Untitled

For Producer Use Only. Not for use with the general public. Table of Contents
Contact Information
Plan Choices
Benefit Limits/Options
New Business Requirements
Optional Benefits
Administrative Handling
Policy Underwriting
Application Completion
Underwriting Requirements
Underwriting Philosophy
Rate Classes 15
Preferred Criteria 16
Height and Weight Chart 17
Uninsurable Health Conditions
Some Medications Associated With Uninsurable Health Conditions
Health Condition Combinations 21
Medical Impairments 22
Contact Information
Addresses
General
Premium Submission (other than premium collected with the application)
Mutual of Omaha
PO Box 30154
Omaha, NE 68103-1252
Claims Phone
1-877-894-2478
Customer Service
Phone 1-877-894-2478
Licensing Phone
1-800-867-6873
Underwriting Phone
1-800-551-2059
Prequalification E-mail
LTC I and LTC II give your clients a variety of choices, which enables you to help them design a long-term care plan to fit their needs and budget.
Plan Choices
amount and not intended to represent the time for which benefits are payable. Daily benefit amount x benefit multiplier x 365 This chart provides an overview of Mutual of Omaha’s long-term care plans. Certain benefits and features may not be available in all states.
Policy forms LTC041-TQ, LTC041-NTQ, LTC041-AG-TQ, LTC041-AG-NTQ or state equivalent.
Benefit Limits/Options
1. Plans may be issued as Tax Qualified or Non-Tax Qualified (except the Simplified Plan (LTCI) may only be issued as Tax
(LTCI) (One Pool for nursing home/assisted living and home health care)
(a) Benefit multipliers of 3, 5 and Unlimited.
(b) Nursing home/assisted living facility daily benefit amount of $50 – $400 ($500 in NY) in $10 increments.
(c) The amount of the One Maximum Lifetime Benefit is calculated by multiplying the number of years in the benefit multiplier by 365, and then multiplying that amount by the Nursing Home/ALF Maximum Daily Benefit.
(d) Elimination periods of 30 and 90 days.
(e) Home health care daily benefit is 100% of the Nursing Home Maximum Daily Benefit.
(f) Tax Qualified coverage only.
(LTCII) for nursing home/assisted living and home health care:
(a) Benefit multipliers of 2, 3, 4, 5 years and Unlimited.
(b) Nursing home/assisted living facility daily benefit amount of $50 – $400 ($500 in NY) in $10 increments.
(c) The amount of the One Maximum Lifetime Benefit is calculated by multiplying the number of years in the benefit multiplier by 365, and then multiplying that amount by the Nursing Home/ALF Maximum Daily Benefit.
(d) Home health care daily benefit: 50% or 100% of the NH Maximum Daily Benefit.
(e) Elimination periods of 0, 30, 60, 90,180 and 365 days.
If the 30, 60, 90, 180 or 365 day elimination period is chosen, the applicant has the option to choose the Waiver of Elimination Period for Home Health Care (0-day elimination period for Home Health Care).
(LTCII) for confined care (NH/ALF) and home health care:
(a) Benefit multipliers of 2, 3, 4, 5 years and Unlimited.
(b) NH/ALF daily benefit amounts of $50 – $400 ($500 in NY) in $10 increments.
(c) The benefit multiplier for home health care coverage must always be less than or equal to the benefit multiplier for (d) The daily benefit amount for home health care must be at least 50% of the confined care daily benefit amount (rounded up in $10 increments) and cannot exceed the confined care daily benefit amount.
(e) The amount of the Confinement (Nursing Home/Assisted Living Facility) Maximum Lifetime Benefit is calculated by multiplying the number of years in the Confined Care Benefit multiplier by 365, and then multiplying that amount by the Nursing Home/ALF Maximum Daily Benefit. The amount of the Home Health Care Maximum Lifetime Benefit is calculated by multiplying the number of years in the HHC benefit multiplier by 365, and then multiplying that amount by the Home Health Care Maximum Daily Benefit.
(f) Elimination periods of 0, 30, 60, 90, 180 and 365 days.
5. TOTAL DAILY BENEFITS for Nursing Home/Assisted Living or Home Health Care, including all long-term care policies in force, cannot exceed $400 ($500 in NY).
PAYMENT Period Options:(a) 10-year pay,(b) To-age-65 pay, or(c) Level lifetime pay.
7. The following options MUST be offered (for further information, refer to the Underwriting Rules for Optional Benefits The 5% Compound Inflation Benefit (Lifetime) must be offered to all applicants. One inflation protection benefit (GPO, Simple Inflation or Compound Inflation) must be selected at time of application. If the Simple or Compound Inflation Benefits are not chosen, the GPO benefit must be added. (This GPO requirement does not apply when a Limited Payment option or the Return of Premium at Death Less Claims option is selected.) Non-Forfeiture Benefit – Shortened Benefit Period (if not chosen, the Contingent Non-Forfeiture Benefit will be added).
(a) For spouse – 30% discount each (when both are issued coverage).
