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What Is Covered
To qualify for benefits, MetLife, the claims administrator, must authorize benefits, and a 60-calendar-day waiting period must be satisfied. You will be considered eligible for benefits if you meet one of the following conditions:
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You have been certified by a licensed health care practitioner as chronically ill. Chronically ill means you are unable to perform, without substantial assistance from another individual, at least two of the six activities of daily living (ADL) for at least 90 days. The six activities of daily living are:
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Eating;
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Dressing;
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Bathing;
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Transferring (moving from a bed to a chair, etc.);
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Toileting; and
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Maintaining continence.
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You have a severe cognitive impairment that requires you to have substantial supervision to keep you healthy and safe. For example, if you have a disability resulting from organic brain disease, including Alzheimer's disease, or similar disorder, you would be eligible for benefits. The Long-Term Care Insurance Plan also pays benefits in cases where you can no longer care for yourself due to mental or nervous disorders.
Benefits will be paid for services included in a plan of care prescribed by a licensed health care practitioner. This determination will be made by MetLife, based on information provided by you, your representative, your doctor, or other health care professionals.
Covered Services
Covered services include the following:
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Initial care advisory visit;
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Nursing home care, including skilled, intermediate, and custodial care;
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Inpatient and at-home hospice care;
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Assisted-living facilities;
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Home care by a licensed home health agency;
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Adult day care in a licensed facility;
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Ongoing care advisory services;
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Physical, occupational, respiratory, and speech therapy from a licensed home health agency;
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Care from a licensed nurse or therapist;
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Alternate plan of services; and
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Respite services from formal or informal providers (up to 21 days per calendar year).
This list is subject to change at any time.
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