Long Term Care Policy Definitions

Activities of Daily Living

This means any of the following:

• Bathing: Washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower.
• Dressing: Putting on and taking off all items of clothing and any required braces, fasteners or artificial limbs.
• Transferring: Moving into or out of a bed, chair or wheelchair.
• Toileting: Getting to and from the toilet, getting on and off the toilet, and performing related personal hygiene.
• Continence: Ability to maintain control of bowel and bladder function; or, when not able to maintain control of bowel or bladder function, the ability to perform related personal hygiene (including caring for catheter or colostomy bag).
• Eating: Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by feeding tube or intravenously.

Adult Day Care

This is a program, of Qualified Long Term Care Services, for six or more clients furnished at an Adult Day Care Center for the purpose of supporting frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside the home.

Adult Day Care Center

An adult day care center is:

1. A facility operated and licensed and/or certified as an Adult Day Care Center under applicable local laws; or
2. Any other organization that meets ALL of the following requirements: indent withlettersProvides a program of Adult Day Care; a. Keeps a written record of services furnished to each client; b. Has established procedures to obtain emergency medical care; c. Is not a place which chiefly provides services for recreation or social services; and d. Maintains a client-to-staff ratio of eight, or less, to one, with a staff that includes a full-time director, one or more Nurses who are present at least four hours a day during operating hours, and at least two staff members on duty whenever clients are present.

Assisted Living Facility

This is a facility that meets all the following requirements:

• Maintains appropriate licensing to provide Maintenance or Personal Care under the laws of the state where it is located;
• Provides round-the-clock Maintenance or Personal Care services to assists clients whose needs include the inability to perform some Activities of Daily Living or who have Severe Cognitive Impairment;
• Has at least three clients;
• Uses aides trained or certified to provide Maintenance and Personal Care in accordance with any laws which apply to the provision of such care;
• Provides twenty-four hour supervision of clients by a trained and awake staff;
• Has formal arrangements for emergency medical care;
• Maintains written records of services furnished to each client;
• Serves clients three meals a day; and
• Has appropriate methods and procedures to assist in administering prescribed drugs where allowed by law.

An Assisted Living Facility is not, other than incidentally, a hotel, motel, a place for rest, or a place for the treatment or rehabilitation of drug addiction or alcoholism. If an institution has more than one license or purpose, only that section of the institution specifically meeting the definition of Assisted Living Facility will qualify as an Assisted Living Facility.

Care Advisory Services

A Care Advisor provides any number of services:

• Assessing long term care service needs
• Developing a long term care service plan
• Requisitioning and coordinating long term care services
• Implementing the long term care service plan, or
• Periodic monitoring and reassessing long term care services

A Care Advisor is a health care professional from a Care Management Organization.

Care Management Organization

A Care Management Organization is either:

1. An organization operated and licensed as a Care Management Organization under the laws of the state where it is located; or
2. Any organization that meets ALL of the following requirements:
   1. Provides Care Advisory Services;
   2. Has a full-time administrator;
   3. Maintains written records of services performed for each client; and
   4. Has at least one Nurse and one Social Worker on the staff.

Community Care

This is care furnished outside of a Nursing Home, Hospice or Assisted Living Facility. It includes Home Health Care Services and Adult Day Care.

Elimination Period

The number of days after the Original Coverage Effective Date of a policy during which the insured must be: (1) Chronically Ill; and (2) receiving Primary Services, (other than Hospice Care and Respite Care Services) before certain Benefits become payable. These days need not be consecutive.

Formal Caregiver

A Formal Caregiver means any of the following: a Nurse, a Care Advisor, a Therapist, a Social Worker, a Home Health Aide, a Homemaker or a Certified Private Aide. Members of the Immediate Family cannot be Formal Caregivers.

Home Health Care Agency

This is a Hospital or other organization that:

• If licensing or certification is required, is licensed or certified as a Home Health Care Agency, under the laws where it is located, or under a public health law or similar law, to provide Home Health Care Services; or
• Is recognized as a Home Health Care Agency by Medicare; or
• Meets ALL the following requirements:
  1. Is licensed or certified where it is located to provide Home Health Care Services;
  2. Has at least five clients;
  3. Develops and reviews long term care service plans at appropriate intervals;
  4. Uses Home Heath Aides, trained or certified in accordance with any laws which apply to such care, to provide Maintenance or Personal Care;
  5. Provides on-site supervision of Home Health Aides by a Nurse or Social Worker;
  6. Has a Nurse or a Physician on call for a medical emergency during the hours that the Home Health Aide is in the client’s Home;
  7. Maintains a written record of services performed for each client.

Home Health Care Services

Home Health Services are medical and non-medical services provided to ill, disabled or infirm persons in their residences. Such services may include Homemaker Services, assistance with Activities of Daily Living, and Respite Care.