(b) Married – 15% discount if only one spouse applies for coverage, or if both apply and one is declined.
(c) For two-person household – 10% discount each (when both are issued coverage). A Two Person Household is defined as two adults age 18 or older living together on an continuous basis for at least 12 months.
NOTE: A person cannot have both a spouse discount and a two-person household discount.
(d) For members of a affinity associations: 10% discount (spouse, parents (including in-laws) and adult children of the member also qualify for the discount). Limited pay options are not available.
(e) For LTC Employee Paid plans: limited pay options are not available.
(f) For Employer Paid/List Bill plans: 10% discount. (See guidelines below.) NOTE: Spouse/Preferred Health or Spouse/Association discounts are multiplicative. See the rate book for details.
Optional Benefits Available – Cost (please refer to the underwriting rules for each option for additional information)
– SIMPLE INFLATION PROTECTION– COMPOUND INFLATION PROTECTION (LIFETIME)– COMPOUND INFLATION PROTECTION – 20 YEAR– NON-FORFEITURE BENEFIT – SHORTENED BENEFIT PERIOD– INDEMNITY COVERAGE (NH, ALF) – MONTHLY HOME HEALTH CARE BENEFIT– SPOUSE WAIVER OF PREMIUM AND SURVIVORSHIP BENEFIT– SPOUSE BENEFIT– RETURN OF PREMIUM AT DEATH LESS CLAIMS BENEFIT – 10-YEAR PREMIUM PAYMENT OPTION– TO-AGE-65 PREMIUM PAYMENT OPTION Optional Benefits Available – No Cost (please refer to the underwriting rules for each option for additional information)
– GUARANTEED PURCHASE OPTION– CHRISTIAN SCIENCE PROVIDERS Mandated Benefit – No Cost (please refer to the underwriting rules for each option for additional information)
New Business Requirements
LTC Employer Paid Plans
1. Self-employed persons, owner/employees of a corporation, employees and spouses of employees may apply for coverage.
All benefit options are available, except as noted in rules 4 and 5 below. The policy benefit determination is made by the employer.
2. Employee contributions are allowed; however, the employer will be billed for the full premium. Employer contributions or endorsement of the program will require ERISA claims handling. The employee can also purchase his or her own separate individual coverage to supplement the employer-paid plan. A minimum 10% employer participation is required.
3. Underwriting will be handled as follows: Preferred, Select, Substandard (Class I or II) or Decline.
5. No Cash required with Application.
6. No Guaranteed Purchase Option allowed.
7. Three applications are required to set up a list bill. A ten percent (10%) premium discount is allowed (with partial 8. The following special form is required if new Employer Paid Group – LTC New Employer Questionnaire (signed by employer and submitted to insurance company) at time of sale.
* See your compensation schedule for details.
LTC Employee Paid Plans
1. Owner/employees of a corporation, employees and spouses of employees may apply for coverage. All benefit options are
2. Underwriting will be handled as follows: Preferred, Select, Substandard (Class I or II) or Decline.
3. Ten percent (10%) premium discount (with commission offset*) is allowed.
4. Limited pay options are not available.
5. No Cash required with Application.
6. The following special forms are required for payroll deduction.
– LTC New Employer Questionnaire (by Employer) if new Employee Paid Group * See your compensation schedule for details.
Optional Benefits
Simple Inflation Protection – 5%
1. May be added to new issues of the Simplified Plan (LTCI), One Maximum Lifetime Benefit (LTCII) or Two Maximum
2. The underwriting for this benefit will be the same as the policy to which it is attached.
3. This benefit will increase the premium.
4. Only one inflation protection benefit (GPO, Simple or Compound) may be selected.
5. This benefit may be removed after issue with no refund of premium. The daily benefits and remaining maximum lifetime benefit(s) will remain at the level to which they had been increased by this benefit as of the date the benefit is removed. The premium will be changed to the appropriate premium amount for the increased benefit amount provided, based on the age at issue. Compound Inflation Protection Benefit — Lifetime – 5%
1. This benefit must be offered to all applicants.
2. May be added to new issues of the Simplified Plan (LTCI), One Maximum Lifetime Benefit (LTCII) or Two Maximum 3. The underwriting for this benefit will be the same as the policy to which it is attached.
4. This benefit will increase the premium.
5. Only one inflation protection benefit (GPO, Simple or Compound) may be selected.
6. This benefit may be removed after issue with no refund of premium. The daily benefits and remaining maximum lifetime benefit(s) will remain at the level to which they had been increased by this benefit as of the date the benefit is removed. The premium will be changed to the appropriate premium amount for the increased benefit amount provided, based on the age at issue.
