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Glossary of Long-Term Care Terms

You will need to know what is meant by certain terms used to describe your benefits under the Group Long-Term Care Plan. Many of these words are defined below.

Either click on the word you would like defined, or go past the table and scroll through the glossary. If you do not find a word you are looking for, please ask us.


Glossary of Long-term Care Terms (Index)

Actively at Work
Activities of Daily Living
Administrator
Adult Day Care Facility
Adult Day Care
Alternate Facility Care
Alternate Facility
Bed Reservation Benefit
Calendar Year
Care Advisor
Care Advisory Benefit
Cognitive Impairment
Coverage Effective Date
Covered Person
CPI
Custodial Care
End of Plan Coverage
Grace Period
Home Care
Home Health Care Agency
Home Care Agency
Home Health Care
Hospital
Immediate Family
Intermediate Care
Long-term Care
Maximum Daily Benefit
Maximum Lifetime Benefit
Maximum Monthly Benefit
Medical Necessity
Medicare
Mental or Nervous Condition
Nurse
Nursing Facility Care
Period of Care
Personal Care
Premium
Rating Class
Respite Care
Restoration of Benefits
Schedule of Benefits
Service Plan
Skilled Nursing Facility
Unearned Premium
Wait Period



 
Actively at Work
Means work on a regular full-time or regular part-time basis (20 or more hours per week) at one of the Company's business locations or in a location where you are required to be on the Company's business.

 You are not considered Actively at Work on any day you receive sick leave pay, Flexible Time Off for illness pay or income from the Company's Income Protection Plan or you are on a leave of absence.

 In addition, any period while you are on an approved rehabilitation program under the Income Protection Plan will not be considered Actively at Work.

 You will be considered Actively at Work on a day that is not one of the Company's scheduled work days only if you were Actively at Work on the immediately preceding scheduled work day.

You will be considered Actively at Work on any day you receive Flexible Time Off for reasons other than illness.

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Activities of Daily Living
Means certain basic daily tasks necessary to maintain a person's health and safety.

 A person will be considered able to perform Activities of Daily Living if he or she does not require the physical assistance of another person to do the activities. In this Group Long-term Care Plan, "Activities of Daily Living" refers to the activities described below:

     
  1. Bathing means the ability to wash oneself completely in a tub, a shower or by sponge bath; with or without the aid of equipment.

  2.  

     
     
     

  3. Eating means the ability to consume food that has already been prepared and made available; with or without the use of adaptive utensils. "Eating" does not mean an ability or inability to prepare food.

  4.  

     
     
     

  5. Dressing means the ability to: (a) put on and take off all garments and/or any braces or artificial limbs; and (b) to secure and unfasten the garments or devices.

  6.  

     
     
     

  7. Toileting means the ability to do all of the following, with or without the aid of equipment: (a) get to and from the toilet; (b) get on and off the toilet; and (c) maintain a reasonable level of personal hygiene for the body.

  8.  

     
     
     

  9. Transferring means the ability to move in and out of a chair (including a wheelchair) or bed. If a person can move with the help of equipment such as a cane, walker, crutches, grab bars or other support devices, then he or she will be considered able to transfer positions.

  10.  

     
     
     

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Administrator/Program Manager
Means U.S. Care, who has been chosen to administer a Group Long-Term Care Plan on its behalf.
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Adult Day Care
Means a program for six (6) or more individuals, of social and health-related services provided during the day in a community group setting. 

The purpose of the program is to support frail or impaired elderly, or other disabled adults who can benefit from care in a group setting outside the home.

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Adult Day Care Facility
Means a facility which provides Adult Day Care and, in those states that license Adult Day Care, is licensed or certified to provide Adult Day Care.
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Alternate Facility
Means a facility that primarily provides services sufficient to support needs resulting from an inability to perform Activities of Daily Living or Cognitive Impairment to at least six (6) residents in one location and meets all of the following criteria:
     
  1. it provides 24-hour a day care and services sufficient to support needs resulting from inability to perform Activities of Daily Living or Cognitive Impairment;

  2.  

     
     
     

  3. it is state licensed, if required, to provide the level of care and services being rendered;

  4.  

     
     
     

  5. it has supervision to the extent required by law; 
  6. it provides three meals a day and accommodates special dietary needs;

  7.  

     
     
     

  8. it has procedures for procuring the services of a doctor or Nurse to furnish medical care in case of emergency; and,
  9. it has appropriate methods and procedures to assist in administering prescribed drugs.
"Alternate Facility"
May include any of the following types of facilities:
     
  1. Assisted Living Facility
  2. Residential Care Facility
  3. Alzheimer's Facility
  4. Adult Foster Home
  5. Domiciliary Care Facility

  6.  

     
     
     

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Alternate Facility Care
Means care provided in an Alternate Facility.
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Bed Reservation Benefit
Means the payment you receive for room charges in a Nursing Facility or Alternate Facility (to reserve your bed) when you are temporarily hospitalized while receiving benefits. 
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Calendar Year
Means a period of twelve months that begins on January 1 and ends on December 31.
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Care Advisor
Means a health professional designated by U.S. Care to perform your Long-term Care assessment and prepare your Service Plan.
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Care Advisory Benefit
Means the payment for services of a Care Advisor.
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Cognitive Impairment
Means a loss of mental capacity demonstrated by a person's inability to think, perceive, reason or remember. Such impairment: 
  1. Results in a person's inability to care for him or herself without ongoing supervision from another person; and,
  2. Is not due to a Mental or Nervous Condition Without an Organic Cause.
Determination of Cognitive Impairment will be made by U.S. Care on the basis of:
  • clinical data; and,
  • valid standardized measures of such impairment.
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Covered Person
Means a person who is in the Eligible Group and approved for coverage under the Group Long-term Care Plan.
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CPI
Means the Consumer Price Index for all Urban Consumers published by the United States Department of Labor.
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Custodial Care
Means that level of care which is mainly for the purpose of meeting the Activities of Daily Living.

It may be provided by persons without professional skills or training. Such care is intended to:

  • Maintain and support your existing level of health; and,
  • Preserve your health from further decline. It is not primarily for the convenience of you or your family.
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Coverage Effective Date
Means the day upon which your coverage under the Plan starts.

The Coverage Effective Date is shown in the Schedule of Benefits.

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End of Coverage Plan
Means a plan of Long-term Care services prepared by the Care Advisor for which no benefits are payable under the Plan. This plan will be arranged for you when benefits provided by the Plan are about to end due to your Maximum Lifetime Benefit.
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Grace Period
Means the 45 days following the date the Premium payment is due. Although coverage will continue in force during the Grace Period, it will terminate retroactive to the last day through which Premiums are paid, if Premiums due are not paid within the Grace Period.
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Home Care
Means care provided to a person in his or her home which is mainly for the purpose of meeting the Activities of Daily Living. It may be rendered by persons without professional skills or training working under the supervision of a Home Care Agency or a Home Health Care Agency; however, this does not include a member of your Immediate Family.

Home Care includes assisting with or in:

  1. ambulation and exercise;
  2. self-administered medications;
  3. reporting changes in your conditions and needs;
  4. completing appropriate records;
  5. Personal Care;
  6. homemaker services or home health aide services; and,
  7. other services needed to maintain or improve your functional ability.
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Home Care Agency
Means an agency or organization which provides Home Care, and:
     
  1. is supervised by a qualified professional such as a Registered Nurse (RN) or a licensed social worker;
  2. whose employees receive appropriate specialized training;
  3. keeps plan of care records, including doctor's orders where appropriate, on all patients; and,
  4. is state licensed, where required, or accredited by the National Home Caring Council, a Division of the Foundation for Hospice and Home Care, or the Joint Commission on Accreditation of Health Care Organizations, or the National League for Nursing.
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Home Health Care
Means a program of professional, paraprofessional or skilled care provided through a Home Health Care Agency to a patient in his or her home.

Home Health Care may include nursing services provided by a:

  1. Registered Nurse (RN)
  2. Licensed Practical Nurse (LPN)
  3. Licensed Vocational Nurse (LVN)
  4. Licensed Public Health Nurse.
Home Health Care does not include services provided to a patient while confined in a Hospital, Nursing Facility or any other facility which makes a charge for room and board.
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Home Health Care Agency
Means an agency or organization which provides Home Care or Home Health Care, and:
     
  1. Is supervised by one or more: (a) qualified doctors; or (b) Registered Nurses (RN); or (c) licensed social workers; and
  2. Keeps clinical records on all patients; and
  3. Is licensed, certified or approved by state or local law to provide Home Health Care.
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Hospital
Means an institution, operating within the scope of its license when rendering services in treatment of a condition for which claim is made, that is:
     
  1. Accredited as a hospital by the Joint Commission on Accreditation of Health Care Organizations or by the American Osteopathic Association; and,
  2. Licensed as a hospital by the state in which it is located.
"Hospital"does not mean a place or any part of a place, even if it is called a hospital, that is operated mainly for:
  • rest
  • convalescence
  • custodial care
  • care of the aged
  • the care or treatment of drug addicts
  • the care or treatment of alcoholics
  •  rehabilitation; or,
  • training, schooling or occupational therapy.
A hospital operated mainly for the treatment of mental disorders, but lacking surgical facilities, will qualify if it meets all the other requirements of this definition.
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Immediate Family
Means a Covered Person's Spouse, daughter, son, father, mother, sister or brother, granddaughter or grandson, or in-laws.
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Intermediate Care
Means a degree of nursing care and evaluation that is less than that provided for Skilled Nursing Care, but greater than that provided for Custodial Care. This level of care provides a planned, continuous program of nursing care that is preventive or rehabilitative in nature.
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Long-term Care
Means services that are provided in a setting other than an acute care unit of a Hospital. In the Group Long-term Care Plan, "Long-term Care" includes Skilled Nursing Care, Intermediate Care, Custodial Care, Nursing Facility Care, Alternate Facility Care, Home Care, Home Health Care, Adult Day Care, and Respite Care.
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Maximum Daily Benefit
Means the maximum benefit allowed per day as shown in the Schedule of Benefits. The Maximum Daily Benefit will not exceed the daily rate actually charged for the care received in a Nursing Facility or Alternate Facility.
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Maximum Lifetime Benefit
Means the maximum amount of benefits that will be paid for a Covered Person under this Plan during the covered person's lifetime. This benefit limit applies to any combination of Long-term Care services for which a benefit is paid under this Plan.

