LUKA BEAR - LTC Insurance Documentation Package - Eldercare Robotics LLC - CONFIDENTIAL
LTC Insurance Documentation Package
For Families with Long-Term Care Insurance Policies
Alternate Plan of Care Claim - Ready to Submit
This package contains five documents
- Document 1: Physician Letter of Medical Necessity
- Document 2: Written Care Plan (Alternate Plan of Care)
- Document 3: Cost Comparison & Policy Reference Sheet
- Document 4: Medicaid Self-Direction Justification Letter
- Document 5: HSA / FSA Letter of Medical Necessity
LUKA BEAR - LTC Insurance Documentation Package - Eldercare Robotics LLC - CONFIDENTIAL
Document 1 - Physician Letter of Medical Necessity
Instructions for physician: Please complete on your practice letterhead. All fields in brackets are required.
Instructions for family: Take this template to your physician or specialist who manages the dementia diagnosis. Ask them to complete it on their letterhead and sign it. This letter is then submitted to the LTC insurer along with Documents 2 and 3.
[Date]
[Insurance Company Name]
[Claims Department / LTC Division]
[Address]
RE: Alternate Plan of Care Request - Patient: [Patient Full Name] | Policy #: [LTC Policy Number] | DOB: [Date of Birth]
To Whom It May Concern:
I am writing to support an Alternate Plan of Care request for my patient, [Patient Full Name], date of birth [DOB], who is under my care for the management of Alzheimer's disease / dementia.
Diagnosis and Clinical Summary
| Primary Diagnosis | e.g., Alzheimer's Disease, Moderate Stage (ICD-10: G30.9) |
|---|---|
| Date of Diagnosis | e.g., [Month, Year] |
| Current Stage | e.g., Moderate - MMSE Score: [#] |
| Behavioral Symptoms | e.g., nighttime agitation, repetitive questioning, wandering risk, anxiety |
| Current Medications | [List dementia-related medications] |
Functional Limitations
The patient demonstrates the following functional limitations that meet the benefit trigger criteria for this LTC policy:
[ ] Requires supervision or cueing for Activities of Daily Living (ADLs)
[ ] Requires 24-hour supervision due to cognitive impairment and safety risk
[ ] Experiences significant behavioral and psychological symptoms of dementia (BPSD)
[ ] Caregiver(s) are at risk of burnout without additional support
[ ] Other: [describe]
Medical Necessity for Luka Bear
I am prescribing Luka Bear (Eldercare Robotics LLC) as a medically necessary intervention for this patient. Luka Bear is an AI-powered companion device that provides:
- 24/7 cognitive engagement and behavioral monitoring between caregiver or clinician visits
- Nighttime agitation support and caregiver alert system
- Medication and daily routine reminders
- Social interaction and emotional support to reduce anxiety and behavioral symptoms
- Real-time monitoring data accessible to the care team
In my clinical judgment, Luka Bear will substitute for or delay the need for additional in-home aide hours or facility placement. The cost of Luka Bear ($99-$179/month) is significantly less than equivalent in-home care ($4,000-$8,000/month), making it a cost-effective alternative under the patient's Alternate Plan of Care benefit.
Alternate Plan of Care Recommendation
[Patient Full Name] is unable to safely remain at home without the cognitive engagement, behavioral monitoring, and caregiver support that Luka Bear provides. I strongly support the approval of Luka Bear under the Alternate Plan of Care provision of this patient's long-term care insurance policy.
Please do not hesitate to contact my office if additional clinical documentation is required.
Signature
Date
Printed Name & Title
NPI Number
LUKA BEAR - LTC Insurance Documentation Package - Eldercare Robotics LLC - CONFIDENTIAL
Document 2 - Written Care Plan (Alternate Plan of Care)
Instructions: Complete all fields. This document is submitted alongside the Physician Letter (Document 1) to the LTC insurer. It specifies Luka Bear as the prescribed intervention and defines the care arrangement.
