Beginning the Claims Process - for the Federal Long Term Care

The Federal Long Term Care Insurance Program
Beginning the Claims Process
Please refer to this magnet
for contact information.
Note: To protect your privacy, we are only able to
speak with those insured under the FLTCIP or an
authorized legal representative. Authentication
questions will be asked to ensure your protection.
We are happy
to assist you.
For a detailed
description of our
Customer Service
call process,
please refer to
the back cover
of this brochure.
Register for an
Online Account
With a secure online account,
you can access important
information about your
coverage, including:
ff plan information
ff claim information
(if applicable)
ff personal information, which
you can update as needed
ff important brochures
and forms, which can be
downloaded
Please register by visiting
www.LTCFEDS.com/register.
3
Beginning the claims process
Thank you for your participation in the Federal Long Term Care Insurance Program
(FLTCIP). As administrators of the FLTCIP, Long Term Care Partners realizes the need
for long term care can be a stressful time. This brochure is designed to alleviate some
of that stress by explaining the key steps in the claims process, such as determining
your eligibility for benefits, and educating you on what to expect if you are approved.
1
1
Contact Customer Service. . . . . . . . . . . . . . . . . . . 2
2
Review your eligibility requirements. . . . . . . . . . . 2
3
Complete and return the required forms. . . . . 3–12
4
Interview with a care coordinator . . . . . . . . . . . . 14
5
Review the next steps. . . . . . . . . . . . . . . . . . . . . . 15
The Federal Long Term Care Insurance Program
1
Contact Customer Service.
The claims process starts with a call to Long Term Care Partners at 1-800-LTC-FEDS (1-800-582-3337)
TTY 1-800-843-3557. A claim services consultant will explain the process and review the initial information
you will need to provide, which includes the required forms you must fill out and return to us in order to
begin your claim. Once all the requested information has been received, a care coordinator will call you for
an informational interview.
2
Review your eligibility requirements.
You may be eligible to receive the benefits of your plan if a licensed health care practitioner has certified
(provided a written statement describing the nature and degree of physical or cognitive loss, how long
services may be needed, and the services that may be required) in the last 12 months that:
ffyou are unable, without substantial assistance from another person, to perform at least two activities
of daily living for an expected period of at least 90 days due to a loss of functional capacity; or
ffyou require substantial supervision due to your severe cognitive impairment
What are the activities of daily living?
If you need substantial assistance (hands-on assistance, which is physical help by another person, or standby
assistance, which is the presence of another person within arms reach to prevent injury by physical intervention
or cuing) from another person to complete any of these activities, then you are dependent for that activity.
Activities of daily living include:
Bathing
Continence
ffgetting
into and out of a tub or shower
your body in a tub, shower,
or by sponge bath
ffwashing your hair in a tub, shower, or sink
ffmaintaining
ffwashing
ffwhen
Dressing
Eating
ffputting
fffeeding
on and taking off all clothing items and any
necessary braces, fasteners, or artificial limbs
Toileting
ffgetting
on and off the toilet
associated personal hygiene
ffperforming
control of bowel and bladder function
unable to maintain control of bowel or bladder
function, performing associated personal hygiene
(including caring for a catheter or colostomy bag)
yourself by getting food into your mouth
from a container (such as a plate or cup), including
the use of utensils when appropriate (such as a
spoon or fork)
ffwhen unable to feed yourself from a container,
feeding yourself by a feeding tube or intravenously
Transferring
ffgetting
into and out of a bed, chair, or wheelchair
What is a severe cognitive impairment?
A severe cognitive impairment is a deterioration or loss in intellectual capacity (such as Alzheimer’s disease) that:
ffplaces you in jeopardy of harming yourself or others, and therefore you require substantial supervision
(continual monitoring by another person to protect you from threats to your health and safety, for instance,
while wandering) by another person
ffis measured by clinical evidence and standardized tests that reliably measure impairment in:
ffshort or long term memory
fforientation to people, places, or time
ffdeductive or abstract reasoning
If you do not meet the above activities of daily living or severe cognitive impairment criteria, you do not need
to complete the other steps in this brochure. If you have any questions, call Customer Service at 1-800-LTC-FEDS
(1-800-582-3337) TTY 1-800-843-3557 or email [email protected].
Beginning the Claims Process
2
34.
Complete and return the required forms.
Four forms are provided in this section. The first three forms are required and must be returned to Long Term
Care Partners before we can determine your eligibility for benefits. The fourth form is optional.
Care Support History
This form asks for details about you, your health care history, your physician(s), and caregivers. It is a good idea
to make a copy of this form and have it with you for your phone interview with a care coordinator.
Authorization to Use and Disclose Health Information about Me
This health authorization permits others, such as a licensed health care practitioner, medical facility, or any other
entity or person that has any health documentation, to disclose information about you that we will request for a
benefit eligibility decision.
IRS Form W-9
This form should be filled out by you or your legal representative. By completing this form, you are certifying that
the Tax Identification Number (TIN) provided is correct. This TIN is used in our required reporting to you and the
Internal Revenue Service for benefits paid during the year.
Authorization for Disclosure of Information
This form is optional. It is provided if you would like to authorize us to speak with a designated person(s)* about
your coverage on your behalf. (Note: This does not authorize someone to make decisions on your behalf.)
*If a legal representative is authorized to make decisions on your behalf about your long term care insurance policy,
we require a legal copy of your power of attorney or guardianship papers (as determined by your state of residence).
We will not be able to proceed with the claim until we have received the documentation authorizing the legal
representative to make decisions about your coverage on your behalf. Note: A health care proxy is not sufficient
for this purpose.
Please complete these forms and mail them back to us in the enclosed postage-paid envelope.
If you have questions about your policy or our process for determining eligibility for benefits while you are preparing
these forms, call a claim services consultant at 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557.
3
The Federal Long Term Care Insurance Program
Care Support History
During a phone interview, a care coordinator will ask you detailed questions about your health care. This form
will assist you with gathering this information. Please include as much detail as possible and return it to Long
Term Care Partners to make your conversation with the care coordinator and the review of your claim as efficient
as possible.
To protect your personal
information, we will always
ask you to verify who you are.
Name
Address
Date of birth
Social Security number or unique FLTCIP identification number
Please provide a phone number
and the best time to reach you.
Phone number
Time
What are the reasons for requesting
approval of benefit eligibility? Please
write any notes about your health
condition(s) that you will discuss
with your care coordinator, including
the activities of daily living you
need assistance with and/or your
cognitive impairment.
If you have a legal representative
or guardian who can act on your
behalf, please list the following
information:
Legal representative’s name
Legal representative’s phone number
Legal representative’s authority (e.g., power of attorney)
Please note: In order for us to discuss your coverage with another person
designated by you (including your spouse), the following two documents
are required:
ff
a completed Authorization for Disclosure of Information Form (page 12)
ff
a legal
copy of your financial power of attorney or guardianship papers
(as determined by your state of residence)—a claim cannot be submitted
or discussed on your behalf without this authorization
Beginning the Claims Process
4
Please provide the requested
information for all physicians that
you may have seen in the last
12 months that relates to your need
to seek long term care assistance.
If you need additional space for
physician information, you may
provide a separate attached list.
Primary care physician’s name
Primary care physician’s address
City, state, zip code
Physician’s phone
Primary care physician’s specialty
Physician’s name
Physician’s address
City, state, zip code
Physician’s phone
Physician’s specialty
Physician’s name
Physician’s address
City, state, zip code
Physician’s phone
Physician’s specialty
Please provide information
about any medical insurance you
may have, including Medicare,
TRICARE, etc.
Insurance carrier name
If you are covered by another
long term care insurance policy,
please list the following information: Insurance carrier name
Policy ID number
Phone
If you were treated at a hospital
in the last 12 months, please
list the following information:
Hospital name
Hospital address
City, state, zip code
Hospital phone
Date(s) of admission
Date(s) of discharge
5
The Federal Long Term Care Insurance Program
If you were treated at a nursing
home, assisted living facility,
or other skilled care facility in
the last 12 months, please list
the following information:
Facility name
Facility address
City, state, zip code
Facility phone
Date(s) of admission
Date(s) of discharge
If you were treated at home by
a formal or informal caregiver
in the last 12 months, please
list the following information:
For formal caregivers
A formal caregiver is any of the following providers: 1) nurse, 2) therapist,
or 3) home health aide or homemaker whose services are arranged and
supervised by a home care agency.
Caregiver’s name
Agency’s name
Agency’s address
City, state, zip code
Agency’s phone
Start date(s) of care provided
Stop date(s) of care provided
For informal caregivers
An informal caregiver is a person providing maintenance or personal care
who is not a formal caregiver. The term includes a homemaker whose services
are not arranged and supervised by a home care agency or facility. The term
does not include anyone who normally lived in your home at the time you became
eligible for benefits.
Caregiver’s name
Caregiver’s address
City, state, zip code
Caregiver’s phone
Start date(s) of care provided
Stop date(s) of care provided
Number of hours
Rate of pay
Beginning the Claims Process
6
Please indicate who is currently
living with you in your home.
Name
Relationship
Name
Relationship
Keep a copy of this form for your reference when you speak with the care coordinator.
Return your completed form to:
Long Term Care Partners, LLC | P.O. Box 797 | Greenland, NH 03840-0797 | Fax: 1-866-513-2674
FLTCIP009364 v. 2 0514
7
The Federal Long Term Care Insurance Program
Authorization to Use and Disclose Health Information about Me
Insured’s name
First name
/
Date of birth
M.I. Last name
/
MonthDay Year
For claim-related purposes of the Federal Long Term Care Insurance Program, including determining eligibility for
benefits, care coordination, claim decision-making, coordinating benefits with other insurance companies or payers,
claim payment, claim appeals, and claims management activities, I authorize any licensed health care practitioner,
medical facility, employer, insurance company, or any other entity or person that has any health information about
me to give that health information to Long Term Care Partners, LLC, John Hancock Life & Health Insurance Company,
their reinsurers, and their subcontractors who need to know health information to provide contracted services.
The health information I am permitting to be disclosed and used for the Federal Long Term Care Insurance Program
includes any information on my medical history, and the diagnosis, prognosis, and treatment of any physical or mental
condition. It includes the disclosure of any medical care or surgery, psychiatric or psychological care or examinations,
and information about alcohol or drug use (including any information otherwise protected by Federal Regulations
42 CFR Part 2 or other applicable laws). I understand that this authorization includes my consent to use and disclose
medical information that relates to mental illness, HIV, AIDS, HIV-related illness, and sexually transmitted diseases
or other serious communicable diseases, but only in accordance with any law or regulation that applies to any such
disclosure of this information about me.
I understand that:

If I do not sign this authorization, any claim for long term care insurance benefits may be denied.

I may revoke this authorization at any time, except to the extent that

action has already been taken in reliance on it prior to my revocation, or

Long Term Care Partners or my insurer has a right to contest my long term care insurance claim
or coverage.

If I do revoke this authorization, I understand that any claim for long term care insurance benefits
may be denied.

To revoke this authorization, I must notify Long Term Care Partners, LLC, P.O. Box 797, Greenland,
NH 03840-0797, in writing.

If I do not revoke this authorization, it will be valid from the date I sign it to the date the claim is closed.

My health information may be redisclosed and no longer protected by applicable law, including
federal health information privacy regulations. This can occur only if such redisclosure is required
or allowed by law (e.g., in response to a subpoena).

A copy of this authorization is as valid as the original.
Insured’s signature
(Required) Date signed
/
/
(Required: mm/dd/yy)
If the insured is unable to sign for him- or herself, please include a legal copy of the power of attorney or guardianship
papers, if not already submitted.
Legal representative’s signature
(Required) Date signed
/
/
(Required: mm/dd/yy)
Return your completed form to:
Long Term Care Partners, LLC | P.O. Box 797 | Greenland, NH 03840-0797 | Fax: 1-866-513-2674
8
Long Term Care Partners, LLC | P.O. Box 797 | Greenland, NH 03840-0797 | Fax: 1-866-513-2674
A007C v. 3 0514
9
The Federal Long Term Care Insurance Program is
sponsored by the U.S. Office of Personnel Management,
offered by John Hancock Life & Health Insurance Company,
and administered by Long Term Care Partners, LLC.
W-9
Form
(Rev. August 2013)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Exemptions (see instructions):
Check appropriate box for federal tax classification:
Individual/sole proprietor
C Corporation
S Corporation
Partnership
Trust/estate
Exempt payee code (if any)
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Other (see instructions) ▶
Address (number, street, and apt. or suite no.)
Exemption from FATCA reporting
code (if any)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Social security number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Employer identification number
Part II
–
–
–
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign
Here
Signature of
U.S. person ▶
Date ▶
General Instructions
withholding tax on foreign partners’ share of effectively connected income, and
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. The IRS has created a page on IRS.gov for information
about Form W-9, at www.irs.gov/w9. Information about any future developments
affecting Form W-9 (such as legislation enacted after we release it) will be posted
on that page.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your
correct taxpayer identification number (TIN) to report, for example, income paid to
you, payments made to you in settlement of payment card and third party network
transactions, real estate transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or contributions you made
to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN to the person requesting it (the requester) and, when
applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct.
Note. If you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requester’s form if it is substantially
similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S.
person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or organized in the
United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in
the United States are generally required to pay a withholding tax under section
1446 on any foreign partners’ share of effectively connected taxable income from
such business. Further, in certain cases where a Form W-9 has not been received,
the rules under section 1446 require a partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
U.S. person that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership income.
Cat. No. 10231X
Form W-9 (Rev. 8-2013)
Authorization for Disclosure of Information (optional)
If you would like to authorize us to speak to a designated person about your coverage, please complete the
following and mail it back to us in the enclosed postage-paid envelope.
Until we have received this authorization form or a legal copy of your financial power of attorney or guardianship
papers (as determined by your state of residence), we will not be able to discuss your coverage with anyone other
than you (including your spouse). Note: The type of power of attorney will determine the authorization your designated
person has on your behalf. For example, we cannot share specific policy information or act on instructions from
