Nursing Home, Hospice Facility and Assisted Living Facility Benefits

The provisions in the sample long term care insurance policy clearly state the specific conditions under which benefits will be paid. Most policies contain provisions similar to those outlined below.

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We will pay up to the applicable Maximum Daily Benefit Amount shown on the Schedule of Benefits page for the actual charges You incur for the following Covered Services received in a Nursing Home, Hospice facility or Assisted Living Facility:

  1. Room and board;
  2. Nursing Care, Maintenance or Personal Care, Therapy Services and Hospice Care, from a Formal Caregiver; and
  3. Bed Reservation Benefits up to thirty days per Policy Year. “Bed Reservation Benefits” means the Benefits We will pay for actual charges You incur to hold a space in a Nursing Home, Hospice or Assisted Living Facility to enable You to return to that facility. The amount We will pay for Bed Reservation Benefits will not be more than the applicable Benefits We would pay if You had been confined in the Nursing Home, Hospice facility or Assisted Living Facility on those days.

COMMENT: The Schedule of Benefits will show separate Maximum Daily Benefit Amounts for Nursing Home, for Hospice, and for Assisted Living Facility. The Benefit Amounts may be different. An example might be a Maximum Daily Benefit Amount of $150 for Nursing Home and Assisted Living Facility and $100 for Hospice facility, but it is not uncommon for the Benefit Amountto be the same for all three.

If you are in a Nursing Home and your daily room and board charge is $90 and your Nursing Care fees are $25, and, on a given day, your Maintenance and Personal Care fees are $30 and your Therapy Service fees are $50, your total daily expenses for that day are $195. If your Maximum Daily Benefit Amount for Nursing Homeis $150, that is the total amount the insurance company will pay toward that day’s expenses.

If, on the next day, you do not incur any expenses for Maintenance and Personal Care or for Therapy Services, your total charges are $115 and that is the amount the insurance company will pay. The unused $35 for that day will be available for use on another day if the policy has a stated Total Lifetime Benefit dollar amount. If the Total Lifetime Benefit is unlimited, no unused Maximum Daily Benefit Amount will be carried forward, since the Maximum Daily Benefit Amount is available forever. If, on the other hand, there is a stated Total Lifetime Benefit, the Maximum Daily Benefit Amount stops when the stated Total Lifetime Benefitdollar amount is used up.

Therapy Servicesunder the policy are limited to physical, respiratory, speech and occupational therapy.

Note that a Formal Caregiver, as defined in the policy, must provide all care – Nursing Care, Maintenance and Personal Care, Therapy Services and Hospice Care – if you are to receive compensation. Members of the Immediate Family (spouse, child, parent, sibling, grandchild, in-law, or anyone else who normally lives with you) are not regarded as Formal Caregivers.

The policy is careful to state that the insurance company will not pay more for Bed Reservation Benefits than what it would pay if you had actually been confined on that day. In other words, it will not cover any additional payment you may make to guarantee your right to return. This benefit is only available to enable you to RETURN to the facility. It is not available for a first-time reservation.