Annuicare® Glossary

A life insurance policy provision under which the policyowner may choose to have a certain portion of the policy proceeds paid out before death under conditions spelled out in the policy. These conditions could include long-term care needs, terminal illness or permanent confinement in an institution.

Everyday functions and activities individuals usually do without help. ADL functions include bathing, continence, dressing, eating, toileting and transferring.

Immediate, short-term, medical treatment for a serious illness or injury, usually in a hospital or skilled nursing facility. May be contrasted with “chronic care.”

A nonresidential setting for those who cannot safely remain at home alone due to physical or mental impairment. Day health centers also provide social, developmental, nutritional and therapeutic activities.

A brain disease which causes loss of memory and serious mental deterioration.

Determining the level of impairment of an individual and the type and extent of services needed.

A process through which a doctor or supplier agrees to accept Medicare’s approved amount as payment in full for services rendered (except for deductible and coinsurance amounts payable by the patient).

A facility that allows for independence, but provides individualized personal care and health services for people who require assistance with Activities of Daily Living.

The amount payable by an insurance company to a claimant or beneficiary when the insured suffers a loss covered by the policy.

Amount of money or days of care beyond which a long-term care policy will no longer pay benefits.

The period of time that begins when the insured becomes eligible for benefits and ends when the insured has been out of claim service for a given period of time, such as 60, 90 or 120 days.

This is the point at which criteria used to determine eligibility for benefits is met. Triggers are based on the need for assistance with ADLs or cognitive impairment or both.

Usually a registered nurse or licensed social worker who evaluates and monitors the patient’s needs and Plan of Care. Will work with the patient’s doctor and coordinate health care providers. May also act as an advocate for the insured/patient.

A person providing care to someone with chronic illness or disability. The caregiver can be an unpaid member of the family, friend or volunteer or a paid professional providing care in the home, community, or institution.

A professional service that arranges and coordinates health and/or social services through assessment, service plan development and modification, monitoring, and quality assurance.

Continuous, long-term care for persons suffering from chronic conditions. May be contrasted with “acute care.”

A cost-sharing requirement that provides that a Medicare beneficiary must assume a portion or percentage of the costs of covered services. Medicare coinsurance amounts are usually stated either in dollars or as a percentage of the reasonable charge for services.

Problems with attention, memory or loss of intellectual capacity requiring supervision to help or protect the impaired person.

Interrelated and connected range of services ranging from home and community-based programs to institutionalization as needed by seniors at various stages of disability.

Also known as Maintenance or Personal Care. Provides assistance with personal needs such as bathing, dressing, and eating.

The amount of health care expense that a Medicare beneficiary must first incur and pay out-of-pocket annually before Medicare will begin payment for covered services. Medicare deductibles include the Part A hospital deductible; the deductible for all covered services under Part B; and the blood deductible.

A category of related diagnoses identified by health insurance plans and by Medicare, for which a hospital is paid a flat amount as part of the health plan coverage or Medicare’s Prospective Payment System (PPS).

The initial number of days before benefits are paid by an insurance company once the insured becomes eligible for benefits under an LTC policy.

Any condition or expense for which a policy will not pay.

The amount of time, usually 30 days, during which the policyowner may return the policy for any reason and receive a full refund of premiums paid.

This provision of an LTC policy states that the insured’s coverage cannot be canceled except for nonpayment of premium. The insurer may only change premium rates or benefits by class. Required in all LTC policies.

A type of prepaid health care plan consisting of physicians, hospitals, and other medical service providers that offers a range of health care services for a fixed fee paid in advance. Federal law requires employers with 25 or more employees to offer HMOs as an alternative to traditional health insurance plans in local areas where HMOs are available. HMOs may contract with Medicare to offer Medicare beneficiaries all services covered by fee-for-service Medicare.

A public or private organization that specializes in providing skilled nursing services and other therapeutic services such as physical therapy in a patient’s home.

Medical and non-medical services provided to ill, disabled, or infirmed persons in their residences. Such services may include Homemaker Services, assistance with Activities of Daily Living, and Respite Care services.

An organization that primarily provides pain relief, symptom management, and support services for terminally ill patients and their families.

Care provided to patients diagnosed with a terminal illness. A team of caregivers and other professionals is usually assembled to provide medical and supportive social services.

That part of the Medicare program that helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care.

An age-segregated facility where healthy, mobile seniors live on their own with a minimum of assistance.

An insurance provision that allows the policyowner to increase benefits over time to offset higher service costs associated with inflation. Offered as an option in an LTC policy.

Occasional nursing and rehabilitative care, ordered by a doctor, that can only be performed by, or under the supervision of, skilled medical personnel.

A physician, registered nurse, or licensed social worker.

Extended care, including both medical and non-medical services, provided to a person who is chronically ill.

The welfare health care program for the poor, jointly administered by the federal and state governments. To qualify for Medicaid, persons must meet poverty standards.

That part of Medicare which helps pay for medically necessary physicians’ services, outpatient hospital services, home health care services, and a number of other medical services and supplies that are not covered by Medicare Part A.

Federal program designed to provide those over age 65, some disabled persons and those with end-stage renal disease with help in paying for hospital and medical expenses. Does not provide benefits for long-term care. 

A private health insurance policy designed to supplement Medicare by “filling in the gaps” in Medicare’s coverage. Most Medigap policies pay all or part of the deductibles and coinsurance costs otherwise payable by the patient, and some Medigap policies cover services for which no benefits are payable under Medicare.

That part of Medicare that covers inpatient hospital care, skilled nursing facility care, home health care, and hospice care.

That part of Medicare that covers physicians’ services, outpatient hospital services, the cost of medical equipment and supplies, outpatient hospital services, and a variety of other medical services not covered by Medicare Part A.

A written, individualized plan of services prescribed by a LHCP to accurately and appropriately address the patient’s needs for care. The Plan is updated as the patient’s needs change.

Medical condition that existed before a person purchases an insurance policy. Laws may vary from state to state. Generally, it is any condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage. LTC policies may place certain limits on benefits payable for such conditions.

A system under which hospitals are paid fixed amounts based upon the principal diagnosis for each Medicare patient’s hospital stay.

A group of practicing doctors and other healthcare professionals under contract to the federal government to review the care provided to Medicare patients. Also known as a Peer Review Organization (PRO).

A form of temporary care in the home, or in a more formal care setting, to relieve the primary caregiver who has been providing constant care.

Daily nursing and rehabilitative care, ordered by a doctor, that can be performed only by, or under the supervision of, skilled medical personnel.

A specially qualified facility which has the staff and equipment to provide skilled nursing care or rehabilitation services, and related health services.

Depletion of assets to pay for long-term care to the point where a person becomes eligible for Medicaid.

This provision of an LTC policy allows the insured to stop paying premiums during the period when the benefits are being received.