OREGON LONG-TERM CARE INSURANCE: COMPANIES & CONSUMER TIPS SHIBA OREGON SENIOR HEALTH INSURANCE BENEFITS ASSISTANCE PROGRAM

Transcription

1 SHIBA OREGON LONG-TERM CARE INSURANCE: COMPANIES & CONSUMER TIPS OREGON SENIOR HEALTH INSURANCE BENEFITS ASSISTANCE PROGRAM

2 Table of Contents An introduction to long-term care...1 Paying for long-term care...1 Long-term care insurance...1 Long-term care insurance resources...2 Oregon consumer protection laws for long-term care insurance...2 Is long-term care insurance right for you?...3 Companies authorized to sell long-term care insurance in Oregon Long-term care insurance personal worksheet...5 Glossary of insurance terms About the Senior Health Insurance Benefits Assistance Program (SHIBA)...9 Where to call for help Oregon Department of Consumer & Business Services Insurance Division Senior Health Insurance Benefits Assistance (SHIBA)...(503) or (800) Information about Medicare and other health insurance (toll-free in Oregon) Publication requests Consumer Protection Section...(503) or (888) Complaints about insurance companies or agents (toll-free in Oregon) Publication requests Authorized insurance companies... (503) Licensed insurance agents... (503) TTY access... (503) Web site... Oregon Department of Human Services Senior & Disabled Services Division...(800) (toll free) Licensed long-term care facilities Medicaid (state and federal help for low income and medically needy) Long-term Care Ombudsman...(800) (toll free) Complaints about long-term care providers In compliance with the Americans with Disabilities Act (ADA), this publication is available in alternative formats. Call (503) or (503) (TTY).

3 Long-term care insurance: companies & consumer tips An introduction to long-term care Long-term care helps people with chronic conditions, such as illness or disabilities, compensate for limits on their ability to live independently. A variety of medical, personal, and social services are available, ranging from in-home-care to care at a skilled nursing facility. Oregon has developed one of the most comprehensive long-term care programs in the nation, based on the belief that Oregonians have a right to the most independent living situation possible. The least-restrictive service is home care; other available services include: Custodial nursing care Intermediate nursing care Skilled nursing care Assisted living Adult foster care Residential care Adult day care Respite care Long-term care is most often provided by a family member. Other long-term care providers can supplement or replace it. Paying for long-term care Long-term care can be expensive. Medicare and Medicare supplement policies don t pay for most long-term care services. If you are 65 or older, find out what Medicare and Medicare supplement policies cover. Most private health insurance policies don t pay for long-term care. Find out if your health insurance covers any long-term care services. Medicaid pays most long-term care expenses for eligible beneficiaries. Contact your local Senior and Disabled Services Division office or Area Agency on Aging to see if you qualify for Medicaid. Veterans may be eligible for service-related care covered by the Veterans Administration. Long-term care insurance A long-term care insurance policy may pay most of the costs for your care in a nursing home, assisted living facility, adult foster care, or home care. You may be able to deduct qualified long-term care insurance premiums from your income taxes in the same way medical expenses are now deducted. To see if your policy qualifies for the deduction, contact one or more of the following: Your insurance agent or company Your tax consultant The Internal Revenue Service The Oregon Department of Revenue The Senior Health Insurance Benefits Assistance (SHIBA) program, (503) , or (800) (toll-free in Oregon) It s OK to change your mind If you aren t satisfied with the long-term care insurance policy you purchase, you always have a 30-day free look period during which you can cancel the policy for a full refund without penalty. If your insurance company denies you this free look period, call our Consumer Protection Section, (503) , or (888) (toll-free in Oregon). 1

