you do not get satisfactory answers, contact the Office of the Commissioner of Insurance, P.O. Box 7873, Madison, Wisconsin, 53707-7873. Phone: 1-800-236-8517. Deaf, hearing, or speech impaired callers may reach OCI through WI TRS. For your convenience, a complaint form is included in OCI's Web Site.

OCI's World Wide Web Home Page

http://badger.state.wi.us/agencies/oci/oci_home.htm

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If you have a specific complaint about your insurance, refer it first to the insurance company or agent involved. If you do not receive satisfactory answers, please contact the Insurance Commissioner's Office at: