ENROLLMENT

The section will provide you with information pertaining to the process of Enrollment.
Enrollment is process of entry and tracking of information of new applicants.
Enrolment can be through a paper based application or online, where an applicant applies
electronically for coverage.
Following are a few of the key stages involved in the enrolment process:

Applicant
Who applies for insurance and is interested to get the coverage.
Application Form
The form is used to capture the necessary details of the person who wishes get insured
(applicant). Each form has a unique form number.
Using form number, insurer can uniquely identify the options and features selected by the
applicant.
The Application form (paper/electronic) contains the following details
Applicant Information
Medical Information
Insurability Information

Services which are covered.

Features/options and Riders provided.
Plans Offered.
Other details.

Applicant Information
Personal information related questions.
Medical Information
To identify and classify the risk posed by an applicant to the insurer, insurer has the right to
ask applicant for information about their health and lifestyle. An insurer will use this
information applicants evidence of insurability - in deciding if his application for insurance is
acceptable and at what premium rate.
Insurability Information
Critical questions which may result straightway in disqualification/rejection of the applicant
like Do you have Cancer? If the applicant answers this question as Yes, then in most of the
cases the application is rejected straightaway.
Services
The following are different services provided by the insurer.
Long Term Care Facility:
It is an institution, licensed or certified as a nursing home (if licensing or certification is
required) and operates under the law as a nursing home, to provide skilled, intermediate and
custodial care under the orders of a Physician and under the supervision of professional
nurses.
Professional Home Care (PHC):
This coverage includes visits to insureds home by a licensed Home Health Care Provider
during which skilled nursing care, physical, respiratory, occupational, dietary or speech
therapy, or homemaker services are provided.
The daily/monthly PHC benefit is generally equal to around 75% of the Long Term
Care/Facility daily/Monthly Benefit Amount.
Adult Day Care and Hospice are common types of PHC.
Total Home Care:
This coverage includes visits to insureds home by a licensed Home Health Care Provider to
provide skilled nursing care; physical, respiratory, occupational, dietary or speech therapy,
and homemaker services; or care provided by an informal caregiver, such as insureds friends
or relatives.

Assisted Living Facility (ALF):

An institution that is licensed by the appropriate agency (if required) to primarily engages in
providing ongoing care and services to a minimum of 6 residents in one location and operates
under state licensing laws and any other laws that apply.
Respite Care:
Care provided to you for a short period of time to allow insureds informal caregiver a break
from his/her care giving responsibilities.
Comprehensive:
An insured covered under a comprehensive plan can avail all of the available service
Facilities-Only
An insured covered under facilities only plan has an access to a few specific set of services.
The table below lists the services provided under coverage types (Comprehensive or
Facilities) discussed above

Types of Services Covered

FacilitiesOnly

Nursing Home Care

All levels of care including skilled, intermediate and custodial nursing care.
Charges for services including room and board are covered up to 100% of
insureds Daily Benefit Amount
Assisted Living Facility Care
Charges for services including room and board are covered up to 100% of
insureds Daily Benefit Amount.
Home Care
Not Included
Includes care provided at home by a nurse, home health aide, therapist or other
authorized provider. Home care also includes informal care from family members,
friends, and other non-licensed providers who didn't normally live with you at the
time you became eligible for benefits. When informal care is provided by family
members, it is covered for up to 365 days in insureds lifetime. Charges for
services are covered up to 75% of insureds Daily Benefit Amount
Adult Day Care

Not Included

Charges for services are covered up to 75% of insureds Daily Benefit Amount
Hospice Care in a facility
Charges for services are covered up to 100% of insureds Daily Benefit Amount
Hospice Care at home
Not Included
Charges for services are covered up to 100% of insureds Daily Benefit Amount
Respite Services

Comprehe
nsive

Charges for these services are covered up to 100% of insureds Daily Benefit
Amount for a calendar-year maximum of 30 times insureds Daily Benefit Amount.
Facilities-Only plans cover respite services in facilities. Comprehensive plans
cover respite services in facilities and at home.
International Coverage
Charges for services received outside the U.S. are covered up to 80% of
insureds Daily Benefit Amount for up to 80% of insureds Maximum Lifetime
Benefit. The remaining 20% of insureds Maximum Lifetime Benefit would be
available for services received in the U.S. (If you have the unlimited benefit
period, insureds maximum lifetime benefit for care received outside the U.S. is
limited to 10 years (3,650 days) x insureds Daily Benefit Amount)

Plan/ Features/ Options/Riders:

Features/Options: A Plan consist of a set of Features, a feature consist of set of options
which the customer can select. These combinations of the options define the plan or
coverage level for the customer.
Following are a few features commonly used in plan
Benefit Period:
The amount of time an insurance company will make payments to the individual to pay for
care; etc after the deductible has been satisfied.
Benefits/ Benefit Amount:
Money paid by the insurance company to the claimant (insurer when approached for Claims).
Benefit Limits:
An amount that represents the daily benefit times the maximum number of days customer
can receive for all benefits combined under the policy.
Daily Benefit Period:
The period of time for which the daily benefit amount will be provided.
Daily Benefit Rate:
The rate predetermined by the policy provider to cover daily benefits.
Elimination Days:
A period of time between the initial need for care and the beginning of the payments from the
insurance company.
Elimination Period:

The number of days that you have to pay benefits before the coverage begins to pay for
benefits.
Maximum Lifetime Benefit:
The total amount an insurance company will pay insured in the lifetime for all benefit provided
under the policy.
Waiver of Premium:
A provision which allows you to stop paying premiums once you are in a period of covered
care.
Feature can have one or more options to choose from. A feature can have multiple options
but an option can be part of one and only one feature.
Each of the above mentioned Features has some predefined option which the customer can
choose. For Feature Benefit Period the options could be 90 days, 100 days etc. For
Benefits/ Benefit Amount the option could be $40, $50, $90 etc.
Examples: For FEATURE Elimination Period (Waiting Period, OPTIONs could be 15, 30, 60,
90, 180 days. For FEATURE Maximum Benefit Period, Options could be 3, 4, 5 years or
Lifetime. For FEATURE Daily Benefit Amount, OPTIONs could be $50, $100 or $150.
In addition to the Options provided insured can choose Riders.

RIDER
A rider is a written contract agreement between insurers and insured which changes the
policy or certificate. Rider provides some options which the insured may or may not choose.
An example of rider can be Inflation Rider. The rider increases insureds maximum daily
benefit either on a simple or compound basis, depending on the rider chosen.
Following are some of the riders:
Nonforfeiture benefit rider
State insurance regulations often require that long-term care insurers offer nonforfeiture
benefit riders. Furthermore, this option must be offered if you're buying a tax-qualified policy.
As the name suggests, this rider assures that you won't forfeit all of insureds benefits even if
you stop paying premiums before making a claim. You will pay premiums that are 40 percent
higher (or more) for a policy with this rider. It will probably require that the policy be in force
for a specified length of time before any benefit is available, insureds benefit will be lower or
payable for a shorter period than it would be if you had continued paying the premium.
According to the United Seniors Health Cooperative, an independent consumer advocacy
group, you'll pay in the neighborhood of 40 percent more for a policy with a nonforfeiture
benefit rider attached to it.
Return-of-premium rider

A return-of-premium rider is considered to be a type of nonforfeiture benefit. Insureds estate

or a designated beneficiary will be entitled to the return of some or all of insureds premiums if
the policy isn't used during insureds lifetime. With certain versions of this rider, after a
specified number of years, you can drop the policy altogether and receive some portion of
insureds premiums back. Return-of-premium riders are not available from all companies nor
in every state. Some experts argue its value, the rider allows people to hedge their bets by
buying the insurance coverage and get money back if they decide long-term care isn't
necessary. Still others contend that you're paying more for the privilege of dropping the policy
at a stage in life when there's a greater risk of needing long term care.
Shared-benefit rider
A shared-benefit rider lets you extend the duration of insureds benefit if both spouses have
coverage. If both the husband and wife have a policy, the rider lets either draw from the
other's policy if their own benefits are exhausted. Ligare says GE Financial Assurance builds
this "shared care" feature into certain policies without using a rider and permits couples to
share one single pool of benefits. It's less expensive than buying two separate policies.

Inflation rider
No matter which long-term care policy you buy, an inflation rider is an important option. These
riders help ensure that insureds long-term care policy payments keep pace with the
escalating cost of care. Because this coverage is so important, insurance regulators in many
states require any purchaser of a long-term care policy to specifically reject the inflation rider.
PLAN
A Plan is combinations of the options (for each of the features opted) into units, which the
insured can directly select. Each plan has a unique plan name which help the Data Entry/
Underwriting team to directly select all of the features that applicant opted for.
(An insured can select either individual options to make up a plan or the plan directly
which in turn will have a predefined set of options. This is dependant upon the
insurance company).
Feature is the fundamental building blocks of Plan. Each feature adds value to the Long
Term Care Insurance purchased by an applicant.
Examples: Elimination Period (aka Waiting Period), Non-forfeiture, Inflation, Lifetime
Maximum, Daily Benefit Amount.
The insurance company will come up with a set of predefined combinations of the
features/options called Plans.
A Plan can be defined as a combination of options.
The set of Plans will be finite. The insured (customer) can choose a plan which satisfies his
needs.
Following is an example of a plan:

BASE PLAN

Level of Care

: Long Term Care Facility, Professional Home Care

Benefit Amount

: $100 per week

Assisted Living Facility

: 55% of Benefit Amount

Professional Home Care Benefit Amount: 75% Benefit Amount

Benefit Duration

: 3 years

Elimination Period

: 30 Days (must be satisfied once per lifetime)

OPTINAL FEATURES
Inflation Protection

: 5% Compound Uncapped

As shown above the prospective insured may be offered some optional features which
can be included under his coverage if he chooses. Here the Optional feature forms the
Rider (Additional features to the base Plan).
Plans can be of different types
Group Plans
These plans are filed as group plans. There are advantages to the employer and to the
carrier. For the employer, these plans are usually (but not always) guaranteed issue (no
disqualifying health questions) for all full-time employees. With guaranteed issue, no
employee gets discriminated against if he or she has a disabling or potential disabling
condition. As a group plan, a select set of identical benefits can be offered to all employees
no matter which state they live in. Other benefits other than the select set may be available
but usually require medical underwriting, i.e.. health questions are asked and medical records
obtained.
The advantage of Group to carriers is that company representatives do not have to be
licensed agents in every state to represent the plan and enroll participants.
Individual Plans
These plans are filed as individual plans in each state where the employee resides. There
may be variations on the benefits depending on restrictions of specific states, but to the
employer this is usually of little consequence. Representatives of the carrier must be
licensed, appointed agents in each state in which an employee enrolls. The plans may be
designed only for groups or they may be the same policy sold to the public and may include
additional group discounts. As with group, a select set of benefits is offered but on a modified
guaranteed issue basis. Other benefits are available through medical underwriting.
Modified guaranteed issue means no medical underwriting is used but one or more
disqualifying questions are asked to eliminate very sick or disabled employees. Here are
some typical questions: Transamerica: "During the past 6 months, have you missed 5 or
fewer days of work due to insureds accident, sickness or other physical or cognitive

infirmity?" A "Yes" to this question requires medical underwriting and based on the findings
results in acceptance or denial of coverage.
Individual Plans with Group Discounts
These are the identical plans that are offered to the public but the premiums are discounted
5% to 15% for the group, depending on the carrier. The employee can select any of hundreds
of benefit options since everything is medically underwritten. For large groups, sometimes
underwriting concessions are offered. These may also include Spousal Discounts.
(discounted premium if both married couple take same plan).
Individual group plans are similar to true group plans but usually offer more options such as
shortened payments, couples discounts, survivorship, return of premium, etc. These options
are available as riders to the 3 basic plans.
Coverage:
The amount of protection provided under the contract of insurance is called the coverage.
The services covered, the features which constitute a PLAN describe the coverage Level of
the insured.

Other Details
Payment Options and Payment Methods These define the way insured chooses to pay the
premium.
Payment Options: The frequency at which the insured can pay the premium. Following are

some of the options

Weekly
Monthly
Bi-Monthly
Quarterly
Semi Annual
Annual
Payment Methods: The mode which insured can choose to pay premium. Following are

some of the modes

Salary Deduction
Pension Deduction
EFT

Enrollment Period

The period during which participants in the Plan may select among the alternate health
benefit programs that are offered by the Plan or eligible individuals not currently enrolled in
the Plan may enroll for coverage. The Plans Open Enrollment Period is described in the
Eligibility chapter of the Plan Document.

Freelook Period
Most state insurance departments require insurance companies to provide a "free-look"
period after you have purchased the policy. It is typically a 10-day span in which you can pull
out of the contract and obtain a refund based on contract terms or state law. You should use
this time to review the policy, ask insureds insurance agent or stockbroker any additional
questions and make a final decision as to whether the annuity you selected was right for you.
Policy Lapse
The insurer can terminate a policy in the event of non payment of premium for a particular
period of time.
Agents
Insurance Agent / Sales Agent is an authorized person by an insurance Co. to represent the
Co. in its dealings with applicants for insurance.
Persons (Agents) licensed by the state insurance authorities can sell the life and health
insurance. In order to obtain an agent's license the prospective agent must
be sponsored for licensing by a licensed insurance company
complete approved educational course work and/or pass a written examination
provide assurance that he is of reputable character.
A sales agent selling these investment type products must be registered with the National
Association of Securities Dealers (NASD) as a broker/dealer and must also be licensed by
the state as insurance agent.

Agents role in renewal of premium:

Policy owner do not pay renewal premium to a sales agent of the insurer because these
agents generally authorized to accept only initial premiums. Home service agents generally
are authorized to accept renewal premium payments.