4 Long-term care insurance resources Free publications available SHIBA published this booklet to help you decide if long-term care insurance is right for you. It includes: General information about long-term care insurance A summary of Oregon laws relating to longterm care insurance Names and phone numbers of companies approved to sell long-term care insurance in Oregon A worksheet to help you decide if you need long-term care insurance A glossary of common long-term care insurance terms A Shopper s Guide to Long-term Care, published by the National Association of Insurance Commissioners (NAIC), provides additional information to help answer your questions about long-term care. You should have received a copy with this booklet. If you didn t, please call (503) , or (800) (toll free). Volunteers provide one-on-one help The SHIBA program uses trained volunteers to help Medicare beneficiaries with their healthinsurance questions. SHIBA volunteers also can help you understand your long-term care insurance options. For a referral to a volunteer near you, call (800) (toll-free in Oregon). Oregon law protects insurance consumers Policy requirements Each long-term care insurance policy sold in Oregon today must do the following: Provide benefits for custodial nursing care, intermediate nursing care, and skilled nursing care. Pay for treatment of Alzheimer s disease and related dementias diagnosed after the policy is purchased. Base benefits on an impairment of your cognitive ability and ability to perform activities of daily living (ADLs), such as eating, bathing, walking, toileting, and dressing. Pay for adult foster care, stays at assistedliving facilities, and home care, as well as nursing home care. Have the same (or less restrictive) eligibility standards for home care benefits as for nursing home stays. Not require you to go to a hospital before it pays for long-term care services. Not require you to receive a higher level of care before it pays for a lower level of care. For example, some older policies state that you will not qualify for home-care benefits unless you have received skilled nursing care and intermediate care in a nursing facility. Cover pre-existing conditions after six months. 2

5 Is long-term care insurance right for you? Questions before you buy a long-term care insurance policy: How much insurance do you need? Don t buy more coverage than you need. Do you understand the policy? Don t buy any policy you don t understand. How do you feel about your adult children or other relatives caring for you? How do you feel about living with your adult children or other relatives? Are your adult children or others available and willing to care for you? How do you feel about receiving Medicaid? (If you are eligible for Medicaid, you don t need to buy a long-term care insurance policy.) How much can you afford to pay for longterm-care insurance? (Completing the personal financial worksheet on Page 5 will help you decide if you can afford long-term care insurance.) Are your adult children or others able and willing to help pay the premiums? Do you have friends or peers you can ask about their long-term care insurance policies? Other consumers can be an excellent resource. What is your personal and family health history? Do you prefer to buy insurance through a local agent or directly from an insurance company? Do you have a friend or relative who can go with you when you meet with an insurance agent? (Having a third party present may discourage use of scare tactics by an agent and help you remain objective.) Check out agencies and companies before buying insurance Is the agent licensed in Oregon? Call our Agent Licensing Unit, (503) , or check the insurance agent search page on our Web site. Is the company authorized to sell long-term care insurance in Oregon? See Page 4 for a list of companies authorized to sell long-term care insurance in Oregon. Is the company financially strong? Insurer rating services provide information about a company s financial strength. Find this information at the public library or on the Internet. How does the company treat its policyholders? The Insurance Division publishes the Consumer Guide to Oregon Insurance Complaints, which rates insurers based on the number of consumer complaints received by the Insurance Division. The booklet also explains how to find out if a company is financially strong. To request a free copy, call (503) , or (888) (toll-free in Oregon), or write to: Publications Oregon Insurance Division 350 Winter St. NE, Room 440 Salem, OR Visit our Web site for the Consumer Guide to Oregon Insurance Complaints and other insurance publicatons: 3

6 Companies offering long-term care insurance in Oregon The following companies have met Oregon Insurance Division requirements to market long-term care insurance in Oregon. The Insurance Division does not recommend one company over another. This list is subject to change without notice. Some plans are available only to limited groups and aren t included here. Aid Association for Lutherans (800) AIG Life Insurance Co. (800) Allianz Life Insurance Co. of North America (800) Allied Life Insurance Co. (800) American Family Life Assurance Co. of Columbus (800) American Family Mutual Insurance Co. (608) American Fidelity & Liberty Insurance Co. (800) American Travellers Life Insurance Co. (800) Bankers Life and Casualty Co. (800) , ext Bankers United Life Assurance Co. (800) Catholic Order of Foresters (800) Combined Insurance Co. of America (503) or (541) or (916) Continental Casualty Co. (800) Continental General Insurance Co. (800) Country Life Insurance Co. (888) CUNA Mutual Life Insurance Co. (800) Equitable Life and Casualty Insurance Co. (800) Farmers New World Life Insurance Co. (206) Federal Home Life Insurance Co. (800) First Penn-Pacific Life Insurance Co. (888) Fortis Benefits Insurance Co. (800) Fortis Insurance Co. (800) General Electric Capital Assurance Co. (800) Great American Life Insurance Co. (800) Hartford Life Insurance Co. (800) IdeaLife Insurance Co. (800) IDS Life Insurance Co. (800) John Alden Life Insurance Co. (888) John Hancock Mutual Life Insurance Co. (800) Life Investors Insurance Co. of America (800) Lincoln Benefit Life Co. (877) Massachusetts Casualty Insurance Co. (800) Medico Life Insurance Co. (800)

7 Metropolitan Life Insurance Co. (AARP) (800) Monumental Life Insurance Co. (800) Mutual of Omaha Insurance Co. (800) Mutual Protective Insurance Co. (800) National States Insurance Co. (800) New York Life Insurance Co. (800) Northwestern Long Term Care Insurance Co. (414) Pacific Life Insurance Co. (949) PFL Life Insurance Co. (800) Physicians Mutual Insurance Co. (800) Prudential Insurance Co. of America (800) Pyramid Life Insurance Co. (800) Southwestern Life Insurance Co. (800) Standard Life and Accident Insurance Co. (888) (888) (Oregon Director) State Farm Mutual Automobile Insurance Co. (970) State Life Insurance Co. (818) Teachers Insurance & Annuity Association (800) Transamerica Occidental Life Insurance Co. (800) Travelers Insurance Co. (800) Trustmark Life Insurance Co. (800) Union Labor Life Insurance Co. (800) United American Insurance Co. (972) Unum Life Insurance Co. of America (800) Long-term care insurance personal worksheet What is your annual income? Under $10,000 $30,000 to $50,000 $10,000 to $20,000 Over $50,000 $20,000 to $30,000 It may not be a good idea to buy a policy if the premiums will be more than seven percent of your income. How do you expect your income to change over the next 10 years? No change Increase Decrease Where will you get the money to pay each year s premium? Income Savings Other family members will pay Could you afford to keep this policy if the company raised your premiums by 25 percent? Yes No Don t know Not counting your home, what is the approximate value of all of your assets (savings and investments)? $0 to $20,000 $30,000 to $50,000 $20,000 to $30,000 Over $50,000 It may not be a good idea to buy this policy if your assets are less than $30,000. How do you expect your assets to change over the next 10 years? No change Increase Decrease 5

8 Glossary Active assistance: The hands-on help of another person in performing activities of daily living (ADLs). Activities of daily living (ADLs): Daily activities such as getting out of bed, walking, going to the toilet, bathing, dressing, eating, and taking medications. Acute: A medical condition that begins suddenly and doesn t last very long. Adult day care: Temporary daytime care provided for frail and isolated persons who seldom leave their homes. Day care includes social contact and health monitoring. This can be a source of respite care when care providers need a break from providing 24-hour in-home care. Adult foster care facility: A state-licensed facility for five or fewer adults who need assistance with bathing, medications, grooming, dressing, eating, etc. See Residential care. Age at issue: The age of a person at the time the application for insurance is made or on the effective date of an insurance plan. Premiums based on age at issue will not automatically increase whenever the insured has a birthday. Assisted living facility: A state-licensed facility providing home and community services in a comfortable, homelike environment. Residents have medical staff available 24 hours a day. They live in their own apartments with their own belongings. Meals are generally served in a central dining room. Attained age policy: Insurance for which premiums will increase as you grow older. Some companies increase the rate annually; some use age bands. For example, premiums may increase every five years. Benefit period: The period of time for which benefits are payable. Chronic: A medical condition that lasts for a long time or recurs frequently. Cognitive impairment: Deterioration of intellectual capacity as shown by measurable loss in the areas of memory, orientation, and reasoning. Co-insurance: The amount of a covered expense that an individual is required to pay. Also known as a co-payment. Compound: Used to describe inflation protection, when the amount of increase in benefits is computed based on the current benefit amount (the original amount plus any subsequent increases). Covered expenses: Those medical expenses that your policy pays for under the terms of your contract. Custodial care: Care that assists an individual in the activities of daily living (see ADLs ). This care can be provided by those without professional licenses or extensive training. Oregon does not license custodial care facilities, although custodial care is provided in many licensed facilities. About the Oregon Insurance Division The mission of the Insurance Division is to protect the insurance-buying public by administering and enforcing the Insurance Code. We ensure the financial soundness of insurers, the availability and affordability of insurance, and the fair treatment of consumers by doing the following: Serving as an advocate for consumer interests on insurance issues Resolving consumer complaints Investigating and penalizing violations of insurance law Reviewing insurance policies and premium rates for compliance Licensing insurance companies and agents Monitoring insurers for solvency and marketplace conduct Educating the public about insurance issues 6

