Facility: A Skilled Nursing Facility, as defined in the Medicare program; a convalescent nursing home, as defined in the Medicare program; an extended care facility, as defined in the Medicare program; a residential care facility, as defined in the California Health and Safety Code; or a residential care facility for the elderly, as defined in the California Health and Safety Code.
Home Care or Community-Based Services: Home health care, adult day care, personal care, homemaker services, hospice services and respite care as each is defined below.
| 1) | “Home health care” is skilled nursing or other professional services in the residence, including, but not limited to, part-time and intermittent skilled nursing services, home health aid services, physical therapy, occupational therapy, or speech therapy and audiology services, and medical social services by a social worker. |
| 2) | “Adult day care” is medical or nonmedical care on a less than twenty-four (24)-hour basis, provided in a licensed facility outside the residence, for persons in need of personal services, supervision, protection, or assistance in sustaining daily needs, including eating, bathing, dressing, ambulating, transferring, toileting, and taking medications. |
| 3) | “Personal care” is assistance with the activities of daily living, including the instrumental activities of daily living, provided by a skilled or unskilled person under a plan of care developed by a physician or a multidisciplinary team under medical direction. “Instrumental activities of daily living” include using the telephone, managing medications, moving about outside, shopping for essentials, preparing meals, laundry, and light housekeeping. |
| 4) | “Homemaker services” is assistance with activities necessary to or consistent with the insured’s ability to remain in his or her residence, that is provided by a skilled or unskilled person under a plan of care developed by a physician or a multidisciplinary team under medical direction. |
| 5) | “Hospice services” are outpatient services not paid by Medicare, that are designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and to provide supportive care to the primary care giver and the family. Care may be provided by a skilled or unskilled person under a plan of care developed by a physician or a multidisciplinary team under medical direction. |
| 6) | “Respite care” is short-term care provided in an institution, in the home, or in a community-based program, that is designed to relieve a primary care giver in the home. |
Service providers outside the State of California shall be defined as comparable in licensure and staffing requirements to providers in the State of California.
Physician: A person who is licensed in the United States as a medical doctor (M.D.) or a doctor of osteopathy (D.O.) and who is practicing within the scope of his or her license. The term “Physician” does not include an Owner or joint owner; an Insured; a Family Member of an Owner, joint owner, or Insured; or an employee, officer, director, owner, partner, member, or agent of a non-natural Owner or joint owner.
Registered Nurse: A person who is licensed in the United States as a nurse and who is practicing within the scope of his or her license. The term “Registered Nurse” does not include an Owner or joint owner; an Insured; a Family Member of an Owner, joint owner, or Insured; or an employee, officer, director, owner, partner, member, or agent of a non-natural Owner or joint owner.
Licensed Social Worker: A person who is licensed in the United States as a social worker and who is practicing within the scope of his or her license. The term “Licensed Social Worker” does not include an Owner or joint owner; an Insured; a Family Member of an Owner, joint owner, or Insured; or an employee, officer, director, owner, partner, member, or agent of a non-natural Owner or joint owner.
Family Member: A spouse, child, parent, grandparent, grandchild, sibling, aunt, uncle, first cousin, niece, or nephew, or any such relative by marriage or adoption, including in-laws and step-relatives.