Compound Inflation Protection Benefit — 20 Year – 5%
1. May be added to new issues of the Simplified Plan (LTCI), One Maximum Lifetime Benefit (LTCII) or Two Maximum
2. The underwriting for this benefit will be the same as the policy to which it is attached.
3. This benefit will increase the premium.
4. Only one inflation protection benefit (GPO, Simple or Compound) may be selected.
5. This benefit may be removed after issue with no refund of premium. The daily benefits and remaining maximum lifetime benefit(s) will remain at the level to which they had been increased by this benefit as of the date the benefit is removed. The premium will be changed to the appropriate premium amount for the increased benefit amount provided, based on the age at issue.
Guaranteed Purchase Option
1. This benefit must be added to new issues of the Simplified Plan (LTCI), One Pool (LTCII) or Two Pool (LTCII) coverage
if Simple or Compound Inflation Protection has not been chosen by the applicant, except as shown in rule 3 below.
2. The underwriting for this benefit will be the same as the policy to which it is attached.
the Return of Premium at Death Less Claims option; or 4. Only one option offer will be made on the offer date following age 80.
Non-Forfeiture Benefit – Shortened Benefit Period
1. This benefit must be offered to all applicants.
2. May be added to new issues of the Simplified Plan (LTCI), One Pool (LTCII) or Two Pool (LTCII) coverage.
3. The underwriting for this benefit will be the same as the policy to which it is attached.
4. This benefit will increase the premium.
5. This benefit may be removed after issue. If it is removed, the Contingent Non-Forfeiture Benefit must be added Indemnity Benefits (NH and ALF)
1. May be added to new issues of the One Pool (LTCII) or Two Pool (LTCII) forms.
2. The underwriting for this benefit will be the same as the policy to which it is attached.
(b) if the Spouse Benefit is attached to the policy; or 4. This Indemnity Benefit applies to nursing home confinement and assisted living facility confinement. 5. This benefit may be removed at the request of the Insured.
Monthly Home Health Care Benefit
1. May be added to new issues of the One Pool (LTCII) or Two Pool (LTCII) forms.
2. The underwriting for this benefit will be the same as the policy to which it is attached.
3. This benefit may be removed at the request of the Insured.
Spouse Waiver of Premium and Survivorship Benefit
1. May be added to new issues of the Simplified Plan (LTCI), One Pool (LTCII) or Two Pool (LTCII) coverage.
2. The underwriting for this benefit will be the same as the policy to which it is attached.
3. Both husband and wife must apply for and be issued this benefit at the same time.
(a) to Class I and Class II health risks; 5. This benefit may be removed at the request of the Insured. Spouse Benefit
1. May be added to new issues of the One Pool (LTCII) or Two Pool (LTCII) forms.
2. No underwriting applies to the dependent spouse.
(c) Spouse Waiver of Premium and Survivorship Benefit; (d) Principal insureds with Issue ages greater than age 69; (e) Principal insureds that are Class I or Class II risks; or 4. The 30% Spouse Discount does not apply; the 15% insurable spouse discount will, if the requirements explained under 5. This benefit may be removed at the request of the Insured.
Return of Premium at Death Less Claims Benefit
1. May be added to new issues of One Pool (LTCII) and Two Pool (LTCII) coverage.
2. The maximum issue age for this benefit is age 65.
3. The underwriting for this benefit will be the same as the policy to which it is attached.
4. This benefit will increase the premium.
5. This benefit may be removed and the premium reduced after issue with no refund of premium.
6. This benefit is not available if Guaranteed Purchase Option is selected.
10-Year Premium Payment Option
1. May be added to new issues of the Simplified Plan (LTCI), One Pool (LTCII) or Two Pool (LTCII) coverage.
2. The underwriting for this benefit will be the same as the policy to which it is attached.
3. Only one limited payment option may be added: (a) 10 year, or (b) To Age 65 (described below).
4. A limited payment option may be removed at the request of the insured. The premium after removal will be based on the original issue age. No premium credit (refund or an advance of the paid-to-date) will be given. (a) the Spouse Waiver of Premium and Survivorship Benefit; (d) Class I and Class II health risks.
To-Age-65 Premium Payment Option
1. May be added to new issues of the Simplified Plan (LTCI), One Pool (LTCII) or Two Pool (LTCII) coverage.
2. The underwriting for this benefit will be same as the policy to which it is attached.
3. Only one limited payment option may be added: (a) 10 year (described above), or (b) To Age 65.
4. A limited payment option may be removed at the request of the insured. The premium after removal will be based on the original issue age. No premium credit (refund or an advance of the paid-to-date) will be given. 5. The maximum issue age for the To Age 65 limited payment option is through age 54.
(a) the Spouse Waiver of Premium and Survivorship Benefit; Christian Science Providers
1. May be added to new issues of the Simplified Plan (LTCI), One Pool (LTCII) or Two Pool (LTCII) coverage at the
request of the applicant/policyowner.
2. No underwriting applies to this benefit.
Contingent Non-Forfeiture
1. Will be automatically added to new issues of Simplified Plan (LTCI), One Pool (LTCII) or Two Pool (LTCII) forms if the
Shortened Benefit Period Non-Forfeiture Benefit is not purchased.