9 Deductible: A predetermined amount of money to be paid by the insured before the insurance policy begins to pay. Directional assistance: Help by instruction or reminder help in performing activities of daily living. Effective date: The date the policy begins. This date is used to determine when coverage begins for eligible expenses. Elimination period: See Waiting period. Endorsement: See Rider. Exclusion: Specific conditions or circumstances for which the policy will not pay. Typical exclusions include suicide attempts, losses related to alcohol and drug use or abuse, and mental illness. Grace period: The number of days after your premium due date in which it can still be paid without cancellation, usually 31 days. Guaranteed renewable: A policy that can t be canceled as you grow older or if your health worsens, unless you fail to pay your premiums. Guaranty association: An organization created by Oregon law to protect consumers when an insurance company becomes insolvent. Home health care: Assistance that allows people to stay in the most independent of all long-term care settings. Advances in medical technology mean that some ill and frail people can receive skilled medical care at home. Home care includes personal hygiene/bathing, housekeeping, skilled nursing care, social or emotional support, mobility and activity assistance, nutrition and feeding, assistance with self-administered medication and other needs, meal preparation, shopping, laundry, dressing, and money management. Home care also may include personal care. That means a certified nurse assistant provides care under a doctor-prescribed plan. Personal care services may include bowel and bladder care, first aid, emergency care, and assistance with feeding, bathing, and dressing. Indemnity: A fixed dollar amount paid to the policyholder for a covered service without regard to the actual cost. Intermediate care: This care is less specialized than skilled care and may involve more personal care. It is provided under a doctor s orders. Lifetime benefit: The maximum total benefits that an insurance policy will pay over the life of the policy. Long-term care: A range of medical, personal, and social services designed to meet the needs of people with disabilities and chronic illnesses. Loss ratio: Claims divided by premium. A loss ratio represents the percentage of premium dollars paid out in benefits by an insurer. For example, a loss ratio of 60 percent means 60 cents of every dollar in premium has been paid in the form of benefits. Oregon law requires individual long-term care policies to maintain at least a 60-percent loss ratio. Maximum benefit: A time limit or dollar amount that an insurance policy will pay for covered services in a benefit period. Medicaid: The state and federal medical assistance program for low-income people. Medicare: The federal health insurance program for people 65 and older, people of any age with permanent kidney failure, and certain disabled people under 65. There are two parts: hospital insurance (Part A) and medical insurance (Part B). Medicare + Choice: New health-care options created by the federal Balanced Budget Act of Nonforfeiture benefit: A cash value to a long-term care insurance policy that may be paid if the longterm care benefits are not used or if the policy lapses. Nursing facility (nursing home): A statelicensed facility where care ranges from acute care follow-up with skilled nursing care to custodial care providing assistance with ADLs and other nonmedical services. Option to buy: An opportunity to buy additional insurance benefits in the future. 7

