A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services

Transcription

1 2012 Before You Buy A Description of the Caifornia Partnership for Long-Term Care Prepared by the Caifornia Department of Heath Care Services Page 1 of 13

2 Ony ong-term care insurance poicies bearing any of the Caifornia Partnership for Long-Term Care ogos (shown above) are approved by the State of Caifornia, Department of Heath Care Services, Caifornia Partnership for Long-Term Care. Insurance companies may se severa different ong-term care insurance poicies. But ony poicies bearing any of the three Partnership ogos shown above and the foowing statement body dispayed on the first page of the outine of coverage quaify for a Medi-Ca asset disregard. This statement reads: THE BENEFITS PAYABLE BY THIS POLICY/CERTIFICATE QUALIFY FOR MEDI-CAL ASSET PROTECTION UNDER THE CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE. Page 2 of 13

3 Before You Buy A description of the Caifornia Partnership for Long-Term Care, a program of the Department of Heath Care Services Pease take your time and read this brochure carefuy. If any information is uncear, pease contact the Caifornia Department of Aging, Heath Insurance Counseing and Advocacy Program (HICAP) HICAP can aso provide you with a copy of Taking Care of Tomorrow: A Consumer s Guide to LongTerm Care, which contains a checkist of terms and options you shoud examine in evauating ong-term care insurance. The Caifornia Partnership for Long-Term Care (Partnership) is an aiance between the State of Caifornia s Medi-Ca Program, private ong-term care insurance companies, and you Caifornians interested in panning for your own, or a oved one s, potentia ong-term care needs. You have probaby read other materias about the Partnership and about specific Long Term Care (LTC) insurance poicies approved by the Partnership. Shoud you decide to purchase a Partnershipapproved LTC insurance poicy, you wi receive documents from your Insurer, detaiing a of the provisions of your insurance poicy. This booket from the Caifornia Department of Heath Care Services wi inform you about Medi-Ca s roe in the Partnership. It wi expain in detai the specia Medi-Ca asset protection feature unique to Partnership-approved LTC insurance poicies. It wi aso discuss: How the Partnership asset protection is determined and documented; When and how you coud transition from your private LTC insurance coverage to Medi-Ca; What requirements you woud need to meet for Medi-Ca eigibiity; and What services you woud be entited to once you were eigibe for Medi-Ca. Page 3 of 13

4 Unique Features of Partnership Poicies The Caifornia Partnership for Long-Term Care has four specia features to hep you pan to meet your ong-term care needs. 1 Insurance poicies sod under the Partnership are required to meet stringent insurance standards. Many of these standards are more strict than those appied to ong-term care poicies not participating in the Partnership. 2 Poicies sod under the Partnership aow you to protect assets equa to what your Partnership poicy paid for ong-term care services in addition to the amount Medi-Ca woud normay aow. These protected assets wi be disregarded if you appy for the Medi-Ca program. 3 With a Partnership poicy, you may eect to buy insurance equa to the amount of assets you want to protect to achieve ifetime protection against the costs of ong-term care. This wi make purchasing insurance coverage more affordabe for many. 4 Impartia consumer information and assistance from the Caifornia Department of Aging s HICAP are avaiabe to assist you in evauating whether a Partnership poicy is right for you. Just ca Additiona Standards for Partnership Poicies A ong-term care poicies sod in Caifornia must meet certain consumer standards estabished by state aw. A Partnership poicies incude many additiona standards. Among those standards are the foowing provisions: A Partnership-approved poicies use the same set of criteria to determine eigibiity for benefits. These criteria are based on the inabiity to perform activities of daiy iving and/or cognitive imitation; Page 4 of 13

