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Glossary of Terms

Activities of Daily Living (ADLs)
Activities that people do independently every day—eating, toileting, transferring, bathing, dressing, and maintaining continence.
Acute Care
Medical care that is required for a short period of time to cure a certain illness and/or condition.
Adult Day Care
Health support and rehabilitation services provided in the community to people who are unable to care for themselves independently during the day, but are able to live at home at night.
Alternate Level of Care
Care received in a hospital inpatient setting for those persons waiting to be placed in a nursing home or while arrangements are being made for home care.
Assisted Living
Services provided to support an individual in the performance of activities of daily living (ADLs) or severe cognitive impairment, usually in a community-based residence. Assisted living in the Total Asset 50 and Dollar for Dollar Asset 50 are paid as home care benefits. Assisted living facilities are now licensed in New York State and are identified as an Adult Care Facility or an Assisted Living Residence.
Assisted Living Facility
A residential facility providing ongoing care and related services for persons needing assistance in the activities of daily living.
Care Management
The consultative and planning services provided by a professional, typically a licensed nurse or social worker, to assess, coordinate and monitor the overall medical, personal and social services needed by an individual requiring long-term care.
Chronically Ill Individual
A person who is unable to perform without substantial assistance from another individual at least 2 ADLs (Activities of Daily Living) for a period of at least 90 days due to a loss of functional capacity, or a person requiring substantial supervision to protect the person from threats to health and safety due to severe cognitive impairment.
Cognitive Impairment
The loss or deterioration of intellectual capacity in people suffering from conditions, such as Alzheimer's disease or similar forms of irreversible dementia, characterized by such symptoms as: short- or long-term memory loss; loss of orientation as to people, places or time; and loss of ability for deductive or abstract reasoning.
Combined Home Care Benefit
May be offered by an insurer, and it permits combining of home and community-based care benefit days to pay an amount in excess of the daily benefit amount for home and community-based care benefits set forth in the policy. Where this benefit is stated in the policy, the combination of benefit days shall result in no more than the equivalent of 31 days of home and community based care benefits being paid at the home and community based care daily benefit amount in any one month period.
Community Based Services
Long-term care services that are rendered generally at the insured's home, but include services rendered in a group setting, such as an adult day care center, or where human assistance is required by the insured to aid in necessary travel, such as to a physician's office.
Copayment or Coinsurance
The amount you must pay for each medical service, outpatient hospital service or hospital stay.
Custodial Care
Non-medical care that addresses personal needs, and is available to a chronically ill individual.
Daily Benefit Amount
The amount your insurance policy will cover for each day of services provided. Some policies pay a flat daily benefit amount, while others will pay reasonable and customary charges up to the daily benefit amount.
Deductible
The amount you must pay for health care before Medicare or private medical insurance begins to pay.
Dementia
Impairment of intellectual faculties due to a disorder of the brain.
Dollar for Dollar Asset Protection
The amount of assets that are disregarded by Medicaid resource spend down rules, and is equal to the amount benefits paid from the Dollar for Dollar 50 or Dollar for Dollar 100 plans.
Elimination Period
The number of days of out-of-pocket expense paid by the insured for long-term care services after the insurance benefits are triggered. Sometimes this period is defined as the waiting or deductible period. It can be no greater than 100 days in a Total Asset Protection plan and no greater than 60 days in a Dollar for Dollar Asset Protection plan. Policies are available with shorter elimination periods at higher premium cost.
Extended Grace Period
At least an additional 30 days of grace period resulting from designation of a person to receive notice when the policy is about to lapse. This time is in addition to the normal grace period provided by the insurer.
Free Look Period
Time period after receipt of the policy during which a policyholder can cancel and get a full refund. In New York State this period is 30 days for long-term care insurance policies.
Functional Impairment
The need for assistance to carry out a specific number of activities of daily living.
Guaranteed Renewable
Individual policy can be continued in force by the insured through the timely payment of premiums, and the insurer has no unilateral right to make any change in any provision of the individual policy while the insurance is in force except that premium rates may be revised by the insurer on a class basis. The insurer cannot decline to renew the individual policy as long as the insured makes timely payment of premiums, and, as long as the individual policy was delivered or issued for delivery in New York State, the insurer cannot change the premium rates on a class basis without the approval of the New York State Department of Financial Services.
Home Care and Home and Community Based Care Benefits
A wide range of long-term health care services including skilled nursing care, home health care, personal care services, assisted living, and adult day care.
Home Health Care
A wide range of long-term health care services, from skilled care and physical therapy to personal care delivered at home or in a residential setting.
Hospice Care
A program of care and treatment for persons who are terminally ill and have a life expectancy of six months or less.
Independent Provider Benefit
A home care benefit will be paid to an independent provider who is certified or licensed as a health care practitioner, even though the provider is not associated with an agency licensed or certified by New York State.
Inflation Protection Benefit
Increases the daily benefit amount and policy maximums over time to help keep pace with inflation and increased expenses.
Lapse
A policy that has been cancelled due to the non-payment of premiums.
Level Premium
A policy that is sold on the basis that the premium will remain the same throughout the life of the policy. An insurer may seek a premium increase for all policyholders in an insured class, and such an increase will apply to all policyholders within the class if granted. The New York State Insurance Department reviews such requests to determine whether they are justified on the basis of the insured class solvency.
