NOTICE TO Sharing Member: This Long Term Care Benefit Program (LTCBP) may not cover all of the costs associated with long term care incurred by the Sharing Member during the period of benefits. The prospective Sharing Member is advised to carefully review all LTCB limitations.

CAUTION: The issuance of this LTCBP is based upon the responses to the questions on the Application. If the responses fail to include all material medical information requested, We may have the right to deny benefits or rescind this LTCBP. The best time to clear up any questions is now, before charges are incurred. If, for any reason, any of the responses are incorrect, please contact Us.

Additionally, the Sharing Member affirms all SHARING MEMBER QUALIFICATIONS AND REQUIREMENTS NOTED IN THE SHARING GUIDELINES.

GENERAL LEGAL NOTICE

This program is not an insurance company nor is it offered through an insurance company. Whether your shared long term care needs are paid depends on funds available in the Members’ Escrow Account. Lifeline Alliance is appointed as Escrow Agent and has no independent obligation to pay Members’ shared needs. Our role is to enable member to member voluntary contributions for disbursement through the Member Escrow Account to defray long term care expenses.

This program is not an investment nor is it offered through an investment company. Any distributions for Reward Programs are solely dependent on available funds in the Members’ Escrow Account. Lifeline Alliance is appointed as Escrow Agent and has no independent obligation to pay for Member Rewards.

SHARING AGREEMENT AND EFFECTIVE DATE: Subject to the terms and conditions described in this LTCBP, Lifeline Alliance as Escrow Agent, agrees to disburse funds from the Members’ Escrow Account to You the benefits described in this LTCBP. We make this agreement in consideration of: (a) the statements made in the signed Application to and made a part of this LTCBP; (b) affirmation of all sharing member qualifications and requirements noted in the Sharing Guidelines; and (c) payment of the initial Sharing Contribution. This LTCBP takes effect on the LTCBP Effective Date shown on the LTCBP Schedule.

RENEWABILITY: SHARING CONTIBUTIONS ARE SUBJECT TO CHANGE. This LTCBP is guaranteed renewable for the life of the Sharing Member. You have the right, subject to the terms of this LTCBP and Sharing Guidelines, to continue it as long as the suggested contributions are paid on time. We cannot cancel or refuse to renew this LTCBP. We may change Sharing Contributions if We change the Sharing Contribution rates for all LTCBP bearing the Plan number and type that appears on your LTCBP Schedule. We will give You at least sixty (60) days written notice at Your last address shown in Our records before We change Your Sharing Contribution.

DEFINITIONS

This section provides the definitions of words used in this LTCBP that have a special meaning when applied to coverage under this LTCBP. To help in the recognition of these special words and phrases, the first letter of each word is capitalized wherever it appears.

Activities of Daily Living :

• Bathing: means washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower.
• Continence: means the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).
• Dressing: means putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs. 
• Eating: means feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously.
• Toileting: means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
• Transferring: means moving into or out of a bed, chair, or wheelchair.

Adult Day Care means a program, for six (6) or more individuals, of social and health related services provided during the day in a community group setting for the purpose of supporting frail, impaired, elderly or other disabled adults who can benefit from care in a group setting outside the Home.

Adult Day Care Center means a facility licensed or certified under state law, if any, to provide Adult Day Care to adults who do not require twenty-four (24) hour institutional care, but are not capable of full-time, independent living.

Alternative Plan of Care Services means :

• treatments or services not otherwise specified in this LTCBP including but not limited to Durable Medical Equipment and Home Modification; or
• treatments or services provided in a setting or by a provider not otherwise specified in this LTCBP.

Ambulance Services means transportation by ambulance from the Sharing Member’s Home to a Facility, or to and from a Facility for purposes of receiving Respite Care.

Ancillary Services means physical, occupational, speech and respiratory therapies, wound care, medication management, supplies and services for continence care support and similar care-related services or supplies that support Activities of Daily Living.

Application means the written application form provided by Us and completed by You when applying for Sharing Membership.

Assessment means an evaluation, with objective results, done by a Licensed Health Care Practitioner to determine or verify that the Sharing Member is Chronically Ill.

Assisted Living Facility means a facility which is engaged primarily in providing Qualified Long Term Care Services and that meets the following criteria :

• has the appropriate state licensure or certification as an Assisted Living Facility; OR 
• if such licensing or certification is not required:
• provides Qualified Long Term Care Services for at least six (6) residents in one (1) location;
• has at least one (1) trained and ready-to-respond staff member actively on duty in the facility twenty-four (24) hours per day to provide the services and care;
• provides room and board to include at least three (3) meals a day and accommodation of special dietary needs;
• has appropriate procedures to dispense and monitor prescription medications; and maintains records of important health changes in its residents.

An Assisted Living Facility is not a Hospital, a Nursing Home, an individual residence or an independent living unit. Unless otherwise excluded in this LTCBP, Assisted Living Facilities include facilities otherwise named, which meet the above criteria, including secure Alzheimer’s units.

If a facility has multiple licenses, a portion, wing, ward, or unit will qualify as an Assisted Living Facility only if it is engaged primarily in providing Qualified Long Term Care Services and meets all of the above criteria.

Caregiver Training means training provided by a health care professional, approved by Us, to an Informal Caregiver. Examples of such training may include, but are not limited to:

•  the proper care and use of medical devices such as catheters, intravenous medications, colostomy bags or suctioning tubes;
•  the proper assistance with medications, bandages and dressings; or
•  the proper performance of various procedures to assist the Sharing Member with Activities of Daily Living. Caregiver Training is provided in a setting other than a Hospital, Nursing Home or Assisted Living Facility.

