LUKA BEAR - Funding Documentation Templates - Eldercare Robotics LLC
Funding Documentation Templates
For families using long-term care insurance, HSA/FSA accounts, or Medicaid self-direction
Templates you complete with your physician, care manager or support broker
This package contains five templates
- Document 1: Physician letter for a long-term care insurance Alternate Plan of Care request
- Document 2: Written care arrangement (Alternate Plan of Care)
- Document 3: Cost and policy reference sheet
- Document 4: Medicaid self-direction request letter
- Document 5: HSA / FSA letter of medical necessity (completed by the physician)
How to read these templates: Luka Bear is an assistive, non-medical companion device. Statements about a person's diagnosis, functional needs or care plan are made by the treating physician, care manager or plan team in their own words. The templates describe what Luka Bear does; they do not make medical claims, and approval decisions rest with the insurer or program. Every insurer and program has its own rules, so confirm the current requirements before submitting.
LUKA BEAR - Funding Documentation Templates - Eldercare Robotics LLC
Document 1 - Physician Letter (Long-Term Care Insurance, Alternate Plan of Care)
Instructions for physician: Please complete on your practice letterhead, using your own clinical findings. Fields in brackets are for you to fill in or remove.
Instructions for family: Take this template to the physician who knows your family member's condition. Ask them to complete and sign it on their letterhead. Submit it to the LTC insurer together with Documents 2 and 3. Many policies allow non-listed supports under an "Alternate Plan of Care" provision when the insurer agrees they are appropriate and cost-effective; the insurer decides.
[Date]
[Insurance Company Name]
[Claims Department / LTC Division]
[Address]
RE: Alternate Plan of Care Request - Insured: [Full Name] | Policy #: [LTC Policy Number] | DOB: [Date of Birth]
To Whom It May Concern:
I am writing in support of an Alternate Plan of Care request for my patient, [Full Name], date of birth [DOB], who is under my care for [condition, in the physician's own words].
Clinical Summary (physician completes)
| Primary Diagnosis | [Physician's diagnosis and code, if required by the insurer] |
|---|---|
| Date of Diagnosis | [Month, Year] |
| Current Functional Status | [Physician's description] |
| Day-to-day Challenges | [e.g., repeated questions, evening restlessness, missed routines, isolation, caregiver strain] |
| Current Medications | [Physician completes if required] |
Functional Limitations (physician checks those that apply)
The insured demonstrates the following functional limitations relevant to this policy's benefit criteria:
- [ ] Requires supervision or cueing for Activities of Daily Living (ADLs)
- [ ] Requires ongoing supervision because of cognitive impairment
- [ ] Experiences anxiety, restlessness or repetitive behaviors that increase care needs
- [ ] Family caregiver(s) need additional support to sustain care at home
- [ ] Other: [describe]
Recommended Support: Luka Bear
As part of this person's plan of care, I recommend Luka Bear (Eldercare Robotics LLC), an assistive, non-medical companion device. Luka Bear is placed in the home and provides:
- Personalized conversation and companionship throughout the day, with no wake word needed
- Reminders set up by the family for medications, meals, appointments and routines (reminders only; Luka does not dispense or manage medication)
- Evening and night calming routines, including a familiar family voice
- Brain games, music and photo visits for engagement
- A private caregiver app so family members can stay connected and receive a phone call if the person asks Luka for help
Luka Bear is not a medical device and not an emergency response system. It supplements, and does not replace, the care provided by family and professional caregivers.
Alternate Plan of Care Recommendation (physician's own words)
In my clinical judgment, [Full Name] [physician describes why this support fits the person's plan of care and current needs]. The monthly cost of Luka Bear is substantially lower than the cost of additional in-home aide hours or a facility placement, and I believe it is an appropriate and cost-effective component of this person's Alternate Plan of Care. I support its approval under the Alternate Plan of Care provision of this policy.
Please contact my office if additional clinical documentation is required.
LUKA BEAR - Funding Documentation Templates - Eldercare Robotics LLC
Document 2 - Written Care Arrangement (Alternate Plan of Care)
Instructions: Complete all fields. Submit with the physician letter (Document 1). It describes the care arrangement and where Luka Bear fits in it.