Hospice

This is a facility, unit of a facility, public or private agency or unit of a public or private agency that meets federal certification requirements as a Hospice, or is comparably licensed under the laws where it is located to provide care or management of the Terminally Ill.

Hospice Care

These are services furnished by a Hospice for the care or management of a Terminal Illness.

Hospice Care includes care in a hospice facility and similar end-of-life care in other locations, such as an assisted living facility or in your home.

Hospital

This is a facility that is licensed as a Hospital and provides:

• A broad range of medical and surgical services for sick and injured persons twenty-four hours a day by, or under the supervision of, a staff of Physicians; and
• Nursing Care twenty-four hours a day.

Immediate Family

This means a spouse, child (natural, step or adopted), parent, sibling, grandchild or in-law. It also includes anyone who normally lives in your house.

Licensed Health Care Practitioner

This means a Physician, a registered professional Nurse or a licensed Social Worker.

Maintenance or Personal Care

This describes any care with the primary purpose of providing needed assistance to the Chronically Ill (including protection from threats to health and safety due to Severe Cognitive Impairment). Maintenance or Personal Care services may include Custodial Care and needed assistance with Activities of Daily Living.

Nurse

This is a registered professional nurse (R.N.), a licensed practical nurse (L.P.N.) or a licensed vocational nurse (L.V.N.) who is licensed under the laws where the services are performed.

Nursing Care

This means services requiring the professional skills of a Nurse, performed by a Nurse, under the orders of a Physician, and to improve or maintain Your health.

Nursing Home

This is a nursing facility licensed under the laws where it is located; or any other facility that meets ALL of the following requirements:

• Provides twenty-four hour a day Nursing Care;
• Provides twenty-four hour a day Maintenance or Personal Care performed by a trained/certified and awake staff supervised by a Nurse;
• Keeps a written record of all services performed for each client;
• Has formal arrangements for emergency medical care;
• Offers services not limited to provision of food and shelter, such as laundry and other residential services.

A Nursing Home is not a Hospital (except when it is located in a part of a Hospital designated as a nursing facility), residential facility, hotel, motel, place for rest, home for the aged, sheltered living accommodation, facility for the treatment of mental illness, continuing care retirement community or similar entity, or place for the treatment or rehabilitation of drug addiction or alcoholism.

Physician

The term Physician is defined in section 1861(r)(1) of the Social Security Act.

Plan of Care

Means a written plan prescribed by a Licensed Health Care Practitioner that identifies ways of meeting the Qualified Long Term Care Service needs of a person who is Chronically Ill.

Qualified Long Term Care Services

This means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitative services, and Maintenance or Personal Care services which: (a) are required by a Chronically Ill individual; and (b) are provided pursuant to a Plan of Care prescribed by a Licensed Health Care Practitioner.

Social Worker

This means a person who is licensed as a Social Worker. This includes any Social Worker who has a license, certificate or similar permit to act as a Social Worker from a state or a body authorized by a state to issue such permits, or a person with a Masters degree in Social Work from an accredited university.

Terminal Illness

This means an illness or injury that a Physician certifies is likely to result in a person’s death within six months.

Therapist

This means a person who has a license or appropriate professional certificate to provide Therapy Services under the laws where the services are being provided.

Case Studies: Exploring Long-Term Care

Case Study 1: The Importance of Adult Day Care Services

John is a 75-year-old retiree who lives alone and has been experiencing declining health. He struggles with daily tasks and requires assistance with medication management. To maintain his independence and socialize with others, John decides to enroll in an Adult Day Care program.

This program not only provides him with support but also offers various activities tailored to his needs. By utilizing Adult Day Care services, John can receive care in a group setting outside his home, allowing him to remain active and engaged in his community.

Case Study 2: Transitioning to an Assisted Living Facility

Sarah is a 80-year-old widow who has been living independently in her own home. However, due to her deteriorating health and limited mobility, she decides to explore options for assisted living. After careful consideration, Sarah chooses an Assisted Living Facility that meets her requirements.

The facility offers personalized care, assistance with daily activities, and a safe living environment. Sarah’s decision to transition to an assisted living facility ensures she receives the necessary support while still maintaining a level of independence.

Case Study 3: Navigating Home Health Care Services

Michael, a 68-year-old retired veteran, has been diagnosed with a chronic illness that requires ongoing medical care. He prefers to receive treatment and support in the comfort of his own home. Michael decides to engage the services of a Home Health Care Agency, which provides a range of medical and non-medical services.

With the help of a skilled nurse, he receives regular check-ups, assistance with daily activities, and necessary therapy. Home health care services allow Michael to manage his condition while remaining in a familiar and supportive environment.