Chronically Ill means within the previous twelve (12) months a Licensed Health Care Practitioner has certified that the Sharing Member :

•  is unable to perform, without Substantial Assistance from another person, at least two (2) Activities of Daily Living for a period that is expected to last at least ninety (90) consecutive days due to loss of functional capacity; or 
• has a Severe Cognitive Impairment.  

Confinement or Confined means the Sharing Member is a resident in a Nursing Home, an Assisted Living Facility or a Hospice Facility for a period for which a room and board charge is made.

Covered Expenses means the amount of benefit payable by Us as a result of the Sharing Member’s receipt of Qualified Long Term Care Services. The Covered Expense for each benefit available under this LTCBP is defined in the Benefit Provisions of this LTCBP.

Covered Partner means spouse of a Sharing Member who is also a Sharing Member and a participant in the same LTCBP Plan as their spouse.

Dates of the LTCBP refers to :

Anniversary Date means the LTCB Anniversary Date as shown on the LTCB Schedule;

Effective Date means the date coverage is effective under this LTCBP as shown on the LTCB Schedule; and

Year means the period from the LTCBP Effective Date to the first LTCB Anniversary Date or the period LTCBP Anniversary Date to the next LTCPB Anniversary Date.

Durable Medical Equipment means equipment included in the Sharing Member’s Plan of Care which :

• is functionally necessary;
• is designed for repeated and prolonged use;
• is suited for use in the Home; and
• can enhance the Sharing Member’s ability to perform Activities of Daily Living.

Infusion pumps, special hospital-style beds, walkers, or wheelchairs are examples of types of equipment that may be considered Durable Medical Equipment. Durable Medical Equipment does not include any Home Modification, motorized scooter, or sporting, athletic or exercise equipment.

Elimination Period/Waiting Period means the required number of days the Sharing Member must receive either Facility Services or Home Care Services, as defined in this LTCBP, pursuant to a Plan of Care, while this LTCBP is in force and the Sharing Member is certified as being Chronically Ill, before We will begin paying benefits. For each day the Sharing Member receives Facility Services or Home Care Services, We will credit one (1) day toward satisfaction of the Waiting Period. These days do not need to be consecutive. Once the Sharing Member has satisfied the Waiting Period, no future Waiting Period is required. Days may be accumulated under separate billing forms in order to satisfy the Waiting Period.

The Waiting Period is not applicable to or satisfied by the Caregiver Training Benefit, the Respite Care Benefit or the Personal Care Advisory Services Benefit.

Days used to satisfy the Waiting Period will not satisfy the Waiting Period for Coverage Outside of the United States

The Waiting Period is shown on the LTCB Schedule.

Elimination Period/Waiting Period for Coverage Outside of the United States means the number of days after the Sharing Member has satisfied the Waiting Period previously defined and receives either Facility Services or Home Care Services Outside of the United States, while this LTCBP is in force and the Sharing Member is certified as being Chronically Ill, before We will begin paying benefits for coverage outside of the United States. Days on which the Sharing Member receives Facility Services and Home Care Services Outside of the United States will first be used to satisfy the Waiting Period previously defined. Once this Waiting Period has been satisfied, We will credit one (1) day towards satisfaction of the Waiting Period for Coverage Outside of the United States for each day the Sharing Member receives Facility Services or Home Care Services Outside of the United States. These days need not be consecutive, however, days will not be accumulated under separate bills in order to satisfy the Waiting Period for Benefits Outside of the United States. The Sharing Member must first satisfy the Waiting Period before days will count towards satisfaction of the Waiting Period for Coverage Outside of the United States.

Emergency Response System means a personal service the Sharing Member can alert easily (such as pressing a button on a bracelet or pendant) when in distress and in need of help. This does not include a home alarm system.

Expense Sharing means the process of generating and submitting a bill for eligible benefits to a Sharing Member.

Facility means a Nursing Home, Assisted Living Facility, or Hospice Facility.

Facility Services means Qualified Long Term Care Services received by the Sharing Member while Confined in a Facility and performed by appropriate personnel under the supervision of a RN, including:

• Room and board;
• Ancillary Services; and 
• Hospice Care provided in a Hospice Facility.

Facility Services does not include comfort and convenience items such as televisions, telephone, beauty care and entertainment, or services provided to an individual other than the Sharing Member (e.g. guest meals or spouse charges).

Family Member means the Sharing Member ‘s spouse and the following relatives by blood, marriage, or adoption, of the Sharing Member or the Sharing Member’s spouse:

• grandparents;
• parents, aunts, or uncles;
• siblings, first cousins;
• children, nieces, or nephews; and
• grandchildren.

Hands-On Assistance means the physical assistance of another person without which the Sharing Member would be unable to perform the Activity of Daily Living.

Home means the place where the Sharing Member maintains independent residence. Home does not include a Facility, a Hospital, or any other institutional setting where the Sharing Member is dependent on others for assistance with the Activities of Daily Living.

Home Care Services means :

• Adult Day Care provided to the Sharing Member in an Adult Day Care Center;
• Home Health Care provided to the Sharing Member at Home; or
• Hospice Care provided to the Sharing Member at Home.

Home Health Aide means a person, other than an RN or nurse, who provides Qualified Long Term Care Services through a Home Health Care Agency or as an Independent Home Health Caregiver. A Home Health Aide must be licensed or certified under state law, if any, and acting within the scope of his or her license or certification at the time the Qualified Long Term Care Services are provided.

Home Health Care means a program of Qualified Long Term Care Services provided to a Chronically Ill individual, including:

• professional nursing care by or under the supervision of an RN or other licensed nurse;
• care by a Home Health Aide;
• care by an Informal Caregiver;
• therapeutic care services by or under the supervision of a speech, occupational, physical or respiratory therapist licensed or certified under state law if any, or a registered dietician; or
• Homemaker Services.
• Home Health Care is provided to the Sharing Member in a setting other than a Hospital or Facility.

