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HEALTH CONDITION(S) OR SITUATION(S)*TRUE FREEDOM HOME CARE PLANMANHATTAN LIFE HHC SELECTGTL HOME HEALTH CAREAETNA HOME CARE PLUSMANHATTAN LIFE OMNIFlex™ STC PLANWELLABE STC PLAN**AETNA RECOVERY CARE STC PLANGTL RECOVER CASH STC PLANCigna STC
Issue Ages18-9945-8961-8550-8945-8940-8950-8940-8418-89
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Sub Products Limited BenefitsFull BenefitsEssential CareEssential Care Plus
Need Assistance with ADL's, Receiving HHC Services or Living in an ALF, NH or some other care facility?
(Currently)
(Currently)
(Currently)
(Currently)
(Currently)
(OR recommended by physician)
(OR recommended by physician)
(Currently)
(24 Mos.)
(Currently)
Alzheimer's, Dementia, or Cognitively Impaired?
(Currently)
Not On App.
(Currently)
(Currently)
(24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(36 Mos.)
In next 60 Days, expect to be admitted to hospital, ALF, NH, require HHC, or have surgery?
(Option A/B); NO (Option C)
Not On App.
Kidney Failure (due to diabetes)
(12 Mos.)
(Currently)
(Currently)
(24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(36 Mos.)
Parkinson's Disease (Stages 4-5)
(24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(36 Mos.)
Diabetes with insulin AND in conjunction with heart failure?
(Currently)
(Currently)
(24 Mos.)
(24 Mos.)
(Currently)
(24 Mos.)
(12 Mos.)
Internal Cancer (besides skin cancer in-Situ), leukemia, lymphoma, malignant melanoma, or cancer that has spread
(12 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(36 Mos.) ANY cancer (excluding non-melanoma skin cancer)
AIDS, ARC, HIV?
(Ever)
(Ever)
(10 Yrs.)
(36 Mos.)
(10 Yrs.)
(Currently)
Diabetic complications resulting in neuropathy, proliferative retinopathy, kidney disease or failure, kidney dialysis or renal insufficiency
(Besides Kidney Failure)
(Currently)
(Currently)
(24 Mos.)
(24 Mos.)
(Currently)
(24 Mos.)
(12 Mos.)
Been advised to have tests, treatment, surgery that has not yet been performed, or have pending results
(12 Mos.)
(12 Mos.)
(12 Mos.)
Not On App.**
Not On App.**
(12 Mos.)
(24 Mos.)
(Currently)
Huntington's (Chorea) Disease
(Currently)
(Currently)
(24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(24 Mos.)
Currently eligible for Medicaid or on early Medicare due to disability (prior to age 65), or disabled
(Unless for specific knockout)
(Currently)
(Currently)
Not On App.**
Not On App.**
(Unless for specific knockout)
(Currently)
(Except for Medicaid)
Parkinson's Disease (Stages 1-3)
Tier 1
Tier 2 ( 24 Mos.)
(24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(36 Mos.)
Oxygen use due to respiratory disease
Tier 1
Tier 2 ( 24 Mos.)
(12 Mos.)
(12 Mos.)
(24 Mos.)
(24 Mos.)
(Currently)
Multiple Sclerosis
Tier 1
Tier 2 ( 24 Mos.)
(24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(36 Mos.)
Chronic Obstructive Lung or Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, or Respiratory Disease Requiring Oxygen
Tier 1
Tier 2 ( 24 Mos.)
UNLESS Oxygen, then NO
(24 Mos.)
(24 Mos. If Oxygen or 3+ Meds)
(24 Mos.)
(Currently) including Interstitial Lung Disease
Heart Disease, Congestive Heart Failure, Heart or Valve Surgery?
(No- Heart Attack or Heart Surgery- 12 Mos.)
Tier 1
(Unless CHF - 24 Mos.)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(24Mos.) Including Cardiomyopathy; and any disease req. implanted defibrillator
Stroke (CVA)
(12 Mos.)
Tier 1
Tier 2 ( 24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
Kidney Failure (any reason besides due to diabetes)
(12 Mos.)
Full UW
(If dialysis needed 24 Mos.)
(36 Mos.)
(24 Mos.)
(Currently) Any Reason
Prescribed daily nebulizer use with Oxygen (NOT due to respiratory disease)
(12 Mos.)
(12 Mos.)
(24 Mos.)
(24 Mos.)
Use of wheelchair, walker, motorized cart, motorized mobility device?
(Cannot be 'confined' to wheelchair)
(6 Mos.)
(6 Mos.)
(Currently)
(24 Mos.)
(Currently)
Require a hospital bed?
(6 Mos.)
(6 Mos.)
(Currently)
Use of 4+-prong cane?
(6 Mos.)
(6 Mos.)
(Currently)
(24 Mos.)
Organ transplant (other than corneal)?
Tier 1
Tier 2 ( 24 Mos.)
Not On App.
Not On App.
(24 Mos.)
