Q: When can I use my for Long Term Care (LTC) insurance benefits?
A: Long term care is the type of care you need due to a chronic illness if you are unable to perform two or more Activities of Daily Living without substantial assistance (stand-by or hands-on), or if you require supervision from another individual due to a cognitive impairment, putting your health and safety at risk.
To qualify for benefits, you must satisfy the elimination period, and be receiving qualified long term care services to treat a chronic illness. A licensed health care practitioner will need to certify that you meet the requirements above for at least 90 days and provide a treatment plan (Plan of Care) for you, and the insurance company must approve the claim.
THE ACTIVITIES OF DAILY LIVING ARE:
BATHING, DRESSING, TOILETING, CONTINENCE, TRANSFERRING, FEEDING
Q: How does the Elimination Period work?
A: The Elimination Period of 90 days is much like a waiting period. It is the amount of time you are chronically ill and receiving qualified long term care services before the benefits begin to pay. The care or services can be provided in a facility or by a licensed home health care agency or professional.
Each calendar week during which you receive at least one day of home care services will be counted as seven days toward the completion of your Elimination Period. Your Elimination Period can be accumulated over a period of 730 consecutive days and needs to be satisfied only once during your lifetime.
Q: When should I file a claim?
A: You should file a claim as soon as you begin to need assistance with your Activities of Daily Living or have a Severe Cognitive Impairment and anticipate needing long term care services at home or a facility. The claim must be filed as soon as is reasonably possible.
Q: How do I file a claim?
A: If you wish to file a claim for benefits, reference the claim procedures described in your insurance certificate. You may download a copy of the claims form HERE or visit LAFRALTC.com to download it under Plan Details/Documents. You may also call 1-800-227-4165 to request one.
To allow a third party to discuss your claim with the insurance company, please also complete the authorization form found HERE.
Q: What services does the policy cover?
The policy covers care in a Nursing, Residential Care, Hospice, Alzheimer’s or Rehabilitation Facility, as well as Home Care Services provided by a Licensed Home Health Care Professional.
Home Care Services may include skilled nursing services, home health aid services, physical therapy, occupational therapy, speech therapy and audiology services, and medical social services by a social worker. Other qualified services include homemaker services, hospice services, personal care, and respite care.
Q: What are Qualified Long Term Care Services
A: Any necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitative services, and maintenance of personal care services that are required by you. The services must be provided pursuant to a written Plan of Care. You must be receiving these services in a facility or by a licensed home health care professional.
Q: How does the benefit work?
A: When you sign up for the LAFRA benefit, you choose a monthly benefit amount and a duration. The monthly benefit options for LAFRA are $1,500 to $8,500 per month (in $1,000 increments) as the monthly benefit. The choices for duration are 2 years, 5 years, or Lifetime. You can also elect to add inflation protection, to help your benefit grow over time.
Your choice of a monthly benefit and duration total the maximum benefit dollar amount that will pay over the life of the policy. This is called the Lifetime Maximum.
For Example: If you choose the $3,500 Facility Monthly Benefit Amount and a 2 Year Duration, your Lifetime Maximum is calculated as: $3,500 per Month X 12 Months X 2 Years = $84,000 Lifetime Maximum
The policy pays 100% of your monthly benefit for care in a Facility and 1/30th of the Home Care Monthly Benefit shown in your Schedule of Benefits for each day you are receiving at least one (1) hour of Home Care Services.
For Example: If you have a policy worth $1,500/month, the benefit would be calculated at $1,500 divided by 30 days which would give you a daily benefit amount of $50. If you receive 15 days of home care in a month, you will be eligible for $750 (15 days x $50). The remaining $750 of your monthly benefit would remain in your Lifetime Maximum to be used in the future.
The policy will never pay more than your monthly benefit amount in a month, but it may pay less. It is important to remember you will be able to use your LTC policy until your entire lifetime maximum is used, no matter how long it takes to use it.
Q: Waiver of Premium
A: After you have satisfied your Elimination Period, and while you are receiving benefits under the policy, your premium payments will be waived. However, premium payments will not be waived if you are only receiving Respite Care Benefits or Additional Care Benefits. If you are no longer receiving benefits, you must resume premium payments.
