Additional Services: Needs Assessment Benefits, Informal Caregiver Training Benefits

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Jun 19, 2018

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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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Additional Services may be received on the same day as Primary Services without affecting the Primary Services benefit amounts. The Maximum Benefit Amounts We will pay for Additional Services are shown on the Schedule of Benefitspage.

COMMENT: The term Primary Services is not actually defined in the Policy, but the covered Primary Services are listed on the Schedule of Benefits page. They include Nursing Home Care, Hospice Facility Care, Assisted Living Facility Care, Respite Care, and Home Care and Community Care. Separate Maximum Benefit Amounts are shown on that page for each of the Additional Services. As the policy states, availing yourself of Additional Services on the same day you make use of Primary Services does not have any impact on the benefit amount for the Primary Services. In fact, they are measured differently.

Two kinds of Additional Services are available for coverage under the Policy: Needs Assessment Benefits and Informal Caregiver Training Benefits. These are discussed below.

Needs Assessment 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.

After You become eligible for Benefits, You can receive, at no extra charge, one Needs Assessment from a Care Management Organization, selected by Us and to whom We make direct payment. Or, You may select a Care Management Organization to conduct one Needs Assessment and We will pay as a Covered Service the actual charges You incur up to the Maximum Benefit Amount for Needs Assessment shown on the Schedule of Benefitspage.

You do not need to satisfy the Elimination Period for this Benefit to be payable. Receipt of this service will not count toward satisfying the Elimination Period. Payment of this Benefit will not reduce Your Total Lifetime Benefit.

COMMENT: Needs Assessment is defined in the policy as the services provided by a Care Advisor to: (1) assess your needs for long term care services; (2) develop or work with others to develop options for your long term care; and (3) discuss the long term care options with you or your Representative.

A Care Management Organization is an organization, usually but not always licensed, that has a full time administrator, maintains written records, has at least one full time Nurse and Social Worker, and provides Care Advisory Services. Care Advisory Services are those provided in the Needs Assessment, plus assistance with the implementation of a long term care service plan.

Note that no Maximum Benefit Amount is applied if the insurance company selects the Care Management Organization for the Needs Assessment. If, however, you select the Care Management Organization, the Maximum Benefit Amount applies.

Informal Caregiver Training 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 Maximum Benefit Amount for Informal Caregiver Training, shown on the Schedule of Benefits page, for the actual charges You incur to train an Informal Caregiver to perform Maintenance or Personal Care services for You in Your Home. This training can take place while You are at Home, or in a Hospital, Nursing Home, Hospice facility or Assisted Living Facility, to make it possible for You to return Home and be cared for by the person who received the training. We will not pay for training someone who will be paid under the terms of this Policy to care for You.

You do not need to satisfy the Elimination Period for this Benefit to be payable. Receipt of this service will not count toward satisfying the Elimination Period. Payment of this Benefit will reduce Your Total Lifetime Benefit.

COMMENT: An Informal Caregiver is a person who provides Maintenance or Personal Care, but not as a Formal Caregiver. Members of the Insured’s Immediate Family qualify as Informal Caregivers Friends and other relatives also may serve as Informal Caregivers.

Note that this training is covered only if the training is not for someone who will be paid policy benefits for providing services of any kind. This benefit is not available for training to perform services that are compensable under this policy.

Note that, unlike Needs Assessment, payment of this benefit will reduce your Total Lifetime Benefit.

Both of these Additional Services (Needs Assessment Benefits, Informal Caregiver Training Benefits) have their own lifetime Maximum Benefit Amounts. It is not a daily benefit. The lifetime Maximum Benefit Amount for each is usually somewhere between $250 and $750.

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