2. Will be added to an in-force policy (as listed above) if the Shortened Benefit Period Non-Forfeiture Benefit was purchased and then removed at the policyowner’s request after issue.
Administrative Handling
Downgrades/Premium Paying Period Changes
Downgrades/Dropping Coverage
■ Continuing benefits keep original issue age.
■ Continuing benefits continue to pay renewal compensation.
■ Shortened Benefit Period nonforfeiture, ■ Effective on original effective date if requested within 60 days ■ If requested more than 60 days after issue, effective date is ■ Print new policy and new Schedule Page.
Downgrades/Reducing Coverage
■ All benefits keep original issue age.
■ Continuing benefits continue to pay renewal compensation.
■ Effective on original effective date if requested within 60 days of ■ If requested more than 60 days after issue, effective date is ■ Print new Endorsement with benefit change and new Changes to Premium Paying Period
Convert from limited pay to lifetime pay.
■ Lifetime premium at original age.
■ No credit given for payment made during limited pay period.
■ Pay renewal commissions based on lifetime premium ■ Effective on original effective date if change requested within 60 days of original effective date.
■ If change request more than 60 days after issue, effective date is ■ Print new policy and new Schedule Page.
Policy Underwriting
Application Received Date The application must be received in our Service Office within 30 days of the application date.
Applications more than 30 days old when received will require a currently dated application. Premium will be based upon
the applicant’s age as of the new application signing date.
Benefit Decreases are allowed. Refer to Downgrades/Premium Paying Period Changes chart.
Benefit Increases may be allowed within 60 days after policy issue subject to underwriting approval. A completed Statement
of Good Health M24181 is required.
Coverage Effective Date (if policy is issued)
New Business Money Submitted – application signing date
New Business No Money Submitted – policy issue date
Replacement Money Submitted – requested effective date up to 60 days after the application signing date
Replacement No Money Submitted – requested effective date up to 60 days after the application signing date, but not prior to
policy issue date
No coverage will be in effect before the Coverage Effective Date
Foreign Nationals – A policy will not be issued to Foreign Nationals living in the United States for less than 36 continuous
months or to those who do not have a valid permanent resident card Form I-551 (“Green Card”).
Initial Premium submit the full initial modal premium. Two months for monthly bank draft. Available modes include:
■ monthly
■ quarterly ■ semi-annual■ annual■ *See the separate explanation of PRD and employer paid requirements.
Issue Ages 18-79
Non-Forfeiture Benefit – Shortened Benefit Period MUST be offered. If not chosen, the Contingent Non-Forfeiture benefit
will be added.
Replacements and Conversions require full underwriting. A replacement form must be submitted for all applicants
replacing other policies. The prior coverage must be shown on the application.
Reinstatements – A client may be eligible for reinstatement of their policy if their attained age is less than 72 and the policy
has been lapsed for less than 180 days. The former insured should contact Customer Service to initiate the reinstatement.
They will be mailed an application for completion. The underwriter may or may not require that a current phone interview
and medical records be obtained. If reinstatement is approved, the client must pay all back premium within 35 days of
reinstatement approval. If money is not received timely, the client is ineligible for reinstatement and must reapply for
coverage with premium at current age.
Save Age – Premium will be based upon the applicant’s age on the date the application is signed. If the applicant’s date of
birth is within 30 days of the application signing date, rates will be based upon the younger age.
Suitability – A completed Long-Term Care Personal Worksheet is included in each application packet and must be submitted
with each application. The agent is responsible for verifying that the coverage is affordable for the applicant. Minimum
financial guidelines are an annual household income of $16,000 or $50,000 in noncountable assets. This policy is not
available to an individual who meets Medicaid eligibility guidelines.
Application Completion
The application packet includes the application and any vital state forms.
The application must be taken on the client’s resident state application packet. Submission of a nonresident state application will require submission of the correct state application before a policy can be issued. The producer must be licensed in the signing state for in person applications, and in the solicitation state for mailed applications.
Only one applicant per application. Separate applications are required for each person applying for insurance. Only the applicant for insurance may complete and sign the application. White out is not allowed. If a question is answered in error, draw a single line through the error, and have the correction initialed by the applicant. “N/A” is an unacceptable answer. Instead the questions should be answered “no” or “none.” Include a copy of your quote with the application packet.
Indicate on the application the best time to contact the applicant for a telephone interview or face to face examination. Inform the applicant of the interview or face to face process, provide them with, and help them to complete, the Importance of an Accurate Health History brochure MC31306. Underwriting Requirements
All underwriting requirements will be ordered by underwriting once an application is received. Telephone Interview – required for every applicant age 71 and under.
Face to Face – required for every applicant age 72 and above. Younger ages at underwriter discretion.
Review and leave with the applicant a copy of the “Importance of an Accurate Health History” brochure.
An applicant who does not read, speak, and understand English well enough to complete the interview in English is ineligible for coverage. A translator cannot be used to assist with the interview.