your designated person with regard to your claim if your representative has a health care power of attorney (referred
to in some jurisdictions as a health care proxy).
Insured’s name
First name
M.I.
Last name
Address
CityState/Territory
Country
Date of birth
/
Zip/Foreign postal code
/
MonthDay Year
I, the insured named above, authorize Long Term Care Partners (LTCP), LLC, to disclose information about
my insurance coverage and benefits under the Federal Long Term Care Insurance Program (FLTCIP), including
demographic information, billing and payment information, claim and related medical information, and other
information related to the FLTCIP, to the person(s) listed below. This will allow that person(s) to assist me in
matters related to my coverage under the FLTCIP.
Name
Relationship
Name
Relationship
–
–
Phone number
–
–
Phone number
I understand that this authorization is voluntary. I understand this authorization will be valid until the earlier of: such
time as I no longer have this coverage under the FLTCIP (at which time it will expire) or such time as this authorization
is revoked by me. I understand that I may revoke this authorization at any time by notifying LTCP in writing at:
Long Term Care Partners, LLC, Attn: HIPAA Privacy Office, P.O. Box 797, Greenland, NH 03840-0797. Revoking this
authorization will have no effect on any information released in reliance on this authorization before LTCP received the
revocation. I further understand that LTCP will not condition treatment, payment, enrollment, or eligibility for benefits
on whether I sign this authorization.
I understand that the individual(s) listed above may re-disclose any information received. Once information is
disclosed to the individual(s), I understand that the information may no longer be protected by the Health Insurance
Portability and Accountability Act (HIPAA) regulations and other applicable privacy laws.
Signature (insured person or legal representative)
Date signed
/
/
If signed by a personal representative of the insured, please describe the authority under which the personal
representative is authorized to act and enclose any related documentation (e.g., legal copy of your power of attorney):
Return your completed form to:
Long Term Care Partners, LLC | P.O. Box 797 | Greenland, NH 03840-0797 | Fax: 1-866-513-2674
12
Long Term Care Partners, LLC | P.O. Box 797 | Greenland, NH 03840-0797 | Fax: 1-866-513-2674
A008C v. 4 0514
13
The Federal Long Term Care Insurance Program is
sponsored by the U.S. Office of Personnel Management,
offered by John Hancock Life & Health Insurance Company,
and administered by Long Term Care Partners, LLC.
4
Interview with a care coordinator.
A care coordinator will call you for an interview once all the requested information and required forms have been
received. During your interview, you will be asked detailed questions about your health, assistance needs, and
family support, as well as information about your physician(s). This will help us determine if you are eligible for
the benefits of your plan. You may wish to use your copy of the Care Support History form as reference.
In order to make our decision regarding your eligibility for benefits, we will also request additional information by:
ffcontacting you, your physician, or other persons familiar with your condition
ffaccessing your medical records
ffhaving you examined, at our expense, by a licensed health care professional
ffconducting an on-site assessment
This process can take up to a few weeks depending on the amount of information (and its availability) needed
to determine your claims benefit eligibility date (when you started needing long term care assistance, according
to the policy).
After we receive all the requested information, we will send you a written notice of our decision on whether or
not you are eligible for benefits no later than 10 business days.
About our care coordinators
Our care coordinators are registered nurses experienced
in long term care. If your benefit eligibility is approved,
we will assign a personal care coordinator to work with you
and your family members to develop a plan of care that
meets your individual needs. Your care coordinator can also
help you find high-quality care providers in your area; share
the results of state survey reports about service availability,
quality, costs, and licensing; arrange for discounted services;
monitor the care you are receiving; and assist with changing
your plan of care as your needs change.
Beginning the Claims Process
14
5
Review the next steps.
Now that you have completed the initial steps for opening a claim, here’s what you can expect going forward.
If your benefit eligibility is approved