Insured Person
| Full Name | |
|---|---|
| Date of Birth | |
| LTC Policy Number | |
| Insurance Company | |
| Policy Holder Name | (if different from the insured) |
| Primary Caregiver | Name and relationship |
| Caregiver Phone | |
| Home Address | |
| Care Setting | e.g., private home / family member's home |
Care Needs (as described by the physician or care manager)
| Diagnosis | [From Document 1] |
|---|---|
| ADL Support Needed | e.g., bathing, dressing, mobility - list which apply |
| IADL Support Needed | e.g., reminders, meals, household routines |
| Daily Care Hours Currently Provided | Estimated hours/day from family and paid caregivers |
| Main Day-to-day Challenges | e.g., evening restlessness, repeated questions, isolation |
Recommended Support - Luka Bear
| Device | Luka Bear assistive companion (Eldercare Robotics LLC) |
|---|---|
| Vendor | Eldercare Robotics LLC | info@eldercarerobotics.net | (413) 296-LUKA |
| Cost | [Monthly service fee or purchase price, per the current pricing at eldercarerobotics.net] |
| Purpose | Companionship, reminders, calming routines and family connection between caregiver visits |
| Recommended By | Dr. [Physician Name], [Practice Name] |
| Recommendation Date | |
| Term | Month to month, cancel anytime |
How Luka Bear Fits the Care Arrangement
| Care Need | What Luka Bear Does |
|---|---|
| Long stretches alone between visits | A consistent, familiar presence for conversation, music, stories and photo visits |
| Evening and night restlessness | Calming routines in a familiar family voice; a no-response check-in call to the caregiver can be set up |
| Missed routines | Spoken reminders at the times the family sets up |
| Repeated questions and worry | Patient, repeatable answers, redirection to music, stories and brain games |
| Family wants to stay connected | Private caregiver app with a phone call to the caregiver when the person asks Luka for help |
| Caregiver strain | Short breaks while Luka engages the person; this complements, and does not replace, in-person care |
Signatures
| Prepared By | Name and title of the person completing this form |
|---|---|
| Relationship | e.g., Family Caregiver, Geriatric Care Manager, Social Worker |
| Date Prepared |
LUKA BEAR - Funding Documentation Templates - Eldercare Robotics LLC
Document 3 - Cost and Policy Reference Sheet
Use this sheet to show the insurer what Luka Bear costs compared with other in-home supports. Fill in the current Luka Bear price from eldercarerobotics.net and local care rates for your area.
Cost Comparison: Luka Bear and In-Home Aide Care
| Item | Luka Bear | In-Home Aide (typical) |
|---|---|---|
| Monthly cost | [current monthly fee] | [local rate; often several thousand dollars per month for regular hours] |
| Availability | In the home around the clock, with no scheduling | Scheduled hours only |
| Companionship and engagement | Ongoing, personalized to the person | During visits only |
| Reminders | Spoken reminders at the times the family sets | During visits only |
| Family connection | Private caregiver app; phone call to the caregiver when the person asks for help | Not typically included |
| Hands-on personal care | Not provided - Luka complements in-person care | Provided |
Policy Provisions That May Apply (verify with your insurer)
| Insurer | Provision families have used for assistive devices | Note |
|---|---|---|
| Transamerica | "Therapeutic Device or Technology" benefit (policy-dependent) | Confirm with your policy documents |
| Genworth | Home Assistance Benefit: "assistive devices and supportive equipment" | Confirm with your policy documents |
| Mutual of Omaha | Cash Alternative Benefit (percentage of the monthly benefit, flexible use) | Policy-dependent |
| New York Life | In-Home Support Equipment benefit for devices and technology | Policy-dependent |
| John Hancock | Durable equipment and Alternate Plan of Care provisions in legacy policies | Policy-dependent |
Policy language changes and varies by issue date. These are provisions to ask about, not a statement that any insurer covers Luka Bear.
Eldercare Robotics LLC - Company Information
| Company | Eldercare Robotics LLC, Rockville, Maryland |
|---|---|
| Product | Luka Bear assistive companion device |
| Website | eldercarerobotics.net |
| info@eldercarerobotics.net | |
| Phone | (413) 296-LUKA |
| NPI (Type 2) | 1013844018 |
| Pricing | Current pricing is published at eldercarerobotics.net; an invoice or service agreement is available on request |
LUKA BEAR - Funding Documentation Templates - Eldercare Robotics LLC
Document 4 - Medicaid Self-Direction Request Letter
For self-directed or participant-directed HCBS budgets. Instructions for the participant or representative: Give this letter to your support broker, case manager or financial management services (FMS) agency. They will tell you whether assistive technology or enabling technology can be requested in your plan, and how. Each state and program decides what it funds; a request is not an approval.
