An insured’s spouse, children, siblings, parents, grandparents, grandchildren, and any of their spouses.
A licensed medical doctor or licensed doctor of osteopathy operating within the scope of their license. A physician cannot be the insured or a member of the insured’s immediate family.
A physician has certified that the insured has an illness or physical condition that can reasonably be expected to result in death in 24 months or less from the certification date.
Adult Day Care Center
An organization that is state licensed, if the state in which it is located licenses adult day care centers. If the state does not license adult day care centers, the center must meet all of the following criteria:
1. Operates as an adult day care center.
2. Operates at least 5 days a week for a minimum of 5 hours per day, and is not an overnight facility.
3. Maintains awritten record for each client, which includes a plan of care prescribed by a physician, and a record of all services provided.
4. Has established procedures for obtaining appropriate aid in the event of a medical emergency.
5. Has arrangements for providing services of:
– A dietitian.
– A licensed physical therapist.
– A licensed speech therapist.
6. Has on staff all of the following:
– A full-time physician.
– One or more nurses in attendance during operating hours for at least 4 hours a day.
– Enough full-time staff members to maintain a client to staff ratio of 8 or less to 1.
Assisted Living Facility
A separate facility that is licensed as an Assisted Living facility, if the state licenses such facilities. If the state does not license assisted living facilities, then the facility must meet the following criteria:
– It must provide room, board, 3 meals a day, housekeeping, linens, laundry, and all personal services required by a chronically ill individual, as well as protective oversight, in private rooms to all residents who require personal assistance to perform activities of daily living.
– It must provide personal care and substantial hands-on assistance to prevent, by physical intervention, injury to the individual while the individual is performing the activities of daily living. Such assistance may also include transportation, help in dispensing medication, and providing assistance with baths or showers, as well as other individual needs which may be required.
– It must have a staff available to provide such assistance 24 hours per day and 7days a week, and have a staff physician available on call.