10 Glossary, continued Pre-existing condition: A medical condition or problem diagnosed, treated, or needing treatment prior to the purchase of an insurance policy. A policy may exclude pre-exising conditions for a specific period of time, not to exceed six months. Premium waiver: An allowance of some insurance plans that means premiums are not due while benefits are being paid; when the benefits stop, the insured resumes premium payments. Qualified Medicare Beneficiary Program (QMB): A federal Medicaid program that pays Medicare premiums, deductibles, and co-insurances for qualifying low-income beneficiaries eligible for Medicare. Rating organization: An independent organization that reviews the financial condition of insurance companies and provides a rating based on its review. The organization may charge insurance companies to perform this review and also may charge consumers who want rating information. Residential care facility: A state-licensed facility with six or more adults and/or seniors with disabilities. Residents receive room and board and personal and supportive assistance with bathing, grooming, dressing, eating, socialization, survival skills, transportation, and self-care training. Respite care: Care provided to a patient in a hospital, other institutional setting or in the patient s home for a specified period of time to provide the regular caregiver a chance to take care of personal business and relax. People who provide full- or part-time care to family members or friends can be emotionally and physically exhausted. Respite care provides a needed break to assure that care will continue to be of high quality. Return of premium: An insurance benefit that provides a death benefit in the amount of total premiums paid minus any claims paid. This benefit may be subject to limitations. Rider: An endorsement attached to a policy to increase, decrease, or otherwise change policy benefits. SHIBA: The acronym for the Senior Health Insurance Benefits Assistance program. This program trains volunteers to provide one-on-one assistance to Medicare beneficiaries who need help with Medicare, Medicaid, Medicare supplement, Medicare + Choice, and long-term care insurance. Simple: Used to describe inflation protection. It means that the increase in benefits will be computed on the original daily benefit. Skilled care: Care for medical conditions that require care by skilled medical staff, such as registered nurses or professional therapists. It s ordered by a physician and delivered under a plan of treatment. Specified Low Income Medicare Beneficiary (SLMB): A federal Medicaid program that pays a beneficiary s Medicare premium. It s available to low-income individuals. Supervisory assistance: Stand-by help from another person when an individual is performing activities of daily living. Underwriting: A company looks at a person s health history and physical condition to decide if that person is an acceptable risk. Many companies ask health-related questions to help determine an applicant s insurability. Usual and customary charge: The fee most commonly charged by physicians or providers for a particular service, treatment, or supply. This fee may vary from area to area throughout the state. Waiting period: The amount of time that must pass at the beginning of a loss before benefits will be paid. 8

11 Senior Health Insurance Benefits Assistance Program (SHIBA) What is SHIBA? SHIBA is a program of the Insurance Division of the Oregon Department of Consumer & Business Services. SHIBA can do the following: Help Medicare beneficiaries make better health insurance decisions. Provide confidential, uniform, and objective health insurance assistance to Medicare beneficiaries. Support and recognize the efforts of volunteers. Why was SHIBA created? Health insurance and the wide array of state and federal programs confuse some seniors. Many Oregon seniors have too much or inappropriate health insurance. Others don t get all their medical claims paid because they re overwhelmed by the paperwork. Many Medicare beneficiaries pay too much out of their own pockets and don t participate in programs that may help them. SHIBA helps Oregon Medicare beneficiaries avoid these pitfalls and enjoy the benefits to which they are entitled. SHIBA is funded by the federal Health Care Financing Administration s Senior Health Insurance Assistance Program and the State of Oregon. What are SHIBA s services? SHIBA provides the following services through a statewide network of volunteers and a toll-free hotline: Information Medicare beneficiaries have access to a range of information and materials through SHIBA s toll-free hotline. SHIBA staff also conduct seminars for groups interested in senior health insurance issues. Counseling SHIBA volunteers provide one-on-one counseling at community sites or in homes. Volunteers help Medicare beneficiaries decide if they re eligible for benefits, compare insurance policies, file claims and make effective appeals and complaints. Assistance activities SHIBA volunteers also are trained to make referrals to federal, state and county agencies, and to identify potential insurance law violations. How can I get more information? Call SHIBA: (503) or (800) (toll-free in Oregon) Be a SHIBA volunteer! SHIBA s success is built on a statewide network of trained volunteers. A good SHIBA volunteer candidate: Enjoys helping others Is dependable, understanding, patient, and compassionate Has good communication skills Can protect client confidentiality Has no conflicts of interest Wants to provide SHIBA services Interested? Please call SHIBA, (800) , and ask for a volunteer application. 9

12 Oregon Insurance Division Winter St. NE, Room 440 Salem, OR (3/00/COM)