Definitions

Long term care certification
A written statement describing the nature and degree of physical or cognitive loss, how long services may be needed, and the services that may be required.

Substantial assistance
Hands-on assistance, which is physical help by another person, or standby assistance, which is the presence of another person within arm's reach to prevent injury by physical intervention or cuing.

Substantial supervision
Continual monitoring by another person to protect you from threats to your health and safety, for instance, while wandering.

Need more help? Get answers to frequently asked questions about claims.

 

EligibilityRequirements

Eligibility Requirements

You may be eligible to receive the benefits of your plan if a licensed health care practitioner has certified in the last 12 months that:

  • you are unable, without substantial assistance from another person, to perform at least two activities of daily living for an expected period of at least 90 days due to a loss of functional capacity; or
  • you require substantial supervision due to your severe cognitive impairment

What are activities of daily living?

If you need substantial assistance from another person to complete any of these activities, then you are dependent for that activity. Activities of daily living include:

Bathing

  • getting into and out of a tub or shower
  • washing your body in a tub, shower, or by sponge bath
  • washing your hair in a tub, shower, or sink

Continence

  • maintaining control of bowel and bladder function
  • when unable to maintain control of bowel or bladder function, performing associated personal hygiene (including caring for a catheter or colostomy bag)

Dressing

  • putting on and taking off all clothing items and any necessary braces, fasteners, or artificial limbs

Eating

  • feeding yourself by getting food into your mouth from a container (such as a plate or cup), including the use of utensils when appropriate (such as a spoon or fork)
  • when unable to feed yourself from a container, feeding yourself by a feeding tube or intravenously

Toileting

  • getting on and off the toilet
  • performing associated personal hygiene

Transferring

  • getting into and out of a bed, chair, or wheelchair

What is a severe cognitive impairment?

A severe cognitive impairment is a deterioration or loss in intellectual capacity (such as Alzheimer's disease) that:

  • places you in jeopardy of harming yourself or others and, therefore, you require substantial supervision by another person
  • is measured by clinical evidence and standardized tests that reliably measure impairment in:
    • short or long term memory
    • orientation to people, places, or time
    • deductive or abstract reasoning


Filing a claim.

Filing a Claim

To start the claims process, you must first call and speak to a claim services consultant who will review the initial information we need from you, including the required forms you must complete and submit. Once we have all of the information we need, a care coordinator will call you for an interview.

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