A care coordinator will call you and additional written notification will state the date you are eligible for benefits.
The notification will also include the necessary claims instruction and/or forms that you can use for the
submission of invoices (along with proof of payment when required) to request care reimbursement or to count
care toward your waiting period. You will also be assigned a personal care coordinator (see page 14) to assist you.
If your benefit eligibility is denied
A care coordinator will call you and additional written notification will state the reason for the denial. If you still
feel strongly that you are eligible for plan benefits, you may request a review of the denial by sending a written
request to us no later than 60 days after the date of the denial. After our review is completed, we will send you
written notice of our decision. If we uphold the initial denial, at that time you may request an appeal.
For more information on the review and appeal process, please refer to the most recent Benefit Booklet we
sent you or review the downloadable PDF version via your online account at www.LTCFEDS.com.
Satisfying your waiting period
If your benefit eligibility is approved, you must first satisfy your plan’s waiting period. Your waiting period
is identified in your current schedule of benefits, and it is similar to a deductible in other insurance plans.
You only have to satisfy your current plan’s waiting period once in your lifetime.
If you have a service day waiting period
A service day waiting period is the number of days you must be eligible for benefits and receiving and paying
for care (care must be approved by your care coordinator) before we will pay the benefits of your plan. We will
request the following information to help determine when your service day waiting period has been reached.
ffitemized bills and an explanation of what services were provided
ffproof of payment for services that were provided by an informal caregiver; do not pay for services in cash
ffinvoices from a formal provider
Services must be paid at the time rendered. Services paid for in cash cannot be validated to count toward the
waiting period or be reimbursed.
If you have a calendar day waiting period
A calendar day waiting period is the number of calendar days you must be eligible for benefits before we will
pay the benefits of your plan.
For detailed information about your waiting period, please review your online account or the most recent
schedule of benefits we sent you.
15
The Federal Long Term Care Insurance Program
Track your progress.
1
Contacted Customer Service Date
2
3
Reviewed my eligibility requirements
Completed and returned the required forms Date mailed
Care Support History
Authorization to Use and Disclose Health Information about Me
IRS Form W-9
Authorization for Disclosure of Information (optional)
4
Interviewed with a care coordinator
We understand that you may have questions along the way. If so, please call Customer Service for status updates
or policy questions, or to contact a care coordinator regarding your claims benefit eligibility and care planning.
Beginning the Claims Process
16
Notes
17
The Federal Long Term Care Insurance Program
Notes
Beginning the Claims Process
18
Contact us
Our Customer Service team is here to assist you. Throughout your claim, they will direct you to
the Care Coordination or Claims Administration department according to your particular needs.
If you have any questions, call 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557. Please be
aware that any time we speak to you or your authorized legal representative about specific health
information or coverage, we are required to verify your identity by asking you to answer some
security questions.
Calling Long Term Care Partners
When you call our toll-free number, you will reach one of our claim services consultants (CSC),
who are trained to support our care coordination and claims process.
Each time, the CSC will ask you to verify three facts:
ffyour claim ID, your unique ID, or your Social Security number (or last four digits)
ffyour date of birth
ffyour address
This security check is required to protect your health information. Without it, Customer
Service will not be able to provide support or refer calls.
Once the security check is successfully completed, the CSC will ask how he or she may assist
you. Many questions can be answered by the CSC. If you need to speak directly to your care
coordinator or if you are returning your care coordinator’s call, the CSC will provide you with
instructions.
The Federal Long Term Care Insurance Program is
sponsored by the U.S. Office of Personnel Management,
offered by John Hancock Life & Health Insurance Company,
and administered by Long Term Care Partners, LLC.
FLTCIP009356 v. 2 0514