Home Health Care Agency means an entity that is regularly engaged in providing Home Health Care for compensation and employs staff, qualified by training or experience, to provide such care. The entity must:

• keep clinical records or care plans on all patients;
• provide ongoing supervision and training to its employees appropriate to the services to be provided; and
• have the appropriate state licensure or certification, where required. If licensure or certification is not required, the entity must be supervised by a qualified professional such as a Registered Nurse (RN), a Licensed Social Worker, or a Physician.

Home Modification means the labor, equipment, and supplies used to make changes in the Sharing Member ‘s Home. These changes must be designed to:

• enhance the Sharing Member’s ability to perform Activities of Daily Living; and
• allow the Sharing Member to live safely and remain at Home.

Homemaker Services means those services provided by an agency or an Independent Home Health Caregiver or an Informal Caregiver that specializes in maintaining cleanliness and hygiene of the internal portions of the Sharing Member’s Home. Services may include cleaning, vacuuming and laundering. Additional services may include purchase and provision of food, as well as transportation to receive care from medical professionals or obtain prescription medications.

Hospice Care means Qualified Long Term Care Services which provide a program of care to meet the Sharing Member’s needs at

Home or in a Hospice Facility in the event the Sharing Member becomes terminally ill. Hospice Facility means a place which:

• has the appropriate state licensure or certification as a Hospice Facility where Licensure or certification is required; and
• provides Hospice Care.

Hospital means an institution or facility that :

• is primarily engaged in providing, by or under continuous supervision of Physicians, to inpatients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons;
• has organized departments of medicine and major surgery;
• has a requirement that every patient must be under the care of a Physician or dentist;
• provides twenty-four (24)-hour nursing care by or under the supervision of RNs;
• has in effect a hospitalization review plan applicable to all patients which meets at least the standards set forth in Section 1861 (k) of the United States Public Law 89-97 (42 USCA 1395x[k]); and
• is duly licensed by the agency responsible for licensing such Hospitals.

Independent Home Health Caregiver means a certified nursing assistant, Nurse, or physical, occupational, respiratory or speech therapist, or any other person approved by Us who meets all of the following criteria:

• is independently employed and not associated with a Home Health Care Agency;
• is qualified by training and experience to provide Qualified Long Term Care Services; and
• is licensed or certified under state law, if any, and acting within the scope of his or her license at the time Qualified Long Term Care Services are provided.

Informal Caregiver means a person providing Maintenance or Personal Care Services who is not a Formal Caregiver, including a person who provides Homemaker Services not supervised by a Home Care Agency. The term does not include anyone who lived in your Home at the time you became eligible for benefits.

Licensed Health Care Practitioner means any legally qualified practitioner of the healing arts acting within the scope of his or her New York State license, including:

• a Physician;
• a Registered Nurse;
• a Licensed Social Worker; or
• any other duly licensed individual who meets the requirements of state law or state regulations as appropriate to a tax- qualified. LTCBP

The Licensed Health Care Practitioner must not be a Family Member.

Licensed Social Worker means a duly licensed social worker acting within the scope of his or her license at the time Qualified Long Term Care Services are provided.

Long Term Care Benefits Program (LTCBP) means the benefit program that enables long term care benefits to a Sharing Member who has affirmed conditions in the Sharing Guidelines.

Maintenance or Personal Care Services means any care the primary purpose of which is the provision of needed assistance with helping the Sharing Member conduct Activities of Daily Living while Chronically Ill. This includes protection from threats to the Sharing Member’s health and safety due to a Severe Cognitive Impairment.

Medicare means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended.

Mental or Nervous Disorder means affective disorders, anxiety disorders, personality disorders, psychotic disorders or other mental or emotional disease or disorders.

Mental or Nervous Disorder does not include Alzheimer’s or other demonstrable organic diseases such as senile dementia.

Nurse means someone who is licensed as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Vocational Nurse (LVN) and is operating within the scope of that license.

Nursing Home means a facility or institution that :

• is licensed or certified by the state in which it is located; or
• if such licensing or certification is not required:
• is a separate facility or a distinct part of another health care facility;
• provides twenty-four (24) hour per day skilled, intermediate or custodial nursing care under the supervision of an RN or Physician; and
• maintains a daily record on each patient.

Nursing Home also means a facility that is licensed as a specialized Alzheimer’s unit in all states where such licensure exists.

A Nursing Home is not: a Hospital, clinic or Assisted Living Facility; a convalescent home; a board and rest home; a home for the aged; an adult residential care facility; a domiciliary and retirement care facility; a training center; a government or veteran’s facility or any other facility where the patient is not required to pay; or the Sharing Member ‘s primary place of residence in an area used principally for independent residential living; or a similar establishment.

If a facility has multiple licenses, a portion, wing, ward, or unit will qualify as a Nursing Home only if it meets all of the above criteria; is authorized to provide nursing care to inpatients; and is engaged principally in providing such nursing care in accordance with that license.

Outside of the United States means outside of the United States or its territories, or Canada.

Personal Care Advisor means a Licensed Health Care Practitioner who is qualified by training and experience to assess and coordinate the overall care needs of a Chronically Ill individual. The Personal Care Advisor is not employed by or under contract to Us. The Personal Care Advisor is employed by or under contract to a Personal Care Advisory Services Provider.

Personal Care Advisory Services means services that identify a person’s functional, cognitive, personal, and social needs for care and services and can help link the Chronically Ill individual to a full range of appropriate services. It may include but is not limited to the following:

• the development of a Plan of Care, including an initial Plan of Care and subsequent updates to the Plan of Care as needed for changes in the Sharing Member ‘s condition; 
• the coordination of appropriate services and ongoing monitoring of the delivery of such services, when desired by the Sharing Member or the Sharing Member’s Representative.