5 The Department of Heath Care Services has estabished minimum daiy benefits for these poicies to guarantee you receive meaningfu coverage; Mandatory automatic infation protection is incuded to hep assure that your coverage wi keep pace with the expected increases in the cost of care; Waiver of premium for a days your poicy pays for care in a Residentia Care Faciity or a Nursing Faciity; Provisions are incuded to keep your coverage affordabe after you purchase a poicy. Among these requirements are imits on any future rate increases; and Requirement that Residentia Care Faciity coverage be incuded. Other Important Provisions Residency Requirements The Partnership is designed to hep Caifornia residents pay for ong-term care needs. Residency must be estabished at two points: In most cases, you must be a Caifornia resident to buy a Partnership approved ong-term care poicy; and You must be a Caifornia resident when you appy for Medi-Ca and take advantage of your accumuated Partnership asset protection. Shoud you need ong-term care services whie you are in another state, your poicy wi pay for your needed care and these insurance payments wi count toward your Partnership asset protection. However, the Partnership asset protection is ony recognized by Caifornia s Medicaid program known as Medi-Ca. You woud need to return to Caifornia to appy for Medi-Ca and take advantage of your Partnership asset protection. Page 5 of 13

6 Eigibiity for Benefits Under Your Partnership Poicy A Partnership poicies use the same criteria to determine eigibiity for benefits. This is caed the insured event. Eigibiity does not automaticay occur because you have a heart attack or break a hip. To meet the insured event two types of criteria are used: The need for substantia human assistance or constant supervision in performing norma Activities of Daiy Living, caed ADLs (which incude bathing, dressing, eating, transferring to/from a bed or chair, getting to and using the toiet as we as maintaining continence); or Severe cognitive impairment such as Azheimer s Disease or other types of dementia that imit cognitive abiities. As a Partnership poicyhoder, you (or a famiy member) shoud contact your insurance company immediatey if you beieve you meet your poicy s insured event. If you enter a hospita or nursing home, inform the admissions staff that you have ong-term care insurance. Care Management A Partnership poicies incude a buit-in care management benefit. It is important to understand what roe a care manager wi have in your care. A care manager is a heath care professiona or a socia worker who is empoyed by a care management agency that provides assessment, care coordination, and monitoring. She or he wi work with you to assess your circumstances, determine the specific services you need, deveop a pan of care to address your needs and, if you desire, coordinate and monitor services to insure you are cared for appropriatey. The care management agencies your Insurer contracts with, and that agency s individua care managers, are a required to meet specific standards estabished by the Partnership. Page 6 of 13

7 What Does Medi-Ca Asset Protection Mean? Medi-Ca asset protection is an essentia feature of Partnership-approved poicies. Asset protection is a right extended to you by Caifornia aw when you use the benefits of a Partnership poicy/certificate. This right aows you to protect one doar of your assets for every doar a Partnership poicy pays out in benefits, in the event you ater appy for Medi-Ca benefits or other quaifying pubic ong-term care benefits. The amount of this asset protection at any time is equa to the sum of a benefit payments made for your care by this poicy. Shoud you ater appy for Medi-Ca or for other quaifying pubic ong-term care benefits, you wi not be required to expend your protected assets before becoming eigibe. Your protected assets wi aso be exempt from any caim the State of Caifornia may have against your estate to recover the cost of State-paid ong-term care or medica services provided to you. The Partnership guarantees a doar s worth of asset protection for each doar your insurance pays out for ong-term care services. This permanent asset protection is over and above the asset amounts Medi-Ca normay exempts. (See Appendices A and B for the Medi-Ca Property and Asset Limits.) Page 7 of 13

8 Do A Insurance Benefits Quaify for the Asset Disregard? You may need some services that are not covered by your insurance pan. You wi have to pay directy out of your income or assets for any needed services that are not incuded in your insurance benefits. These out-of-pocket payments wi not be incuded in cacuating the Partnership asset disregard you are entited to when appying for Medi-Ca. (See Appendix C for more detais). A of the services covered in your Partnership poicy wi count toward your Partnership asset disregard. When you begin receiving benefits, your Insurer wi send you a quartery Medi-Ca Property Exemption Report that documents the insurance benefits paid out, the amount of asset protection earned during that quarter, and the cumuative asset protection you have received. It is your responsibiity to check the accuracy of these quartery statements and report any errors to your Insurer. If you exhaust your insurance benefits or you cance your poicy, your Insurer wi automaticay provide you with a Service Summary statement documenting the tota amount of Partnership asset protection you are entited to. You shoud keep this statement with your other important insurance documents. Shoud you appy for Medi-Ca, you wi be required to submit this Service Summary statement to your county wefare office (usuay the County Department of Socia Services) to verify the additiona Medi-Ca asset disregard you are entited to. When To Appy for Medi-Ca You may appy for Medi-Ca when the asset protection you have accumuated from your Partnership insurance pay outs (as indicated in your quartery Medi-Ca Property Exemption Report ) comes cose to the current amount of your persona assets. Remember, the Partnership asset protection is over and above the asset amounts Medi-Ca normay exempts. Medi-Ca eigibiity is not automatic. You must appy for Medi-Ca to become eigibe for pubic assistance. To become eigibe for Medi-Ca, you must: Be aged, bind, or disabed; Be a citizen or have satisfactory immigration status; and Meet the Medi-Ca property and asset requirements. Page 8 of 13

