Insurance World

The last thing you need from an insurance company is a packet of confusing brochures and tables. The best companies know that sending you more “stuff” will just add to your trash can without helping you figure out the intricacies of LTCi. It isn’t as difficult as it seems, but understanding a company’s language and procedures is crucial to getting the policy that fits your needs. To help simplify this language I have compiled–in plain english–many of the basic definitions of the features and optional riders of a LTCi policy.

LTCi basics
Long term care insurance, an insurance program that pays the bill when you need extended care in your home, assisted living facility or nursing home, consists of basic coverage and features plus riders. The basic coverage is the maximum dollar amount per day times the number of days of coverage for which your company will pay for care. It includes an elimination period–which is simply the number of days that you will have to pay for care. Basic coverage should include nursing home and assisted living along with an option of receiving care in your own home.

LTCi features
Features are benefits that are included with your basic coverage. A feature–with the exception of home care–neither adds to your cost nor takes anything out of your “pot of money.” The following benefits should be included in your policy as features, not riders. You might pay a few dollars more, but it will be worth the cost when you need care.

Home health care at 50% or 100%. HHC is the only feature that should add cost to your policy.
Help with activities of daily living, various therapies, skilled nursing, assistance from home health aid or medical social worker
Domestic services
Waiver of premium/spouse discount
Restoration of benefits
Adult day care
Prescription drugs of type given in nursing home or hospital
Rental of hospital equipment
Care giver training
Respite
Hospice/ambulance
Patient Care Coordinator
Home modifications
Bed reservation
LTCi Riders
A rider is an extra benefit that will increase the premium on your policy, often substantially. A certified agent can be indispensable as he/she will help assess your situation to determine which, if any, riders you need.

Don’t refuse LTCi insurance just because you can’t afford the riders. If the initial price seems too high, ask the agent what riders he has included, as agents often include inflation riders without asking. Also, be aware that companies that appear to have lower premiums may simply be listing several of the features as riders. If so, by the time you include those benefits, you will be paying as much as you would to a company that simply includes them as features.

Waiver of premium for spouse
Nearly all legitimate companies waive the premium for the person who goes on claim. However, only the best waive the premium for both when one person needs care. Others add the second waiver as a rider.

Inflation rider
All companies will urge you to include an inflation rider with your policy. This rider will increase your daily maximum as well as your total pot of money by 3%, 4%, 5% compounded, or by 5 percent simple each year. On a 5% compounded, if you start with a $100 per day benefit, you will have $200 per day in 15 years without increasing your premium each year.

Since nursing home costs increase faster than inflation, it’s a good idea to take some sort of inflation rider if you can afford it. It does nearly double the cost of the policy. An alternative is to start with a higher daily benefit in the first place; for example, starting with $200 a day will be much less than $100 a day with an inflation rider. The draw back is that your ceiling is then $200 a day.

If your health is still good, you will have the option of adding the inflation rider at a later date. Keep in mind, however, that the price of it will be based on your attained age. Your agent can do the math to help you determine which approach will save the most money. LTCi without the inflation rider is better than not having LTCi at all.

Optional Increase
Even if you cannot afford an inflation rider, some companies will offer as much as a 15% increase in your benefit every three years. This will increase your premium at the time you add the increase, and you will not receive the offer again once you have turned it down. The increase will be based on your attained age but will not require medical underwriting.

Return of Premium
Return of premium gives your money back after a certain number of years if you have never needed care. If you do not claim it yourself, the premium goes to your beneficiary. However, this rider increases your premium substantially–as much as double or triple the basic premium. Furthermore, neither you nor your beneficiary will receive the entire premium in one lump sum. It is given back over time at approximately the same rate at which you paid it. Most people do not purchase the ROP rider.

Shared benefit
The shared benefit rider is only for a married couple. With some companies, it simply allows a spouse who has spent all the money in his policy to draw out of his wife’s policy, providing she is not on care herself. With others, the rider purchases a third pot of money, equal to the pot of one spouse, that either spouse can draw from when his or her own pot is exhausted. The spouses must have equal benefits to get this rider, and the extra pot does not receive the “restoration of benefit” if the user goes off claim. An inflation protection option will usually apply to the shared benefit amount, however.