The Maximum Lifetime Benefit is shown in the Schedule of Benefits.

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Maximum Monthly Benefit
Means the maximum benefit allowed during a given month for any combination of Home Care, Home Health Care, and Adult Day Care, as shown in the Schedule of Benefits. The Maximum Monthly Benefit will not exceed the actual charges for all covered services received during the month.
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Medical Necessity
Some policies also allow medical necessity as a qualifying criteria. This usually means that your doctor has certified that your medical condition will deteriorate if you do not receive needed services in a setting such as a nursing home or your own home. In this instance needed services are identified by your doctor in a Plan of Care.
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Medicare
Means all parts of the Health Insurance for the Aged Act under Title XVIII of the Federal Social Security Act.
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Mental or Nervous Condition Without an Organic Cause
Means:
  • Neurosis
  • Psychoneurosis
  • Psychopathy
  • Psychosis; or,
  • A mental or nervous disorder without demonstrable organic disease.
It does not mean senility or Alzheimer's disease.

 The phrase "mental disorders" will be deemed to mean "Mental or Nervous Condition Without an Organic Cause".

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Nurse
Means a legally qualified person, other than a member of your Immediate Family, who is licensed by the state as either:
  • A Registered Nurse (RN)
  • A Licensed Practical Nurse (LPN)
  •  A Licensed Vocational Nurse (LVN); or,
  • A Licensed Public Health Nurse.
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Nursing Facility

Means a facility or part of a facility that is licensed or certified in the state in which it is operating to provide Skilled Nursing Care, Intermediate Care, or Custodial Care.

 Nursing Facility does not mean a Hospital or an institution that is operated mainly for the treatment and care of:

     
  1. Mental Conditions Without an Organic Cause; or
  2. tuberculosis; or
  3. alcoholism; or
  4. drug addiction; or
  5. training, schooling or occupational therapy.
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Nursing Facility Care
Means care or treatment received in a Nursing Facility. It includes Skilled Nursing Care, Intermediate Care, and Custodial Care.
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Period of Care
Means a period of time, after the Wait Period, during which you are receiving Long-term Care due to (a) an inability to perform two or more Activities of Daily Living; or (2) a Cognitive Impairment.

A Period of Care begins on the first day you receive and are paid for Long-term Care through your Service Plan and ends when you are no longer receiving services or the period specified in your Service Plan has ended.

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Personal Care
Means the provision of hands-on services to assist an individual with Activities of Daily Living (such as bathing, eating, dressing, transferring and toileting).
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Premium
Means the monthly amount payable to the Group Long-term Care Plan by a Covered Person.

The Premium amounts are listed in the Schedule of Benefits as determined by the Rating Class of the Covered Person.

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Rating Class
Means a population segment classified by actuaries as having similar coverage risks.
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Respite Care
Means short-term care which is:
  • needed in order to maintain your health or safety; and,
  • provides temporary relief from caregiving duties to a member of your Immediate Family or any other person who is your unpaid, primary caregiver.
Respite Care includes such services as Home Care, Home Health Care and Adult Day Care. It does not include Nursing Facility Care or Alternate Facility Care.
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Restoration of Benefits
A long-term care policy may reinstate benefits you have used, after you have stopped needing care for a prescribed number of days. For example, if you have a 3-year policy, receive benefits for one year, then do not require care for six months, the policy then gives back the year and you have 3 more years of coverage. If a policy offers restoration of benefits, check to see what percentage of the benefit is restored and how long you must be free of treatment for benefits to be restored.
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Schedule of Benefits
Means a schedule of benefit coverage that is provided to each Covered Person which establishes Premium amounts, Premium payment mode and a summary of the benefits and limitations that apply.
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Service Plan
Means a written description of the Long-term Care services appropriate to meet your needs.

The Service Plan will identify the type and frequency of services you need. It will also indicate any benefits you will receive under the Plan for the services rendered.

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Skilled Nursing Care
Means that level of care which:
  1. requires the training and skills of a Registered Nurse; and
  2. is prescribed by a doctor for the medical care of the patient; and
  3. may not be provided by less skilled or less intensive care, such as Custodial Care or Intermediate Care
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Wait Period
Means the number of days of eligible, covered Long-term Care services which must be received before benefits are payable under this Plan. The Wait Period can be met by any combination of eligible, covered Long-term Care services (except Respite Care Benefits and Care Advisory Benefits) described in this Group Long-term Care Plan. The services need not be continuous but must be received during a period of 12 consecutive months.

The Wait Period is 90 days.

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Unearned Premium
Means a Premium amount paid by you for coverage that extends over a period of time during which your coverage is no longer in force.
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End of Glossary.


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