You are eligible for a monthly benefit after:
- You become disabled
- You are receiving services in a long term care facility or assisted living facility or adult foster home; or professional home care services if your plan includes a professional home care services benefit; or total home care if your plan includes a total home care benefit;
- You have satisfied your elimination period; and
- A physician has certified that you are unable to perform, without substantial assistance from another individual, two or more activities of daily living (ADLs) for a period of at least 90 days, or that you require substantial supervision by another individual to protect you and others from threats to health or safety due to severe cognitive impairment. You will be required to submit a physician certification every 12 months.
A monthly benefit will become payable once all of these requirements are met. The treatment and services you receive for your disability must be provided pursuant to a written plan of care developed by a licensed health care practitioner.
If you have an existing loss of ADLs or severe cognitive impairment on your effective date of coverage, that loss or impairment will only be eligible for coverage if you recover from that loss or impairment. The insurance carrier must receive acceptable proof of your ADL or cognitive recovery, such as a physician’s statement or an assessment.
The amount of your monthly benefit will be based on the coverage options you chose and the place of residence used for long term care. If your coverage includes professional home care services, the benefit payment will be based on the number of days you receive these services. Total Home Care Benefit
You will receive the monthly total home care benefit amount if you are disabled and you choose to receive care anywhere other than in a long term care facility or assisted living facility.
This care can be provided at any type of facility, such as an adult day care facility or your home. Care can be provided to you by:
- A formal caregiver, such as a licensed home health care provider, a registered nurse, a licensed practical nurse
- An informal caregiver, such as a friend or relative