If an applicant’s hearing loss prevents them from completing a telephone interview, a note should be included with the application advising that a Face to Face examination is needed. For deaf applicants indicate if they are able to read lips or communicate with sign language.
The Face to Face examination must be completed in the applicant’s home. It cannot be completed at their place of work, a relative’s home, or a public place such as a restaurant.
Medical records will be ordered on all applicants age 65 and above. Medical records on younger ages will be ordered at
underwriting discretion. Any condition listed in the Medical Impairments section as Class I or IC will normally require
medical records.
Please Note:
A doctor visit is required within the 24 months preceding the application date for all applicants age 72 or greater, or those age 70 or younger wishing to qualify for a Preferred rate class. Telephone
Cognitive
Face to Face
Medical Records
Interview
(telephonic or
Interview
face to face)
Underwriting Philosophy
Our LTC Underwriting involves evaluation of the applicant’s health history, cognitive status, daily activities, and the ability to perform and maintain activities of daily living (ADL’s) and instrumental activities of daily living (IADL’s). The application identifies impairments that will disqualify the applicant from coverage. An application should NOT be submitted for an applicant who answers “yes” to an insurability question. A policy will not be issued if the applicant is over or under the height and weight guidelines. Multiple health conditions require evaluation on a case by case basis. Higher risk applicants may receive an offer for reduced benefits and/or may require a premium increase. The producer will be prenotified of any offers that are different than as applied, and will be asked to advise if the coverage can be placed. ADL’s IADL’s
Eating Shopping
Toileting Meal
Transferring HouseworkBathing LaundryDressing Managing An applicant with any of the following is ineligible for coverage.
1. Answers “yes” to an insurability question on the application
2. Requires assistance with any ADL’s
3. Requires assistance with any IADL’s
4. Receiving Meals on Wheels
5. Is
7. Uses a quad cane, crutches, walker, electric scooter, wheelchair, oxygen, or respirator8. Is non-compliant with medications and/or treatment9. Has not pursued additional workup recommended by their physician10. Has a condition listed as a Decline in the Medical Impairment Guide11. In the last 6 months has: (a) Been confined to a nursing home or assisted living facility(b) Received home health care services, or adult day care(c) Received occupational, physical, or speech therapy Rate Classes
Refer to the Medical Impairments section and Build Chart to help determine the appropriate rate class. It is recommended that an applicant never be quoted better than Select. The underwriter will add a Preferred discount to the policy where appropriate.
Applications should not be submitted for persons who are over or under the weight guidelines, are taking a medication, or have a health condition indicated as uninsurable.
Preferred 15% discount at underwriter discretion. Refer to Preferred CriteriaSelect 100%Class I 125%Class II 150% Note:
■
Maximum allowable benefits for Class I and Class II risks is a 5-year benefit period and a minimum 90-day elimination period.
The following benefit options are not available to Class I and Class II risks:■ Spouse Spouse Waiver of Premium and Survivorship Benefit Preferred Criteria
Applicant must meet ALL of the following criteria to receive Preferred.
3. Is not taking any prescription medications other than: Medication for controlled high blood pressure (readings of 140/90 or less for the past 6 months) Medication for temporary, acute conditions 4. Applicant must not have been diagnosed or treated for any of the following within the last 5 years: Balance Disorder, difficulty walking or weakness Cancer (excluding basal cell skin cancer) Circulatory disease or disorder, including, but not limited to Peripheral Vascular Disease, Stroke, TIA Heart disease (excluding controlled high blood pressure) Respiratory disease or disorder, including, but not limited to Asthma, COPD, Emphysema 6. Has not been declined, rated or denied reinstatement for Long-Term Care Insurance within the past 3 years 7. Has seen their physician for a checkup within the last 2 years 8. Height and Weight must be within the Minimum and Preferred Maximum range on the Build Chart 9. The following health conditions may qualify for Preferred: Osteoarthritis, age <60, on one nonsteroidal medication Osteoporosis, age <60, T score –2.9 or better, regular exercise program, taking antiresorptive medication Height and Weight Chart – Unisex
Preferred
Standard
Minimum Weight
Maximum Weight
Maximum Weight
25% Rate Up Maximum
An applicant below the minimum weight is ineligible for coverage.
An applicant who is within the weight requirements but has other health conditions may be ineligible for coverage.
An applicant who exceeds the maximum unrated weight and has any condition listed on the impairment guide as a Class I or IC will be declined.
Uninsurable Health Conditions
Amputation two or more limbs due to trauma Physical Therapy within 6 months**Contact Underwriting to prequalify if within 6 months Some Medications Associated With Uninsurable Health Conditions
This list is not all-inclusive. An application should not be submitted if a client is taking any of the following medications.
Metrifonate DementiaMirapex Parkinson’s Some Medications Associated With Uninsurable Health Conditions
(continued)
Alzheimer’s Disease/Dementia
Multiple Sclerosis
Parkinson’s Disease
Health Condition Combinations
All shaded health condition combinations are ineligible for coverage.
Refer to the Medical impairments section for handling of unshaded health condition combinations.