(36 Mos.)
Alcohol or substance abuse?
Tier 1
Tier 2 ( 24 Mos.)
(24 Mos.)
(24 Mos.)
(12 Mos. - or been advised)
(24 Mos.)
Cerebral Palsy,
Tier 1
Tier 2 ( 24 Mos.)
NO (24 Mos.)
NO (24 Mos.)
(36 Mos.)
(24 Mos.)
Systemic lupus, muscular dystrophy, ALS (Lou Gehrig's Disease), motor neuron disease, psychotic disorders, or other neurological or neuromuscular diseases?
Tier 1
Tier 2 ( 24 Mos.)
(24 Mos., but "Lupus" NOT mentioned on App.)
(24 Mos., but "Lupus" NOT mentioned on App.)
(36 Mos.)
(24 Mos.)
(36 Mos.) *Psychotic disorder not on app
Amputation caused by disease
(12 Mos.)
Tier 1
Tier 2 ( 24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
Diabetes with 50+ units of insulin
(Tier 1); Includes, "or 3+ oral and 1 injectible meds"
(Tier2 -- 24 Mos.); Includes, "or 3+ oral and 1 injectible meds"
(24 Mos.)
(24 Mos.)
(Currently)
(24 Mos.)
(Currently)
Chronic liver disease (Cirhosis)
Tier 1
Tier 2 ( 24 Mos.)
(incl. Hepatitis C -- 24 Mos.)
(24 Mos.)
(24 Mos.)
(36 Mos.) Also for Pancreatitis (24 Mos.)
Transient Ischemic Attack (TIA)
(12 Mos.)
Tier 1
Tier 2 ( 24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
(24 Mos.)
Diabetic with less than 50 units of insulin and only non-proliferative retinopathy
(24 Mos.)
(24 Mos.)
(Currently)
(24 Mos.)
*NO if taking 3 or more diabetic medications
Diabetic complications of heart or artery blockage?
(No- Heart Attack or Heart Surgery- 12 Mos.)
(unless currently insulin diabetic with heart failure… then NO)
(unless currently insulin diabetic with heart failure… then NO)
(24 Mos.)
(24 Mos.)
(Currently)
(unless heart or valve surgery - 24 Mos.)
(Currently)
Use of 2-3 prong cane?
(6 Mos.)
(6 Mos.)
(Currently)
(12 Mos.)
Memory loss (not yet defined as dementia)
(Currently)
(Currently)
(24 Mos.)
(24 Mos.)
(12 Mos.)
(36 Mos.)
Kidney dialysis, renal insufficiency?
(unless considered kidney failure)
(unless due to diabetes… then NO)
(unless due to diabetes… then NO)
(unless due to diabetes)
(24 Mos.)
(36 Mos.)
(24 Mos.)
(36 Mos.)
Overweight or Underweight for Height?
(Currently)
Opiods for Chronic Pain
See medication list
Skin Cancer In-Situ
Paget's Disease (Crippling skeletal disorder), Rheumatoid arthritis or other connective tissue disorders?
Yes
(unless Lupus
Not On App.**
Not On App.**
(36 Mos.)
(24 Mos.)
(currently) YES for Paget's Disease
Any type of seizure?
(unless due to neurological disease, then tier 2 - 24 Mos.)
(unless due to disease or disorder of the nervous system- 24 Mos.)
(unless due to disease or disorder of the nervous system- 24 Mos.)
(12 Mos.)
(unless due to neurological disorder, then - 24 Mos.)
Diabetes with 1-49 units insulin (no complications)
(24 Mos.)
(24 Mos.)
(24 Mos.)
Been hospitalized 3+ times for any reason?
(2+ times - 12 Mos.)
(24 Mos.)
(24 Mos.)
Use of 1 prong cane?
(Currently)
One or more fractures due to osteoporosis?
(24 Mos.)
CRITICAL CASH -- CARDIAC SPECIFIC: Heart Attack, Chest pain, Coronary bypass, angioplasty, stent placement, angina, heart arrhythmia requiring treatment, cardiomyopathy, abnormal heart test"
CRITICAL CASH -- CARDIAC SPECIFIC Continued: High Blood Pressure currently treated with 3 or more medications, Brain Hemorrhage, Carotid or Peripheral Artery Disease, Unoperated Aneurysm, Diabetes with Insulin, or Diabetes Diagnosed Prior to Age 50?"
CRITICAL CASH CANCER SPECIFIC Hodgkin's or Non-Hodgkin's Lymphona, Sarcoma, Myelodysplastic Syndrome, or ANY other type of cancer (excluding skin cancer), or ANY tumor of the brain?"
CRITICAL CASH KNOCKOUTS: ALS (Lou Gehrig's Disease), Central Nervous System Disease, Crohn's Disease, Cystic Fibrosis, Hepatitus B or C (Chronic), Mental Retardation, Motor Neuron Disease, Muscular Dystrophy, Paralysis, Parkinson's, or Ulcerative Colitis?"
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