Paid-up Survivor benefit
The survivor benefit is one of the best riders a married couple could choose and is very inexpensive, adding as little as $5 or $10 to the basic premium. If husband and wife are on the same policy, and have owned it for at least 10 years, the remaining spouse will receive a life time waiver of premium–with no reduction in benefits–when the first spouse dies. This waiver is priceless to the living spouse, but not all companies offer it.

Non-forfeiture rider
The non-forfeiture rider provides you with a reduced benefit if you should ever become unable to pay your premium and be forced to drop your coverage. Generally, if you have owned your policy for a certain number of years–depending on the company–what you have already paid will be applied toward a paid up policy of up to three years. This prevents you from losing several years of premium and is a relatively inexpensive rider.

Survivor maximum benefit increase
Upon one spouse’s death, a company will increase the surviving spouse’s maximum benefit by one half the deceased’s maximum benefit at the time of his or her death. This one is usually less expensive than an inflation rider or a shared benefit rider, but more than a paid-up survivor benefit.

Don’t assume that any rider can be added to your policy later. Any company will require proof of insurability unless you have a clause that says otherwise; for example, the guaranteed purchase option does not require medical underwriting. The inflation rider can be added later, with proof of insurability, with some companies. If you choose to try to sort out various company brochures on your own prior to sitting down with an agent, be sure to write down a list of questions. There is a lot to know about LTCi; understanding what you are getting in the beginning will save you both dollars and frustration later.

State health insurance is a branch of health insurance that is for high-risk individuals with chronic and/or pre-existing conditions. Most common diseases to see on this type of insurance are HIV, AIDS, kidney disease, obesity, and diabetes. This high-risk pool is designed to act as a safety net to offer some form of insurance to these people but for a hefty premium. This program has fewer participants due to the cost. This plan is not low-income friendly. Rates can be as much as double what the normal market value for health insurance is. The pool does tend to offer better benefits but is definitely geared to those people that truly afford insurance. So, most people who fall under this category and require this type of plan are likely to be uninsured due to not being able to afford a plan. This plan is last resort for persons with such illnesses that land them for emergency or hospital care frequently, and it that case pays for itself quickly. Some of the few persons who cannot afford this are lucky enough to have a spouse in the work place that is able to add them to their policy from their employer, these plans cannot discriminate due to chronic or long-term illnesses. The State Health Insurance Pool knows its rates are high, and claims so are medical costs for the chronically ill. They have to charge more to be able to get ahead and stay afloat.

Most risk pools are nonprofit associations ran by the state. Usually they do not use taxes to operate their business. Most persons requiring this type of service usually are filling up the gap in cost of what their normal plan won’t cover or is a temporary pit stop till they can find a plan that accepts them at a lower cost. The people who qualify for this type of coverage must be a resident of the state they are applying in. Most states require you live there for at least six months and some up to one full year before reaching residency status. You also need one of several possible documents from other insurance companies. You will need proof of rejection from at least one company denying them benefits similar to the ones being asked for. You can use proof of insurance with a higher premium as well. You may also be eligible if you can show proof of insurance with a rider or rated policy. Any of the above mentioned could get you approved to apply for the risk pool in the state you reside in. A reciprocity agreement is when a person who is eligible for the plan and is currently on a similar plan, met the waiting period quota, and not used up the lifetime maximum benefits can still be eligible if they move to another state after they meet the residency requirement. Not all states, but most, have this agreement included into their plan.

There is a list of those who are not eligible in the high-risk pool besides non-residents. You are no longer eligible if you move to another state but if you have a reciprocity agreement, you can become eligible in the state you now reside after residency has been established. Most people who are eligible or receive Medicaid or Medicare are also not eligible. Many states do have a high-risk plan for Medicare eligible persons, but if you receive or could receive Medicaid than you don’t qualify. If a person has terminated their coverage in another plan and less than 132 months have passed they are not eligible for the pool till that time is up. Those who have used their maximum lifetime benefits for their plan are also not qualifying. Inmates of a public institution are also not eligible for the risk pool. Other specific exclusions can include state decided specific diseases or medical conditions that they just don’t want to cover. An enrollment cap may also be in affect so only a specific amount of persons may be actively enrolled at any given point of time. All other applicants who are eligible will be placed on a waiting list till there is an opening. There seem to be a higher list of those who don’t qualify then who do for this high-risk benefit that costs an arm and a leg anyway.