Medical Impairments
Every attempt will be made to offer coverage. Multiple medical conditions may result in an offer of reduced benefits, a substandard rating, or a decline.
Conditions listed as IC, Class I or Class II will normally require an APS.
S Select Applicant is a standard health risk
Class I 25% rating, Maximum Benefit Period of 5 years,
Minimum Elimination Period of 90 days.
Class II 50% rating may be offered by underwriting when multiple medical impairments are present,
Maximum Benefit Period of 5 years, Minimum Elimination Period of 90 days.
IC Individual Consideration
D Decline
Addison’s Disease after 3 years, controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
After 12 months, controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADL Deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AIDS/ARC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adult Day Care recipient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Agoraphobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alcohol consumption of 4 or more drinks per day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alcoholism recovered at least 3 years, active in a support group, and
no current alcohol use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Still drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ALS (Amyotrophic Lateral Sclerosis, Lou Gehrig’s Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amputation due to trauma, after 12 months, one limb, no limitations . . . . . . . . . . . . . . . . . . . . . . . . . .
Due to disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Two or more limbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anemia cause identified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Not fully evaluated, cause unknown, or Aplastic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Angina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Angioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aneurysm operated after 6 months, fully recovered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Except cerebral, unoperated, stable for 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cerebral, unoperated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Impairments (continued)
Anxiety
< 70 years of age, after 12 months, controlled with medication, fully functional,
no psychiatric hospitalizations in the past 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
>70 years of age, after 2 years, controlled with medication, fully functional, no psychiatric hospitalizations in the past 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arrhythmia excluding Atrial Fibrillation
Controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Uncontrolled. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthritis after 1 year
Mild, controlled, no ADL/IADL deficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderate, controlled, no ADL/IADL deficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe, uncontrolled, or ADL/IADL deficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rheumatoid Arthritis mild, moderate, stable for 1 year, no limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . On Prednisone >10mg/day, or Methotrexate >20mgs/week, or Gold . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe disease, or with ADL/IADL deficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any, taking a medication indicated for severe arthritis on uninsurable medication list, or requiring chronic narcotic usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Assisted Living Facility Resident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ataxia or muscular incoordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Atrial Fibrillation/Flutter single episode, after 6 months, controlled on medication . . . . . . . . . . . . . . .
Chronic, after 6 months controlled on Coumadin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosed or hospitalized within 6 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . With history of TIA, CVA, or Heart Valve Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DChronic, not on Coumadin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average BP reading >159/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Balance Disorder after 6 months, resolved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Less than 6 months, or currently present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bipolar
After 3 years, controlled on medication, fully functional. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
< 3 years duration, or psychiatric hospitalization within the past 5 years . . . . . . . . . . . . . . . . . . . . . . . . . Blindness
One eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Both eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broken Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brain Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bronchitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bronchiectasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Impairments (continued)
Cancer surgically removed, or fully treated, full recovery, no recurrence
Bladder, transitional, treated, fully recovered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Invasive, after 3 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recurrent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Breast
In situ, treatment completed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stage I, after 1 year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stage II-III, after 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stage IV, after 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Colon, after 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Skin
Basal cell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Squamous cell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stage I after 3 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stage II or III, after 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stage IV after 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prostate
Stage A or B, after 12 months, surgically removed current PSA <0.1 . . . . . . . . . . . . . . . . . . . . . . . . . .
Treated with radiation, current PSA <0.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stage C, after 2 years, current PSA <0.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stage D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age >70 receiving hormone treatment (Lupron, Casodex, Eulixin, Zoladex, Initial Gleason Score < VI, and current PSA < 0.5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All other cancers, or multiple sites or metastatic, 2 years since date of last treatment, no current evidence of disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any cancer, 2 years since date of last treatment, no current evidence of disease, smoker . . . . . . . . . . . . Class I-D Cardiomyopathy hypertrophic, no CHF, no hospital stays, or syncope, or palpitations,
Ejection fraction >45% and stable for 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dilated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carotid Artery Disease/Stenosis operated, fully recovered, nonsmoker, after 6 months . . . . . . . . . . . .
Operated, still smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unoperated, <70% stenosis, no symptoms, nonsmoker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUnoperated, <70% stenosis, no symptoms, smoker. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History of TIA or CVA, or Valvular heart disease, or Type I diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type II diabetes, carotid stenosis >50%, or still smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cerebral Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cerebrovascular Accident (CVA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cerebrovascular Disease
Brain imaging findings of lacunar infarcts, small vessel ischemia, or white matter changes . . . . . . . . . . D
Claudication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Impairments (continued)
Chronic Fatigue after 12 months, no functional limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Any functional limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic pain
Requiring daily narcotics or with ADL/IADL limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
All others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cirrhosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Colitis/Crohn’s stable 1 year no hospitalizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
With complications or not well controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Confusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Congestive Heart Failure (CHF) single episode, recovered, after 12 months . . . . . . . . . . . . . . . . . . . . . .