To: [State Medicaid agency / case management agency / FMS agency]
Re: Request to add assistive technology to my participant-directed plan - Luka Bear companion device
Dear [Support Broker / Case Manager / Program Coordinator],
I am requesting that the Luka Bear companion device (Eldercare Robotics LLC) be considered for my participant-directed plan as assistive technology / enabling technology. Luka Bear is a non-medical device that supports my daily routine, reminders, engagement and connection with my caregivers between visits.
| Participant Name | [Full legal name] |
|---|---|
| Medicaid ID | [State Medicaid number] |
| Date of Birth | [MM/DD/YYYY] |
| Program / Waiver | [Program name] |
| Support Broker / Case Manager | [Name and contact information] |
| FMS Agency | [Name, if applicable] |
How Luka Bear Supports My Plan Goals
| Reminders | Spoken reminders for medications, meals, appointments and activities at the times my family or I set up. (Reminders only; Luka does not manage medication.) |
|---|---|
| Engagement | Conversation, music, stories, photo visits and brain games during the day. |
| Caregiver Connection | A private caregiver app for my approved contacts; if I ask Luka for help, it phones my caregiver. |
| Evening and Night | Calming routines in a familiar voice when I am restless. |
| Independence | Supports my goal of living in my own home with the people I choose around me. |
Cost
Luka Bear is priced as [one-time device cost: amount] plus [monthly service fee: amount], per the vendor's current pricing. My plan team can decide how, if at all, this support changes other services in my plan.
Request
I respectfully request that Luka Bear be reviewed for inclusion in my participant-directed budget as assistive technology / enabling technology, under the rules of my program.
LUKA BEAR - Funding Documentation Templates - Eldercare Robotics LLC
Document 5 - HSA / FSA Letter of Medical Necessity
For Health Savings Account (HSA) and Flexible Spending Account (FSA) reimbursement. Instructions for physician: HSA and FSA administrators generally require a physician's letter for items not listed in IRS Publication 502. Please complete it on your letterhead using your own clinical judgment. Approval rests with the plan administrator.
[Date]
To Whom It May Concern:
Re: Letter of Medical Necessity - Luka Bear companion device for HSA/FSA reimbursement
I am writing on behalf of my patient:
| Name | [Full legal name] |
|---|---|
| Date of Birth | [MM/DD/YYYY] |
| Diagnosis | [Physician's diagnosis and code, as the administrator requires] |
| Treating Physician | [Physician name, MD/DO] |
| Practice / Institution | [Practice name and address] |
| NPI Number | [National Provider Identifier] |
Physician's Statement (physician's own words)
My patient has been diagnosed with [diagnosis], which affects [physician describes the functional effects relevant to daily living, such as memory, routines, orientation, anxiety or isolation]. To help address these documented functional needs, I recommend the Luka Bear companion device for the following purposes:
| Reminders | Spoken reminders for medications, meals and appointments at set times, as a prompt to the person and family. |
|---|---|
| Engagement | Daily conversation, music, stories, photo visits and brain games for engagement. |
| Calm and Routine | Evening and night calming routines in a familiar family voice. |
| Caregiver Connection | A private caregiver app; the person can ask Luka to phone the caregiver. |
| Reduced Isolation | A consistent companion presence between visits from family and caregivers. |
IRS Qualification Statement
In my professional judgment, the Luka Bear companion device is recommended to help mitigate the effects of this patient's documented condition and to support daily functioning and independence, consistent with the medical-expense standard in IRS Publication 502. Luka Bear is an assistive, non-medical device; it is not intended to diagnose, treat or cure any disease, and it is recommended for this person's documented functional needs rather than for general health or wellness.
Device and Cost Information
Device: Luka Bear companion device (Eldercare Robotics LLC) | Cost: [amount, per current pricing] | Vendor: eldercarerobotics.net
Questions? Eldercare Robotics LLC: (413) 296-LUKA | info@eldercarerobotics.net