Long-Term Care
Necessary diagnostic, preventative, therapeutic, curing, treating, mitigating, rehabilitative services and maintenance and personal care services, required by a chronically ill individual pursuant to a plan of care prescribed by a licensed health care practitioner. These services are not limited to a facility. This definition is similarly identified as "qualified long-term care services" in the Internal Revenue Service code.
Long-Term Care Insurance
Insurance available through private insurance companies as a means for individuals to pay for needed care and protect themselves against the high costs of long-term care. This is the most comprehensive level of coverage for long-term care services under insurance regulations in New York State.
Maximum Policy Benefit
The period of time or dollar amount limit for which long-term care benefits will be paid under the policy.
Medicaid
A means-tested program supported by federal, state and local funds, and administered by each state to provide health care for eligible individuals.
Medical Underwriting
A process of examining the current health and health history of a prospect to be insured. The insurer may reject the application for insurance or offer an alternative premium schedule for a person who does not meet the insurer's standards for health or health history at the time of application. A waiver on coverage for existing health conditions, so that the existing conditions are not covered, is another alternative available and used by insurers.
Medicare
A federal government insurance program to assist those 65 and older and the disabled with medical and hospital expenses. Medicare covers only skilled care in a skilled nursing facility and limited nursing care at home. It does not usually provide benefits for personal or custodial care, and for this reason provides limited assistance in a program of long-term care. Medicare requires co-payments and deductibles.
Medicare Supplement "Medigap"
Private insurance policies that supplement Medicare benefits by covering co-payments and deductibles for medical and hospital expenses. Similar to Medicare, these policies do not provide coverage for personal or custodial care, and for this reason provide limited assistance in long-term care situations.
New York City Metropolitan Area
The counties of Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk, and Westchester.
Nonforfeiture Benefit
A benefit designed to ensure that if an insurance policy is lapsed after a specific number of years, some of the benefits from the policy will be retained.
Nursing Home
A a facility that provides room and board and a planned, continuous medical treatment program, including 24-hour-per-day skilled nursing, personal and custodial care. All nursing homes that are licensed or certified and legally operating within the appropriate jurisdiction are deemed to be eligible for benefit payments.
Partnership for Long-Term Care
A public-private partnership which provides that if a long-term care policy qualifying under the partnership program is purchased, the insured will qualify for Medicaid services without "spending down their assets" once the benefits under the policy are exhausted.
Period of Care
A specified number of days of care either in a nursing home or while receiving home care services without a break in the services for a specified number of days.
Personal Care
Assistance provided by another person to help with walking, bathing, eating and other routine activities of daily living. It is provided by aides who are not medical professionals but who are trained to help with these tasks. For tax qualified coverage personal care must meet federal statutory/regulatory requirements to be eligible for benefit payment.
Pre-existing Condition
A condition for which medical advice was given or treatment was recommended by, or received from, a licensed health care provider within six months before the effective date of coverage. If the insurer uses a pre-existing condition limitation, then the pre-existing condition limitation cannot be excluded from coverage for more that six months after the effective date of coverage.
Residential Care Facility
A facility that provides 24-hour care and services sufficient to assist a minimum of three residents with personal needs that result from the inability to perform ADLs (Activities of Daily Living) or from severe cognitive impairment, provides at least two meals per day, has formal arrangements for emergency medical care, and has appropriate procedures in place for the administration of prescribed drugs where allowed by law. All residential care facilities (also known as assisted living facilities, adult care facilities, assisted living residences) that are licensed or certified and legally operating within the appropriate jurisdiction are deemed to be eligible for benefit payments.
Respite Care
Nursing home or home care that temporarily replaces the existing level of support received from an informal, non-paid caregiver for the purpose of providing care and supervision to the patient while relieving the caregiver.
Severe Cognitive Impairment
The loss or deterioration of intellectual capacity in people suffering from conditions, such as Alzheimer's disease or similar forms of irreversible dementia. Severe cognitive impairment must be measured by clinical evidence and standardized tests that reliably measure impairment in the individual's short-term or long-term memory, orientation as to people, places or time, and deductive or abstract reasoning.
Skilled Nursing Care
Nursing and rehabilitative care provided by, or under the direction of skilled medical personnel.
Spending-down
Depleting almost all income/assets to meet usual eligibility requirements for Medicaid.
Tax Qualified Policy
Provides favorable tax treatment for premiums and benefits paid by the policy. These policies must conform to the requirements of the federal Health Insurance Portability and Accountability Act of 1996 and federal regulations/guidance in order to gain the favorable tax status. Long-term care insurance policies approved by the New York State Insurance Department (where the New York State Department of Financial Services has approval jurisdiction) as tax-qualifying, also are provided favorable tax treatment by the State of New York.
Third Party Notice
A policy feature that permits the insured to designate a person who will be notified when coverage is about to end because the premium has not been paid (lapse).
Viatical Settlement
A cash lump sum paid in lieu of a life insurance policy's death benefits.
Waiting Period
The number of days you must be in a nursing facility or the number of days of home health care you must receive before long-term care benefits will be paid under the policy. During the waiting period, you must privately pay for the nursing facility stay or home health care services.
Waiver of Premium
A policy benefit that may be offered by an insurer to waive the payment of premiums after care has begun. This benefit may be offered at an increased premium charge. The period, when waiver of premium begins, and for what specific type of care, nursing home care, residential care facility, home care, or community based services, are specified in the individual policy. The policy should be examined to determine the requirements.