Chronic, mild, well controlled, Lasix <40mg/day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All others, or in combination with atrial fibrillation, diabetes, or heart valve disorder . . . . . . . . . . . . . . COPD (Chronic Obstructive Pulmonary Disease)
Mild, tobacco free for 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mild, smoker diagnosed by chest X-ray only, no medications, no symptoms,stable pulmonary function tests (PFT’s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mild or moderate, tobacco use in the past 12 months, on medication, or symptomatic . . . . . . . . . . . . . DModerate, tobacco free for 12 months, stable PFT’s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Moderate, smoker, on medication, or symptomatic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe, using oxygen, or home nebulizer treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any, hospitalized for an exacerbation in the past 6 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any, FEV1 <65% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coronary Artery Disease (angina, heart attack, Angioplasty, stent, or Bypass)
After 6 months, stable, no limitations, no significant residual heart damage, nonsmoker . . . . . . . . . . . S
After 6 months, stable, no limitations, smoker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
After 6 months, in combination with controlled Type I diabetes, nonsmoker . . . . . . . . . . . . . . . . . . . . . With controlled Type I diabetes, nonsmoker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . With controlled Type 1 diabetes, smoker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . With poorly controlled hypertension (average BP >159/89), or congestive heart failure, or PVD or ejection fraction <45% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . With poorly controlled Type I or Type II diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Defibrillator/Automatic Implantable Cardiac Defibrillator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Depression
<70 years of age, after 12 months, controlled with medication, fully functional,
no psychiatric hospitalizations in the past 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
>70 years of age, after 2 years, controlled with medication, fully functional, no psychiatric hospitalizations in the past 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Impairments (continued)
Diabetes
Type I controlled, stable 6 months, no complications, nonsmoker, insulin <50 units/day . . . . . . . . . . . Class I
Type I controlled, with history of hypertension, or heart disease, nonsmoker . . . . . . . . . . . . . . . . . . . . .
Type I controlled, no comorbids, smoker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type I controlled, smoker, heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type I or Type II with retinopathy, or neuropathy, or nephropathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type I or Type II with peripheral vascular disease, history of TIA or CVA . . . . . . . . . . . . . . . . . . . . . . . Type II controlled stable 6 months, no complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type I or Type II insulin more than 50 units/day. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type I or Type II average BP reading >159/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type I or Type II Hemoglobin A1c>9.0, or noncompliant with treatment . . . . . . . . . . . . . . . . . . . . . . . . Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Difficulty walking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disabled, collecting any type of disability benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dizziness after 6 months, evaluated, resolved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple episodes or associated with falls, or not fully evaluated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Within 6 months, or not fully evaluated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Down’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug Abuse treated, active in support group, drug free for 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Within 5 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Electric Scooter Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Emphysema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Epilepsy after 1 year, controlled with medication, no seizures for 1 year . . . . . . . . . . . . . . . . . . . . . . . . .
1 or 2 seizures per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poorly controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fainting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Falls, single episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple episodes, or with injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fatigue, after 12 months, resolved, no functional limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Within 12 months, or with functional limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fibromyalgia after 1 year, well controlled, no ADL/IADL deficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poorly controlled, or disabling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fracture-Traumatic, one bone, after 3 months, fully recovered, no limitations. . . . . . . . . . . . . . . . . . . .
In combination with mild osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In combination with moderate to severe osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Associated with multiple falls, chronic dizziness, or gait disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fracture-Non traumatic, in combination with any degree of osteoporosis, not on
antiresorptive medication, or with functional impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Impairments (continued)
Frailty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Glaucoma, stable vision, controlled eye pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
All others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grave’s Disease after 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Guillain-Barre Syndrome, after 12 months, no residuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Head Injury after 6 months, no residuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
With residual functional or cognitive impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heart Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Heart Valve Disorder, operated 1 or 2 valves, fully recovered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unoperated, single valve, mild, no symptoms, no surgery planned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unoperated, single valve, moderate to severe, or surgery planned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any, unoperated with Atrial Fibrillation, or history of TIA or CVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemochromatosis after 12 months, successfully treated with phlebotomy, or chelation,
and stable blood counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hemophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatitis A or B after 6 months fully recovered. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C, after 2 years, successfully treated with Interferon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, currently treated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C, unresponsive to Interferon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hepatitis, any, chronic, active, or alcohol related . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . High Blood Pressure, after 6 months compliant with treatment:
Average BP <160/90 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Average BP <170/94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average BP >170/94, or any, noncompliance with treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HIV Positive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hodgkin’s Disease stage I, after 3 years fully recovered. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
All others, fully recovered, after 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Home Health Care received within 6 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Huntington’s Chorea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hydrocephalus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
IADL Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Immune Deficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incontinence, urinary, stress, manages independently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Urinary, uncontrolled, or requires assistance with management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Impairments (continued)
Irritable Bowel Syndrome, controlled, weight stable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
uncontrolled or with weight loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Joint Replacement, one joint after 3 months, fully recovered, no use of assistive devices. . . . . . . . . . . . S
2 or more fully recovered, no limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Surgery recommended or planned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney Disorder, mild renal insufficiency, stable 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderate to severe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney failure, single episode, fully recovered after 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney removal (1) after 2 years with stable kidney function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polycystic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic Kidney Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leukemia
Acute, after 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CLL after 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Liver Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lou Gehrig’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lupus, discoid, after 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Systemic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lymphoma
Stage I or II after 2 years in complete remission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stage III or IV after 4 years in complete remission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Low-grade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Macular Degeneration one eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Both eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Manic Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medicaid Recipient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Memory Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meniere’s Disease after 6 months, symptoms controlled, no limitations . . . . . . . . . . . . . . . . . . . . . . . . .
