LONG TERM CARE 7
California Department of Insurance
Protecting California Consumers
Toll Free 800-927-HELP
What Services Do Insurance Policies Cover?
Insurance policies describe where they
will pay for care, what kind of care they will pay for, who
can provide the care, and conditions that have to be met before
a company will pay benefits. Described below are the services
required in a long-term care insurance policy approved under
current state law. You should be aware however, that California
law has changed many times over the years, and that insurance
policies sold in previous years may have different requirements
than are shown here. Facility Coverage: In California, most
skilled, intermediate and custodial care is received in nursing
homes that are licensed as “skilled nursing facilities”. All
long-term care policies except Home Care Only cover this kind
of care.
Policies sold after October, 2001 (except
Home Care Only policies) are required to include a benefit
to cover care in an assisted living facility licensed as a
Residential Care Facility for the Elderly (RCFE). Some insurance
policies sold before October, 2001 also include this benefit.
RCFE’s are not nursing homes, but living arrangements where
a person can also receive personal care or supervision. Some
RCFEs are large retirement homes, while others are small group
homes.
Home Care Coverage: Every long-term care insurance policy
called “Home Care Only” or “Comprehensive Long-Term Care”
issued after January 1, 1993 must include at least the following
6 Home Care benefits and other consumer protections which
should make it easier to receive care at home.
1) Home Health Care is skilled nursing
care or other professional services in your residence.
2) Adult Day Care is medical or social
care in a daytime program in a licensed facility which provides
personal care, supervision, protection, or assistance in
the following: eating, bathing, dressing,moving about and
taking medications.
3) Personal Care is assistance with any
of the Activities of Daily Living or ADLs including Instrumental
Activities of Daily Living (IADLs) such as using the telephone,
managing medications, moving about outside, shopping for
essentials, preparing meals, doing laundry and light housekeeping.
Under California law, these services may be provided by
a skilled or unskilled person as long as they are required
in a Plan of Care developed by your doctor or a team of
health care workers under medical direction.
4) Homemaker Services assist you with tasks
or activities such as cooking, cleaning and other activities
to help you remain in your home.
5) Hospice Services are services in your
residence designed to provide physical, emotional, social
and spiritual support for you, your caregiver and your family
when a terminal illness has been diagnosed. Some policies
will pay for these services in an institutional setting
as well. Under California law, these services (like Personal
Care) may be provided by a skilled or unskilled person so
long as they are required in a Plan of Care developed by
your doctor or a team of health care workers under medical
direction.
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