Personal Care Advisory Services Provider means an agency, entity or person approved by Us that employs or contracts with Personal Care Advisors to provide Personal Care Advisory Services.

Physician, means a legally qualified practitioner of the healing arts who is authorized to practice medicine and surgery by the state in which he or she performs such function or action, including osteopathic practitioners within the scope of his or her license as defined by state law.

Plan of Care means a written individualized plan of services prescribed by a Licensed Health Care Practitioner developed in consultation with the, Sharing Member based upon an Assessment that states the Sharing Member is Chronically Ill. The Plan of Care will specify the type, frequency, and providers of the services most suitable to meet the ‘s Sharing Member long term care needs and the costs, if any, of those services. The Plan of Care must be updated as the Sharing Member’s needs change. At all times, We retain the right to verify that the Sharing Member’s Plan of Care is appropriate.

Qualified Long Term Care Services means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitative services, and Maintenance or Personal Care Services, which are required by the Sharing Member when Chronically Ill, and are provided pursuant to a Plan of Care prescribed by a Licensed Health Care Practitioner.

Representative means a person or entity legally empowered to represent another because of incapacity or death.

Registered Nurse (RN) means a duly licensed registered graduate professional nurse acting within the scope of his or her license at the time the treatment or service is performed.

Respite Care means Qualified Long Term Care Services provided to the Sharing Member on a short term basis to relieve an Informal Caregiver in the Sharing Member’s residence. Respite Care may be provided in the Sharing Member’s Home, a Nursing Home, Assisted Living Facility or through a community based program.

Severe Cognitive Impairment means the deterioration or loss of intellectual capacity that is comparable to, and includes, Alzheimer’s disease and similar forms of irreversible dementia which requires Substantial Supervision. Severe Cognitive Impairment is measured by clinical evidence and standardized tests that reliably measure a person’s impairment in:

• short or long term memory;
• orientation as to person (such as the person’s identity), place (such as the person’s location) and time (such as day, date and year); and
• deductive or abstract reasoning.

Single Billing Period means a bill for benefits under this LTCBP that is not interrupted by a period of one hundred eighty (180) consecutive days. If the Sharing Member does not meet the requirements of Eligibility for the Payment of Benefits because the Sharing Member is no longer Chronically Ill and no benefits are paid under this LTCBP for a period of one hundred eighty (180) consecutive days or longer, a new Single Billing Period will be established.

Sharing Contributions means monies paid by a Sharing Member to participate in the member to member sharing benefits program of a Health Care Sharing Ministry.

Sharing Member means the person who has affirmed the qualifications and requirements in the Sharing Guidelines of a Health Care Ministry (HCSM) and is Member of the HCSM and the named beneficiary of the LTCBP.

Sharing Guidelines means a document stating qualifications, requirements and other conditions affirmed by the Sharing Member for membership in the Health Care Sharing Ministry described in those Guidelines.

Stand-By Assistance means the presence of another person within arm’s reach of the Sharing Member that is necessary to prevent, by physical intervention, injury to the Sharing Member while performing an Activity of Daily Living.

Substantial Assistance means Hands-On or Stand-By Assistance.

Substantial Supervision means continual supervision by another person to protect a person with a Severe Cognitive Impairment or others from threats to health or safety (such as may result from wandering). Such supervision may include cueing by verbal prompting, gestures or other similar demonstrations.

Total Benefit Amount means the remaining amount of benefits that may be paid under this LTCBP. The initial Total Benefit Amount is shown on the LTCBP Schedule. The Total Benefit Amount after LTCBP issue will be decreased by benefits paid under this LTCBP. The Total Benefit Amount after LTCBP issue will be increased in accordance with the provisions of any attached Addendums to this LTCBP.

Waiting Period see Elimination Period in Definitions

We, Us, Our means Lifeline Alliance Corp.

You, Your means the Sharing Member of this LTCBP as indicated in Our records.

BENEFIT PROVISIONS

Benefits Paid Reduce the Total Benefit Amount

Unless otherwise indicated within this LTCBP, benefits paid under this LTCBP reduce the Total Benefit Amount of this LTCBP.

Daily Benefit Amount

The initial Daily Benefit is shown on the LTCB Schedule. The current Daily Benefit Amount is the initial Daily Benefit Amount adjusted to reflect the provisions of any inflation protection addendum attached to this LTCBP.

Facility Services Benefit

We will pay a benefit equal to the Covered Expenses if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits.

Covered Expenses means the actual daily cost of each day’s Facility Services received up to the Daily Benefit Amount. In no event will We pay less than $100 for each day of Confinement

Facility Prescription Drug Benefit

We will pay a benefit equal to the Covered Expense if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits and is receiving Facility Services.

Covered Services means the actual monthly cost of the Sharing Member’s prescription drugs up to the monthly amount for this this benefit.

The monthly maximum for this benefit is shown in the LTCBP Schedule.

Facility Bed Reservation Benefit

We will pay a benefit equal to the Covered Expenses if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits and is receiving Facility Services.

Covered Expenses means the actual cost charged by the Facility to reserve accommodations for each day the Sharing Member is temporarily absent from the Facility, up to the Daily Benefit Amount.

The maximum amount payable per LTCBP Year for this benefit is shown in the LTCBP Schedule.

Home Care Services Benefit

We will pay a benefit equal to the Covered Expenses if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits.

Covered Expenses means the actual daily cost of each day’s Home Care Services received up to the Daily Benefit Amount. In no event will We pay less than $50 for each day of Home Care Services.

This benefit is not payable for any day on which the Sharing Member receives Facility Services or is confined in a Hospital.