9 Once your eigibiity has been determined, you may be required to pay, from your income, a monthy share of cost for your care. SHARE OF COST is the amount you may have to pay each month toward the cost of your heath and ong-term care, before Medi-Ca wi begin paying. Your share of cost may change when your monthy income changes. You ony pay a share of cost in a month when you actuay get heath or LTC services (See Appendix B for more detais). Once accepted by Medi-Ca, you are eigibe for a services that MediCa covers. Medi-Ca services may be different than those you received under your private ong-term care insurance. For exampe, Medi-Ca has no imits on the number of days covered, if they are medicay necessary. However, Medi-Ca wi not pay for your stay in a Residentia Care Faciity. Medi-Ca wi pay for some nursing services in the home, incuding services in a Residentia Care Faciity, if that is where you ive, and if you are temporariy or permanenty unabe to eave your home. For exampe, if you are recenty discharged from a hospita, Medi-Ca wi pay for foow-up care which can be provided in your home. How to Appy for Medi-Ca In appying for Medi-Ca, you must give your Service Summary report from your Insurer to your county wefare office. The Service Summary wi ist the Medi-Ca approved benefits your Insurer has paid. This wi verify the vaue of assets, over and above those normay exempted, that Medi-Ca wi aow you to keep. It generay takes two months to process a Medi-Ca appication, athough that processing time varies from county to county. Insurance Records/Reease of Information The Caifornia Department of Heath Care Services requires a insurers to maintain detaied records on the individuas who participate in the Partnership. These statistics wi be coected to evauate whether the Partnership is a cost-effective ong-term care program. Insurers are required to document the ong-term care benefits that have been paid out on your behaf to verify your caim for asset protection. Participating insurance companies must aso meet certain Medi-Ca auditing requirements detaied in the Partnership insurance reguations. Page 9 of 13

10 To meet these requirements, if you purchase a Partnership poicy, your insurance company wi ask you to sign an agreement that aows them to reease information about you to the Department of Heath Care Services. You wi aso be asked to provide genera information on your income and assets. This information wi ony be used to hep evauate the effectiveness of the Partnership. This information wi be hed stricty confidentia. Consider Carefuy Remember, ong-term care insurance is not a substitute for Medicare, Medicare Suppementa Insurance (Medigap) or Major Medica Insurance. They a cover specificay different kinds of needs. DO NOT CANCEL ANY CURRENT INSURANCE YOU MAY HAVE UNLESS YOU ARE SURE IT IS IN YOUR BEST INTEREST TO DO SO. Review your circumstances with a knowedgeabe and unbiased person if you are confused. If you doubt whether you have enough assets to protect, or enough resources to pay for a ong-term care poicy, DO NOT BUY A POLICY. There are other options you shoud consider. The Department of Aging s HICAP vounteers can answer specific questions you may have about the Partnership, hep you understand the differences between the poicies you are reviewing, or discuss other financing options for you to consider. Ca to request counseing assistance or to receive the Department of Aging s Taking Care of Tomorrow: A Consumer s Guide to Long-Term Care. BE AN INFORMED CONSUMER The Caifornia Partnership for Long-Term Care, the State of Caifornia and the Department of Heath Care Services do not endorse any Partnership company ong-term care insurance poicy over another. This pubication is for education and consumer information ony. Page 10 of 13

