§ 58003. Benefit Eligibility.

“Benefit Eligibility” in each Policy or Certificate is defined as follows:

(a) “How to qualify for Benefits: We will pay for the Qualified Long-Term Care Services covered by this policy if:

(1) The insured becomes a Chronically Ill Individual, and

(2) The Services are prescribed for the insured in a written Plan of Care.

(b) The insured will be considered a Chronically Ill Individual when one of the following criteria are met:

(1) The insured is unable to perform, without Standby Assistance or Hands-On Assistance from another individual, [2 Activities of Daily Living] due to a loss of functional capacity and the loss of functional capacity is expected to last at least 90 days; OR

(2) the insured has a Severe Cognitive Impairment requiring Substantial Supervision to protect the insured from threats to health and safety.

(c) The certification that the insured is a Chronically Ill Individual must be made by a Licensed Health Care Practitioner, within the preceding 12 months and must be renewed at least every 12 months. The services to be paid by the Policy [Certificate] must be prescribed in a written Plan of Care prepared by a Licensed Health Care Practitioner.

(d) All of the services covered by this policy are Qualified Long-Term Care Services.

(e) The definitions for the following terms will help explain how the insured qualifies for benefits under this Policy:

Activities of Daily Living;

Standby Assistance;

Hands-On Assistance;

Severe Cognitive Impairment;

Substantial Supervision;

Licensed Health Care Practitioner;

Plan of Care; and

Qualified Long-Term Care Services.”

HISTORY

1. New section filed 8-30-93 as an emergency; operative 8-30-93 (Register 93, No. 36). Submitted for printing only pursuant to section 22009, Welfare and Institutions Code.

2. Certificate of Compliance as to 8-30-93 order, including amendment of section, transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No. 4).

3. Renumbering of former section 58003 to section 58002 and new section 58003 filed 10-1-98 as an emergency; operative 10-1-98. Submitted to OAL for printing only pursuant to Welfare and Institutions Code section 22009(d) (Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-29-99 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 10-1-98 order transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No. 12).

Note

Note: Authority cited: Section 22009(a), Welfare and Institutions Code. Reference: Section 22006(c), Welfare and Institutions Code.