Emergency Response System Benefit

We will pay a benefit equal to the Covered Expenses for this benefit if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits and is receiving Home Care Services.

Covered Expenses means the actual monthly cost of the Sharing Member’s Emergency Response System up to the monthly maximum for this benefit.

The monthly maximum for this benefit is shown in the LTCB Schedule.

Ambulance Services Benefit

We will pay a benefit equal to the Covered Expenses if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits and is receiving Home Care Services.

Covered Expenses means the actual cost of each day’s Ambulance Services up to the Daily Benefit Amount.

The maximum amount payable per LTCBP Year for this benefit is shown in the LTCB Schedule.

Caregiver Training Benefit

We will pay a benefit equal to the Covered Expenses if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits.

Covered Expenses means the actual cost of the Caregiver Training up to the LTCB lifetime maximum for this benefit.

The Sharing Member is not required to satisfy the Elimination Period for this LTCBP before We will pay the Caregiver Training Benefit. Receipt of Caregiver Training by the Informal Caregiver does not count towards satisfaction of the Elimination Period.

Respite Care Benefit

We will pay a benefit equal to the Covered Expenses for Respite Care if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits for more than 45 days.

Covered Expenses means the actual cost, up to the Daily Benefit Amount, for each day of Respite Care the Sharing Member receives.

The maximum amount payable per LTCBP Year for this benefit is shown in the LTCB Schedule.

The Sharing Member is not required to satisfy the Elimination Period for this LTCBP before We will pay the Respite Care Benefit. Receipt of Respite Care does not count towards satisfaction of the Elimination Period.

Alternative Plan of Care Benefit

We will pay a benefit equal to the Covered Expenses for Alternative Plan of Care Services, including but not limited to Durable Medical Equipment and Home Modification, if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits and the Sharing Member or the Sharing Member Representative, the Sharing Member’s Licensed Health Care Practitioner and We agree that the Alternative Plan of Care Services:

• are cost-effective;
• are appropriate to the Sharing Member’s needs;
• provide the Sharing Member with an equal or greater quality of care; and
• constitute Qualified Long Term Care Services. Covered Expenses means the actual cost of the Alternative Plan of Care Services received by the Sharing Member subject to any limitations agreed to by the Sharing Member or the Sharing Member’s Representative and Us.

We reserve the right to make the final decision on any request for Alternative Plan of Care Services.

Optional Personal Care Advisor Benefit

The Sharing Member is entitled to the assistance of a Personal Care Advisor. The Sharing Member or the Sharing Member’s Representative or Family Member are encouraged to contact Our office, as soon as a bill is anticipated. The toll-free phone number is on the LTCBP Schedule. We will then contact the Personal Care Advisory Services Provider and instruct them to assign a Personal Care Advisor to the Sharing Member so that the Sharing Member can obtain Personal Care Advisory Services as soon as possible.

If the Sharing Member chooses to utilize the services of the Personal Care Advisor assigned by the Personal Care Advisory Services Provider, the costs of the Personal Care Advisory Services will be billed directly to Us and We will pay the Personal Care Advisory Services Provider directly. The cost of the Personal Care Advisory Services paid by Us will not reduce the Total Benefit Amount under this LTCBP.

The Sharing Member is not required to satisfy the Elimination Period in order to use the services of a Personal Care Advisor. Use of the Personal Care Advisor does not count towards satisfaction of the Elimination Period.

The use of a Personal Care Advisor is completely voluntary. The use or non-use of a Personal Care Advisor does not impact the right to benefits under this LTCBP

Coverage Outside of the United States

We will pay a benefit equal to the Covered Expenses for Facility Services and Home Care Services received Outside of the United States if the Sharing Member meets the requirements of Eligibility for the Payment of Benefits and satisfies the Elimination Period for Coverage Outside of the United States. Benefits will be paid in United States currency at the conversion rate determined by the United States Treasury as of the date benefits are paid.

Covered Expenses means the actual cost of each day’s Facility Services and/or Home Care Services received Outside of the United States subject to the daily and lifetime maximums shown in the LTCBP Schedule.

While We are paying benefits for Coverage Outside of the United States, You are not entitled to receive the Facility Prescription Drug Benefit, Facility Bed Reservation Benefit, Emergency Response System Benefit, Ambulance Services Benefit, Caregiver Training Benefit, Respite Care Benefit, or the Alternative Plan of Care Benefit under this LTCBP.

ELIGIBILITY FOR THE PAYMENT OF BENEFITS

Eligibility for the Payment of Benefits

Subject to all the terms and provisions of this LTCBP, We will pay the Covered expenses for benefits described in this LTCBP when We verify that the Sharing Member meets all of the following conditions:

• the Sharing Member is Chronically Ill;
• the Qualified Long Term Care Services the Sharing Member receives are covered under this LTCBP and are provided pursuant to the Plan of Care;
• coverage under this LTCBP was in force on the date(s) the Qualified Long Term Care Services were received by the Sharing Member;
• unless otherwise indicated within this LTCBP, the Sharing Member has satisfied this LTCBP’s Elimination Period;
• any daily, monthly, annual, or lifetime limits on the specific benefit(s) being requested under this LTCBP have not been exhausted;
• the Sharing Member meets all additional requirements indicated in this LTCBP for the specific benefit(s) being requested under this LTCBP;
• the requirements under the Expense Sharing section of this LTCBP have been satisfied; and
• the benefit is not subject to the Limitations and Exclusions contained in this LTCBP.