Associated with falls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Monoclonal Gammopathy, after 1 year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Muscular Dystrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Myasthenia Gravis, ocular, after 1 year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Generalized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Impairments (continued)
Myelodysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Myocardial Infarction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Neurogenic Bowel or Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Neuropathy, mild, fully evaluated, no limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-IC
Not fully evaluated, related to diabetes or alcohol or with history of falls, or skin ulcers . . . . . . . . . . . . D
Nursing Home Confinement after 6 months, full recovery, no limitations . . . . . . . . . . . . . . . . . . . . . . .
Within 6 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Organic Brain Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Organ Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osteopenia, on medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osteoporosis mild, on medication, no history of nontraumatic fractures . . . . . . . . . . . . . . . . . . . . . . . .
Moderate, no history of nontraumatic fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe T score -3.5 or worse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any, with history of nontraumatic fracture, or not on treatment, or with functional limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oxygen use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pacemaker after 3 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recommended or surgery pending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paget’s Disease, no symptoms and no limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
With symptoms or history of fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pancreas Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pancreatitis after 12 months, single episode, fully recovered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Related to alcohol use, or 2 or more episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Panic Attack/Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Paraplegia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Parkinson’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Impairments (continued)
Peripheral Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Peripheral Vascular Disease
Mild, nonsmoker, no symptoms, no limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderate, or in combination with coronary artery disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe, or still smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average BP reading >159/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any, with limitations, history of leg ulcers, diabetes, or pending surgery . . . . . . . . . . . . . . . . . . . . . . . . . Physical Therapy received within 6 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pick’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pneumonia after 3 months, single episode, fully recovered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Associated with chronic lung disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polio fully recovered and no limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
With recurrence or limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Post Polio Syndrome after 2 years, nonprogressive, no limitations, no assistive devices. . . . . . . . . . . . .
Progressive weakness or fatigue, or with limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polycystic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Polymyalgia Rheumatica mild, after 1 year, no limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderate, no functional limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe, or with limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psoriasis, mild to moderate, controlled with medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Severe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psychosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulmonary Fibrosis, localized, nonprogressive, normal PFT’s, after 2 years . . . . . . . . . . . . . . . . . . . . . .
Active, progressive disease, abnormal PFT’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quad Cane Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quadriplegia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reflex Sympathetic Dystrophy (RSD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Renal Disease/Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retinitis Pigmentosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Impairments (continued)
Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sciatica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Scleroderma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sjogren’s Syndrome
Mild, dryness of eyes and mouth only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
In combination with Rheumatoid Arthritis, connective tissue disease, or other organ involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sleep Apnea responsive to treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Severe or unresponsive to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Spinal Stenosis operated, fully recovered, after 12 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unoperated, mild to moderate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unoperated, severe or surgery recommended. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any, with epidural injections within 6 months, functional limitations, or chronic pain requiring daily narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stroke
Single episode, fully recovered after 2 years, no limitations, nonsmoker . . . . . . . . . . . . . . . . . . . . . . . . . .
Two or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In combination with any of the following: Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unoperated carotid stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heart valve disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average blood pressure reading >159/89. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Previous TIA(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Residual weakness or functional loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Smoking within the past 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ocurred while adequately anticoagulated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Systemic Lupus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thrombocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transient Global Amnesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see TIA
Medical Impairments (continued)
Transient Ischemic Attack (TIA) single episode, fully recovered after 1 year. . . . . . . . . . . . . . . . . . . . . .
Two or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In combination with any of the following: Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unoperated carotid stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heart valve disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Previous stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average BP reading >159/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Residual weakness or functional loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Smoking within the past 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occurred while adequately anticoagulated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tremor fully evaluated, benign familial, no limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S
Not fully evaluated, with limitations, or gait disturbance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Underweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vertigo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Walker Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weight Loss, unexplained, or not fully evaluated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Wheelchair Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mutual of Omaha Insurance CompanyMutual of Omaha PlazaOmaha, NE 68175[email protected]1-800-551-2059

Source: http://www.gatewayinsurance.net/forms/Mutual%20of%20Omaha/ltcUnderwriting.pdf