Policy A Policy B 7. Continued Home care Respite care Adult day care Homemaker/chore services Hospice care Alternate care Other benefits Are benefits restored a period of Yes No Yes No not receiving benefits? How long is the benefit period if different from the maximum? When does a new period of confinement # days after # days after discharge discharge New condition? Y N New condition? Y N How Do You Qualify for Benefits? 8. What level of need is required? Who can certify your condition? Medical necessity due to illness or Yes No Yes No injury Functional incapacity need help Yes No Yes No — with ADLs How many? How many? Cognitive impairment Yes No Yes No Is Alzheimer’s covered? Yes No Yes No Prior hospital stay Yes No Yes No Prior skilled nursing home care Yes No Yes No before other levels are covered Prior nursing home stay before home Yes No Yes No care is covered
Policy A Policy B 7. Continued Home care Respite care Adult day care Homemaker/chore services Hospice care Alternate care Other benefits Are benefits restored a period of not receiving benefits? Yes No Yes No How long is the benefit period if different from the maximum? When does a new period of confinement # days after discharge New condition? Y N # days after discharge New condition? Y N How Do You Qualify for Benefits? 8. What level of need is required? Who can certify your condition? Medical necessity due to illness or injury Yes No Yes No Functional incapacity — need help with ADLs Yes No Yes No How many? How many? Cognitive impairment Yes No Yes No Is Alzheimer’s covered? Yes No Yes No Prior hospital stay Yes No Yes No Prior skilled nursing home care before other levels are covered Yes No Yes No Prior nursing home stay before home care is covered Yes No Yes No
cmte_b_ltc_shop_wg_180917_redline_personal_assessment.docx