LIMITATIONS ON ELIGIBILITY FOR THE PAYMENT OF BENEFITS

Limitations and Exclusions

No benefits will be paid and the Elimination Period will not be satisfied for any

Confinement, care, treatment, or service(s) :

• provided to the Sharing Member by a Family Member or Informal Caregiver living with the Sharing Member at time of eligibility for benefits;
• provided Outside of the United States except as described under Coverage Outside of the United States in the Benefit Provisions section of this LTCBP;
• for which You or the Sharing Member have no financial liability or that is provided at no charge;
• provided in facilities operated primarily for the treatment of alcoholism or drug addiction; or
• provided in facilities operated primarily for the treatment of Mental or Nervous Disorders.

Non-Duplication of Benefits

Benefits are not payable under this LTCBP for: (a) expenses incurred to the extent that such expenses are reimbursed under Medicare or would be so reimbursed but for the application of a deductible or coinsurance amount; or (b) for services for which benefits are provided by any other state or federal workers’ compensation plan or other governmental program (except Medicaid).

For purposes of satisfying the Elimination Period, days on which the Sharing Member meets the requirements of Eligibility for the Payment of Benefits, but coverage is excluded due to Non-Duplication of Benefits, will count toward satisfaction of the Elimination Period.

Expense Sharing

File for Expense Sharing

To file for expense sharing, please provide Us with advance notice or advise Us as quickly as possible by calling the toll-free number shown on the LTCBP Schedule.

Notice of Expense Sharing

We must receive written Notice of Expense Sharing within thirty (30) days after the Sharing Member begins receiving care or services covered under this LTCBP, or as soon thereafter as reasonably possible. The Notice of Expense Sharing must provide Us with sufficient information to identify the Sharing Member. It should be mailed to Us at Our Long Term Care Administrative Office, at the address shown on the front of this LTCBP, or to one of Our agents.

Expense Sharing Billing Forms

After We receive Notice of Expense Sharing, We will send the Sharing Member or the Sharing Member’s Representative a billing form used for filing Proof of Loss. The billing form must be completed and returned to Us.

If We do not send a billing form within fifteen (15) days of the date Notice of Expense Sharing is sent to Us, the Proof of Loss requirement may be met by giving Us a written statement within the time limit stated in the Proof of Loss section. The written statement must give Us information sufficient to identify the Sharing Member and must outline the nature and extent of the loss.

Proof of Loss

We will consider Proof of Loss provided when We receive a completed billing form and any necessary statements or bills which include the date, nature and charges for all covered care the Sharing Member has received. Proof of Loss must be sent to Us within ninety (90) days after the date of the Sharing Member’s loss. If it is not possible to give Us timely Proof of Loss, We will not reduce or deny the expense sharing billing form if Proof of Loss is filed as soon as the information can reasonably be provided to Us.

If We do not pay benefits upon receipt of written Proof of Loss, We will mail the Sharing Member or their Representative within thirty (30) working days, a letter which states Our reasons for not paying the Bill, either in whole or in part. The letter will also provide the Sharing Member with a written itemization of any documents or other information needed to process the billing request or any portions not paid.

In no event, except in the event of the Sharing Member’s legal incapacity, may Proof of Loss be submitted later than one (I) year from the time proof of loss is otherwise required.

Time Payment of Expense Sharing

Benefits payable under this LTCBP for any loss other than loss for which this LTCBP provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written Proof of Loss, all accrued benefits for loss for which this LTCBP provides periodic payment will be paid monthly and any balance remaining unpaid upon termination of liability will be paid immediately upon receipt of due written proof.

Payment of Expense Sharing

We will pay all benefits payable under Benefit Provisions of this LTPBP to You, or to Your assignee. Upon Our receipt of proper written documentation, unassigned benefits remaining due upon Your death shall be paid to Your estate. If benefits are payable to Your estate, We may pay up to one thousand dollars ($1,000) to any relative of Yours by blood or marriage who We find is entitled to it. Any payments made in good faith will discharge Us with regard to such payment.

Subject to Your written direction, We may pay all or a portion of any benefits for care or services covered under this LTCP to the provider of such care or services unless You instruct Us in writing to do otherwise when We receive Proof of Loss. We do not require that the Sharing Member receive care or services from a specifically designated provider.

Extension of Benefits

Termination of this LTCBP will not terminate any benefits payable if eligibility for such benefit or total disability begins while this LTCBP is in force and continues without interruption after this LTCBP terminates. Any benefits payable under this provision are subject to the Total Benefit Amount, any applicable Elimination Period and all other provisions and Limitations and Exclusions of this LTCBP. In the case of Home Care Services, it is limited to twelve (12) months.

Plan of Care Updates and Examinations

While paying benefits under this LTCBP We will periodically require copies of updates to the Sharing Member’s Plan of Care, as well as an updated Licensed Health Care Practitioner certification as described under the requirements of Eligibility for the Payment of Benefits in this LTCBP.

In addition, We may require that a Licensed Health Care Practitioner examine the Sharing Member or provide Us with an Assessment while a bill is pending or while We are paying benefits under this LTCBP, as often as reasonably required. We will pay for these examinations or Assessments and will choose the individual to perform them.

Appealing an Expense Sharing Determination

We will evaluate a bill for expense sharing based on the provisions of this LTCBP and the information given by the Sharing Member, their Licensed Health Care Practitioner and other available sources. We will inform the Sharing Member in writing if We deny expense sharing or any part of expense sharing. If the Sharing Member does not agree with an expense sharing decision, the Sharing Member or their Representative may appeal the denial. The appeal must be in writing to Us and include all information that pertains to the bill. The Sharing Member will have 60 days from receipt of the denial of expense sharing to file a written appeal. No special form is needed. We will review the request and notify the Sharing Member or their Representative of Our decision within thirty (30) working days of receiving the request.

Right of Recovery

If We make any errors in processing a bill, We have the right to recover any overpayment of benefits. We will recover by offset any amounts that have not been previously recovered at the time We make another benefit payment.

