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LONG TERM MEDICAL PLANS

Individual vs. Group Insurance
An individual long-term care insurance policy is a contract between you and the insurer. These policies must be approved by the California Department of Insurance (CDI) and have all of the consumer protections required under California law. Individual policies are “guaranteed renewable” and cannot be canceled by the insurance company unless the premium is not paid on time. However, every company has the right to increase the premiums it charges with proper notification and approval from the Department of Insurance.

Group long-term care insurance is a contract between an insurer and a group, such as an employer on behalf of its employees, or a trade or professional association on behalf of its members. If you are covered under a group plan, you receive a “certificate” rather than a “policy” of insurance. Also, many of the policy terms have already been negotiated by the group, and the group (called the “master policyholder”) has the option to terminate the policy at any time. Often, but not always, group insurance is less expensive than individual insurance. If group coverage is terminated, you have the right to continue the coverage or buy a conversion policy, depending on the provisions of the policy and other factors. If you purchase group coverage, ask about what options will be available to you if the group cancels the policy or if you lose your membership or eligibility. Be sure to ask if the premiums will change, and ask how you will be notified.

Note: If you are considering buying group insurance, investigate the sponsoring group. Be sure the group is negotiating in your interest. Some group policies do not have to be approved by the California Department of Insurance, although the company is required to send information about the policy to the Department for its records. The master policy can be cancelled by the carrier or the sponsoring group, at its option.

What Services Do Insurance Policies Cover?
Insurance policies describe where they will pay for care, what kind of care they will pay for, who can provide the care, and conditions that have to be met before a company will pay benefits. Described below are the services required in a long-term care insurance policy approved under current state law. You should be aware however, that California law has changed many times over the years, and that insurance policies sold in previous years may have different requirements than are shown here.

Facility Coverage: In California, most skilled, intermediate and custodial care is received in nursing homes that are licensed as “skilled nursing facilities”. All long-term care policies except Home Care Only cover this kind of care.

Policies sold after October, 2001 (except Home Care Only policies) are required to include a benefit to cover care in an assisted living facility licensed as a Residential Care Facility for the Elderly (RCFE). Some insurance policies sold before October, 2001 also include this benefit. RCFE’s are not nursing homes, but living arrangements where a person can also receive personal care or supervision. Some RCFE's are large retirement homes, while others are small group homes.

Home Care Coverage: Every long-term care insurance policy called “Home Care Only” or “Comprehensive Long-Term Care” issued after January 1, 1993 must include at least the following 6 Home Care benefits and other consumer protections which should make it easier to receive care at home.

1. Home Health Care is skilled nursing care or other professional services in your residence.

2. Adult Day Care is medical or social care in a daytime program in a licensed facility which provides personal care, supervision, protection, or assistance in the following: eating, bathing, dressing, moving about and taking medications.

3. Personal Care is assistance with any of the Activities of Daily Living or ADL's including Instrumental Activities of Daily Living (IADL's) such as using the telephone, managing medications, moving about outside, shopping for essentials, preparing meals, doing laundry and light housekeeping.

Under California law, these services may be provided by a skilled or unskilled person as long as they are required in a Plan of Care developed by your doctor or a team of health care workers under medical direction.

4. Homemaker Services assist you with tasks or activities such as cooking, cleaning and other activities to help you remain in your home.

5. Hospice Services are services in your residence designed to provide physical, emotional, social and spiritual support for you, your caregiver and your family when a terminal illness has been diagnosed. Some policies will pay for these services in an institutional setting as well.

Under California law, these services (like Personal Care) may be provided by a skilled or unskilled person so long as they are required in a Plan of Care developed by your doctor or a team of health care workers under medical direction.

6. Respite Care is short-term care provided in a nursing facility, in your home or in a community-based program, which is designed to relieve the primary care giver in your home.

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