Patient Information
| Patient Full Name | |
|---|---|
| Date of Birth | |
| LTC Policy Number | |
| Insurance Company | |
| Policy Holder Name | (if different from patient) |
| Primary Caregiver | Name and relationship to patient |
| Caregiver Phone | |
| Patient Address | |
| Care Setting | e.g., private home / family member's home |
Care Need Assessment
| Diagnosis | |
|---|---|
| ADL Deficiencies | e.g., bathing, dressing, mobility - list which apply |
| IADL Deficiencies | e.g., medication management, meal planning, supervision |
| Cognitive Status | e.g., Moderate Alzheimer's, MMSE: ## |
| Daily Care Hours Needed | Estimated hours/day currently required from caregiver |
| Primary Care Challenges | e.g., nighttime agitation, wandering risk, repetitive behaviors |
Prescribed Intervention - Luka Bear
| Device Name | Luka Bear AI Companion (Eldercare Robotics LLC) |
|---|---|
| Vendor | Eldercare Robotics LLC | info@eldercarerobotics.net | (301) 381-LUKA |
| Monthly Cost | $99 - $179/month (subscription-based) |
| Purpose | 24/7 cognitive engagement, behavioral monitoring, caregiver respite |
| Expected Benefit | Substitutes for in-home aide hours; delays or prevents facility placement |
| Prescribed By | Dr. [Physician Name], [Practice Name] |
| Prescription Date | |
| Trial Period | 14 days (free) - then monthly subscription |
How Luka Bear Addresses Care Needs
| Care Need | How Luka Bear Addresses It |
|---|---|
| 24/7 supervision and monitoring | Continuous presence - engages patient, detects behavioral changes, alerts caregiver |
| Nighttime agitation | Active nighttime engagement protocol; plays calming audio and conversation |
| Caregiver burnout | Reduces caregiver direct care hours by providing independent engagement 4-6 hrs/day |
| Repetitive behaviors / anxiety | Redirects through music, stories, familiar conversation, and cognitive exercises |
| Medication reminders | Delivers scheduled verbal reminders at programmed times |
| Isolation and loneliness | Provides consistent companionship and emotional support throughout the day |
Plan of Care Signatures
| Care Plan Prepared By | Name + title of person completing this form |
|---|---|
| Relationship to Patient | e.g., Family Caregiver, Geriatric Care Manager, Social Worker |
| Date Prepared |
LUKA BEAR - LTC Insurance Documentation Package - Eldercare Robotics LLC - CONFIDENTIAL
Document 3 - Cost Comparison & Policy Reference Sheet
Submit this sheet to help the LTC insurer approve Luka Bear as cost-effective under the Alternate Plan of Care benefit. It demonstrates the economic rationale for approval.
Cost Comparison: Luka Bear vs. In-Home Aide Care
| Service / Item | Luka Bear | In-Home Aide |
|---|---|---|
| Monthly cost | $99 - $179 | $4,000 - $8,000+ |
| Annual cost | $1,188 - $2,148 | $48,000 - $96,000+ |
| Availability | 24/7 including nights & weekends | Scheduled hours only |
| Supervision hours provided/day | 24 hours continuous | 4-8 hours typical |
| Behavioral monitoring | Continuous AI monitoring | During visits only |
| Caregiver alert system | Real-time mobile alerts | Not typically included |
| Cognitive engagement | Continuous, personalized | As time allows |
| Startup cost | $0 (free 14-day trial) | Agency fees may apply |
| Cost to insurer vs. in-home care | 97% less than in-home care | Full amount |
Insurer-Specific Policy Language Reference
| Insurer | Applicable Policy Provision | Realistic Monthly Coverage |
|---|---|---|
| Transamerica | 'Therapeutic Device or Technology' benefit - strongest match for Luka Bear | $99-$199/month covered |
| Genworth | Home Assistance Benefit: 'assistive devices and supportive equipment' | $99-$199/month covered |
| Mutual of Omaha | Cash Alternative Benefit: 25-30% monthly benefit, no receipts required | $375-$900/month cash |
| New York Life | In-Home Support Equipment: $5,000 lifetime for devices and technology | $5,000 one-time |
| John Hancock | DME and APC provisions in legacy policies; LifeCare hybrid policies | Policy-dependent |
Eldercare Robotics LLC - Company Information
| Company | Eldercare Robotics LLC |
|---|---|
| Product | Luka Bear AI Companion Device |
| Website | eldercarerobotics.net |
| info@eldercarerobotics.net | |
| Phone | (301) 381-LUKA |
| CEO / Contact | Eduard Takhunts, Founder & CEO | (413) 296-LUKA |
| Monthly Subscription | $99/month (Basic) - $179/month (Premium) |
| Payment | Invoice or subscription agreement available on request |
| Active Pilots | Discovery Memory Care (PA) - 15 months | PA PACE pilot - approved |
LUKA BEAR - LTC Insurance Documentation Package - Eldercare Robotics LLC - CONFIDENTIAL
Document 4 - Medicaid Self-Direction Justification Letter
For self-direction programs: 1915(j) Self-Directed HCBS - Medicaid Self-Directed Personal Assistance Services
Instructions for family / participant: This letter is submitted to your Medicaid Self-Direction program (managed through your FMS agency) to justify Luka Bear as a substitute for human assistance hours. Have your support broker or FMS agency representative assist with submission.