Sharing Contribution Payments

Sharing Contribution Payment Options

You may pay sharing contributions once a year (annually), twice a year (semiannually), or twelve times a year (monthly). If You pay annual Sharing Contributions by installments, there will be an additional charge.

Sharing Contribution Due Dates

The first sharing contribution is due on the LTCBP Effective Date shown on the LTCB Schedule.

After the first sharing contribution has been paid, sharing contributions will be due in the amount and frequency shown on the Sharing Contribution statement that We will send to You.

Benefit Changes

At any time you may request an increase or decrease in your benefits and options by written, email or telephonic request. If an increase is requested, you must provide, at your expense, evidence of your good health by medical review or examination by a medical provider of Our choice. The amount of the increased benefits is subject to the LTCBP options available at the time of your request. Any additional suggested Sharing Contribution increase will be based on your age and the Sharing Contribution in effect at the time the increase in benefit is effective.

Payment Responsibility

You are responsible for payment of all sharing contributions due while a Sharing Member.

Payment must be sent to Us at Our Long Term Care Administrative Office, at the address shown on the front of this LTCBP, or any other office that We may designate.

Unpaid Sharing Contribution

We may deduct any sharing contribution due and unpaid from any Pending payment payable under this LTCB.

Waiver of Sharing Contribution

Sharing Contributions will not be due once We begin paying, and for as long as We continue to pay, benefits for Facility Services or Home Care Services under this LTCBP. We will return any unearned Sharing Contribution to You on a pro-rata basis. Sharing Contribution will again become due when We are no longer paying You because the Sharing Member is no longer receiving Facility Services, or Home Care Services at least once every week.

Grace Period

Except for the first Sharing Contribution, You will have thirty-one (31) days after each due date to pay the Sharing Contribution due. This LTCBP remains in force during the Grace Period.

Unintentional Lapse

If the Sharing Contribution is not paid by the thirtieth (30th) day of the Grace Period, We will provide written notice to You, and any individuals designated by You, to receive notice of non-payment of Sharing Contribution. Notice will be sent at least thirty (30) days before cancellation of Your coverage.

If the Sharing Contribution is not paid within thirty-five (35) days after notice is sent, this LTCBP will lapse for non-payment of Sharing Contribution subject to terms in the Sharing Guidelines

Refund of Unearned Sharing Contribution

Upon death of the Sharing Member, We will refund any unearned Sharing Contribution for this LTCBP on a pro-rata basis. We will make this refund in accordance with the Payment of Expense Sharing provision, within thirty (30) days of receipt of proof of the Sharing Member’s death.

If You request in writing to cancel this LTCBP, We will refund any unearned sharing contributions to You on a pro-rata basis. Cancellation will be effective upon receipt of Your request or a later date specified by You. Cancellation will be without prejudice to any expense sharing originating prior to the effective date of cancellation.

General LTCBP Provisions

Misstatement of Age

If the Sharing Member’s age is misstated on the Application, We may, at any time, adjust Your benefits and/or Sharing Contribution to reflect the Sharing Member’s correct age. If no LTCBP would have been provided based on the Sharing Member ‘s correct age, Our liability is limited to a refund of any Sharing Contribution paid for this LTCBP and this LTCBP is null and void as of the LTCBP Effective Date.

Entire Benefit Program; Changes

This LTCBP and additional attachments, is the entire Benefit Program . No agent, employee or person other than one of Our officers has authority to change this LTCBP. Any change must be shown on this LTCBP and approved in writing.

Incontestability

If this LTCBP has been in force for less than six (6) months, upon a showing of misrepresentation that is material to the acceptance of coverage, We may rescind this LTCBP or deny an otherwise valid bill on this LTCBP.

If this LTCBP has been in force for at least six (6) months, but less than two (2) years, and if We can show the misrepresentation is both material to the acceptance of benefits and that it pertains to the condition for which benefits are sought, We may rescind this LTCBP or deny an otherwise valid bill on this LTCBP.

After this LTCBP has been in force for two (2) years it is not contestable upon the grounds of misrepresentation alone. After two (2) years, this LTCBP may be contested only upon a showing that relevant facts relating to the Sharing Member’s health were knowingly and intentionally misrepresented.

No bill for expense sharing incurred six (6) months or more from the LTCBP Effective Date will be reduced or denied because a physical condition had existed before the LTCBP Effective Date.

LTCBP Termination

This LTCBP will terminate and coverage will end on the earliest of :

• the date that the Total Benefit Amount under this LTCBP is exhausted;
• the date We receive a written request from You to cancel this LTCBP (or a later date specified by You in the cancellation request);
• the date this LTCBP lapses for non-payment of Shared Contribution as described under the Unintentional Lapse provision; or
• the date of the Sharing Member’s death.

Reinstatement – Lapse Due to Severe Cognitive Impairment or Functional Incapacity

If coverage has lapsed due to the Sharing Member’s Severe Cognitive Impairment or functional incapacity, benefits may be reinstated without an application if :

• You or Your Representative requests reinstatement in writing within six (6) months after the last Sharing Contribution was due;
• We receive evidence satisfactory to Us that You have a Severe Cognitive Impairment or functional incapacity; and
• We receive all past due and Sharing Contributions.

This LTCBP will then be reinstated as of the date of lapse and both You and We shall have the same rights that existed prior to the due date of the Sharing Contribution in default. Sharing Contribution rates for this reinstated LTCBP will be based on the Sharing Members’s original issue age.

Reinstatement – Lapse Due to Non-Payment of Sharing Contribution

Without requiring an application, We shall accept past due and unpaid Sharing Contributions, up to one (1) year after lapse. Those payments will reinstate this LTCBP and put it back in force.