11 Appendices APPENDIX A Medi-Ca Property and Asset Limitations There are property/asset imits for the Medi-Ca program. If your property/assets are over the Medi-Ca property imit, you wi not get Medi-Ca uness you ower them according to the program rues. The county ooks at how much you and your famiy have each month. If your property/assets are beow the imit at any time during that month, you wi get Medi-Ca, if otherwise eigibe. If you have more than the imit for a whoe month, you wi be discontinued unti you are once again beow the imits. The home you ive in, furnishings, persona items, and one motor vehice are not counted. A singe person is aowed to keep $2,000 in property/assets, the imit is higher if you are married or have a famiy. For more information, pease ask your county wefare office (usuay the Department of Socia Services) for a form caed Medi-Ca Genera Property Limitations for a Medi-Ca Appicants (MC Information Notice 007). APPENDIX B Medi-Ca Property and Asset Limitations for Married Coupes When One Spouse is in a Nursing Home If one spouse (husband or wife) goes into a nursing home, and the other spouse is sti at home, the spouse at home may keep up to $113,640 whie the institutionaized spouse may keep $2,000 (this is the amount aowed in 2012; the amount is adjusted by the annua increase of the Consumer Price Index). In 2012, the spouse at home may keep a of the coupe s income he/she receives in his/her own name. If this amount is under $2,841 per month, a monthy aocation may be made from the institutionaized spouse to the at-home spouse to bring the at-home spouse s income up to at east $2,841 per month. This is referred to as the at-home spouse s monthy maintenance needs aowance. (This amount is aso adjusted annuay by the cost of iving increase.) Page 11 of 13

12 The at-home spouse may retain additiona income or assets through a fair hearing, or by court order. The spouse in the nursing home is permitted to keep $35 a month for persona needs. APPENDIX C Medi-Ca Share of Cost If you are on Medi-Ca, you may need to use some portion of your monthy income from Socia Security, a pension, etc. to pay for your heath and ong-term care expenses. Your income wi probaby not be enough to pay the entire bi, so Medi-Ca wi pay the rest of your nursing home bi or any other medica expenses you may have. You wi be aowed to keep a certain amount of your income each month. In 2012, you may keep the foowing Maintenance of Need amount: If you are iving in the community, an individua may keep $600*, a married coupe $934*; or If you are in a nursing home, an individua may keep $35 for persona needs. If he or she has a spouse at home, the at-home spouse may keep a of the coupe s income he/she receives in his/her name. If this amount is under $2,841 per month, a monthy aocation may be made from the institutionaized spouse to the at-home spouse to bring the at-home spouse s income up to at east $2,841 per month. In determining your share of cost, Medi-Ca wi cacuate the appicant s/ institutionaized spouse s tota monthy income. This figure is your net income. The county wi subtract the aocation to the at-home spouse, if appicabe. Then the Maintenance of Need amount is subtracted from your net income. The remaining amount is your monthy share of cost the amount you woud have to spend on medica or ong-term care before Medi-Ca begins payment. For more detaied information on how the Medi-Ca share-of-cost is cacuated, contact your county Department of Socia or Human Services (aso known as the county wefare office). *There may be other adjustments aowed based on individua circumstances. Page 12 of 13

13 THE MISSION OF THE CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE The Department of Aging s Heath Insurance Counseing and Advocacy Program (HICAP) provides consumer information and counseing on heath and ong-term care insurance issues. For printed materias, hep with a question you may have, or an appointment with a trained vounteer counseor, just ca The mission of the Caifornia Partnership for Long-Term Care is to increase the number of midde income Caifornians who have quaity ongterm care insurance coverage that prevents or deays their dependence on Medi-Ca. The Caifornia Partnership for Long-Term Care is a program of the Caifornia Department of Heath Care Services. Write to us at: Caifornia Partnership for Long-Term Care Caifornia Department of Heath Care Services P.O. Box MS 4100 Sacramento, CA Fax: (916) E-mai: cptc@dhcs.ca.gov Visit the Partnership s web site at To get free brochures about the Partnership ca CARE-445. Page 13 of 13