To: [State Medicaid Agency / FMS Agency Name]
Re: Justification for Technology-Based Substitute for Human Assistance - Luka Bear AI Companion Device
Dear Self-Direction Program Coordinator,
I am writing to request approval for the Luka Bear AI Companion Device as a participant-directed technology supplement under the 1915(j) Self-Directed HCBS program. Luka Bear directly substitutes for human assistance hours by providing structured daily engagement, medication reminders, cognitive stimulation, and real-time caregiver monitoring - reducing the number of paid aide hours required.
| Participant Name | [Full legal name] |
|---|---|
| Medicaid ID | [State Medicaid number] |
| Date of Birth | [MM/DD/YYYY] |
| FMS Agency | [Name of Financial Management Services agency] |
| Support Broker | [Name and contact information] |
| Diagnosis | [Primary diagnosis qualifying for Self-Direction, e.g. Alzheimer's disease, dementia] |
| Current Aide Hours/Week | [Number of approved weekly aide hours] |
Clinical Justification
Luka Bear provides the following care functions that currently require paid human assistance:
| Medication Reminders | Luka Bear delivers scheduled, audible medication prompts with family alerts if not acknowledged - reducing need for aide visits solely for medication management. |
|---|---|
| Cognitive Engagement | Daily interactive activities (storytelling, music, memory games) provide structured cognitive stimulation, reducing behavioral supervision hours. |
| Caregiver Communication | Real-time status updates and alerts sent to designated family caregiver reduce the need for in-person check-in aide visits. |
| Emotional Regulation | Continuous companion presence reduces agitation episodes, decreasing reactivity hours and behavior management aide needs. |
| Emergency Detection | Motion and inactivity detection alerts designated contacts, supplementing safety monitoring without continuous aide presence. |
Estimated Cost Offset
At current home health aide rates of $25-$35/hour, replacing 2-4 aide visits per week with Luka Bear results in an estimated savings of $200-$560/month - exceeding the device cost and demonstrating cost-effectiveness as required under 1915(j) participant-directed budgets.
Request
I respectfully request approval for the Luka Bear AI Companion Device (one-time device cost: [amount], plus optional monthly service plan: [amount]) to be included in my participant-directed budget as a Technology Supplement / Substitute for Human Assistance under 1915(j) HCBS Self-Direction.
Participant / Authorized Representative
Date
LUKA BEAR - LTC Insurance Documentation Package - Eldercare Robotics LLC - CONFIDENTIAL
Document 5 - HSA/FSA Letter of Medical Necessity
For HSA and FSA reimbursement: Health Savings Account (HSA) / Flexible Spending Account (FSA)
Instructions for physician: Please complete this letter on your practice letterhead. The patient will submit it with their HSA/FSA reimbursement claim for the Luka Bear AI Companion Device. A Letter of Medical Necessity is required for HSA/FSA reimbursement of devices not explicitly listed in IRS Publication 502.
[Date]
To Whom It May Concern:
Re: Letter of Medical Necessity - Luka Bear AI Companion Device for HSA/FSA Reimbursement
I am writing this Letter of Medical Necessity on behalf of my patient:
| Patient Name | [Full legal name] |
|---|---|
| Date of Birth | [MM/DD/YYYY] |
| Diagnosis | [ICD-10 code and description, e.g. G30.1 Alzheimer's disease with late onset; F03.90 Unspecified dementia] |
| Treating Physician | [Physician name, MD/DO] |
| Practice / Institution | [Practice name and address] |
| NPI Number | [National Provider Identifier] |
Medical Necessity Attestation
My patient has been diagnosed with [diagnosis], which results in significant cognitive impairment, memory deficits, and increased risk of medication non-adherence, social isolation, and caregiver burden. I am prescribing the Luka Bear AI Companion Device for the following medically indicated purposes:
| Medication Adherence | The patient requires daily medication reminders. Luka Bear's automated, audible medication prompts directly reduce the risk of medication errors and associated adverse health outcomes. |
|---|---|
| Cognitive Stimulation Therapy | Regular cognitive engagement (memory exercises, storytelling, music therapy) is medically recommended to slow cognitive decline. Luka Bear delivers structured daily cognitive activities. |
| Behavioral Symptom Management | The patient experiences agitation and anxiety associated with dementia. Luka Bear's social interaction capability reduces behavioral symptoms, decreasing the need for pharmacological intervention. |
| Remote Health Monitoring | Luka Bear's caregiver alert system enables real-time monitoring of the patient's activity and responsiveness, supporting early intervention and reducing emergency department visits. |
| Social Isolation Prevention | Social isolation is a documented medical risk factor for this patient. Luka Bear provides continuous companionship, reducing isolation-related depression and cognitive decline. |
IRS Qualification Statement
In my professional medical judgment, the Luka Bear AI Companion Device is a medical device prescribed for the diagnosis, treatment, mitigation, or prevention of a disease or medical condition as defined under IRS Publication 502. The device is not for general health or wellness purposes but is specifically required to address the documented medical needs of this patient.
Device and Cost Information
Device: Luka Bear AI Companion (Eldercare Robotics LLC) | Approximate cost: [amount] | Vendor: eldercarerobotics.net
Physician Signature
Date
Printed Name
Specialty / License #
Phone
Fax
Questions? Contact Eduard Takhunts directly: (413) 296-LUKA | info@eldercarerobotics.net