If We require an application for reinstatement, coverage may be reinstated within one (1) year after lapse if :

• the application for reinstatement is completed;
• We receive all past due and unpaid Sharing Contributions (for which We will provide a conditional receipt); and
• the Sharing Member will pass medical review or examination in effect at the time the completed reinstatement application is submitted to Us. Reinstatement by application will be effective:
• on the date We approve the application; or
• on the forty-fifth (45th) day following the date of the conditional receipt, if We have not previously declined the application in writing.

This reinstated LTCBP will cover only loss due to :

• sickness incurred more than ten ( l 0) days after the date of reinstatement; and
• accidental injury sustained after the date of reinstatement.

Upon reinstatement of this LTCBP both You and We shall have the same rights that existed prior to the due date of the Sharing Contribution in default. Sharing Contributions for this reinstated LTCBP will be based on the Sharing Member’s original issue age.

Rights of LTCBP Sharing Member

You, as the LTCBP Sharing Member may exercise every right and receive every benefit provided by this LTCBP. If the Sharing Member dies, all rights of LTCBP shall be transferred to Sharing Member’s executors or administrators.

Assignment

No assignment of interest under this LTCBP will be binding upon Us.

Conformity with State Statutes

Any part of this LTCBP that, on the LTCBP Effective Date, conflicts with the laws of the state in which You reside on such date, is hereby amended to meet the minimum requirements of those laws. Specific state statutes, disclaimers, and legal notices applying to Health Care Sharing Ministries appear at the end of the Sharing Guidelines in the State Specific Notices section.

LTCBP Addendums

Value Added Programs

Rewards and Benefits

Inflation Protection Option

If you buy your coverage 20, 10 or even five years before you use it, the benefit amount you choose will almost certainly be too low to cover the increased costs of care. That is why Lifeline Alliance offers inflation protection.

Automatic Inflation

Option An automatic inflation option means that the value of your insurance will increase each year by a set rate (e.g., 2% or 4% annually). The initial Sharing Contributions are higher because you are pre-funding automatic future benefit increases that are designed to help keep pace with inflation.

Be sure you know the set rate and if the increase is simple or compound. A compound increase provides the most protection.

Future Purchase Option

A future purchase option allows you to choose to increase your benefits periodically. Each time you buy additional coverage, your Sharing Contribution will go up. If you accept the option regularly, you do not have to show proof of good health or otherwise be subject to medical underwriting.

However, if you decline the option twice a certain number of times — even once with some plans — you may have to provide medical information satisfactory to the benefits program to have access to the inflation increases again.

Your initial fees are lower than the automatic inflation option under this option, but it will increase significantly if you take a number of these inflation offers.

Most benefit programs increase your benefits and Sharing Contributions only if you accept the offer when it is presented.

Terms and Conditions of Inflation Protection

Option Automatic Inflation

Option If you select Automatic Inflation Protection (AIP) the following becomes part of this LTCBP. The Effective Date and specific Terms of the AIP appear on the LTCB Schedule of Benefits.

One each LTCBP Anniversary Date while this LTCB remains in force, and while Sharing Member is not receiving benefits under this LTCBP, We will :

• Increase the LTCB Daily Benefit Amount in effect immediately prior to the LTCBP Anniversary Date by the percentage rate you selected on Your application and shown on the LTCB Schedule; and
• Increase the LTCBP Total Benefit Amount in effect immediately prior to the LTCPB Anniversary Date by the same percentage increase rate.

These increases will be made without requiring evidence of the Sharing Member’s eligibility for the LTCBP. All accrued increases under this AIP will be retained.

Future Purchase Option

If you select Future Purchase Option (FPO) the following becomes part of this LTCBP. The Effective Date and specific Terms of the FPO appear on the LTCB Schedule of Benefits.

One each LTCBP Anniversary Date while this LTCB remains in force, and while Sharing Member is not eligible for benefits under this LTCBP, We will :

• Increase your LTCBP Daily Benefit and the remaining portion of your LTCBP Total Benefit Amount, except as noted below.
• Send notice in the fall for the increase that is scheduled for January 1 of next year. Increase may be elected every two years thereafter. Your LTCBP must have been in effect at least 12 months for you to receive your first increase under this provision. The increase will be based on the change in the Department of Labor’s Consumer Price Index for Medical Care over the most recent two year period.
• Include in the biennial notice the amount of the increase of the LTCBP Daily Benefit and the increase in the suggested Sharing contribution to effectuate the increased benefits.
• Increase your Sharing Contribution (SC) for each increase under the FPO. The additional SC will be based on your age and the suggested SC at the time the increase is effective.

If you do not want the increase, We must receive your rejection before the date specified in the notice of increase. If you want the increase, no action other than paying the additional suggested SC before any due dates. The scheduled increase will automatically be in effect.

Increases under the FPO will be made regardless of your age or evidence of good health. Your benefits will not increase and no FPO Sharing Contributions will be suggested if you are eligible for benefits or if you have declined a total of three prior FPO increases.

Prevention Benefit

The Long Term Care Benefit Program (LTCBP) is additionally focused on prevention of disease and especially cognitive decline in our Sharing Members. This is good for the health of the Member and good for the health of Lifeline Alliance.

Lifeline Alliance’s “Pathway to Memory Preservation and Brain Growth” may reduce the risk of ever having Alzheimer’s Disease. Medical research has documented that brain growth and prevention or removal of Alzheimer’s toxins (beta amyloid and tau proteins) can occur through targeted modification of lifestyle factors including diet, exercise, sleep, and brain stimulation. Such risk reduction though lifestyle modifications is consistent with the affirmation of “healthy lifestyles” required for Membership in Lifeline Alliance. Almost 25% of the disability years attributed to Alzheimer’s can be attributed to modifiable risk factors.

The Lifeline Alliance prevention program can help participating Members achieve this modifiable risk. Participation in this program is elective and incurs additional fees. The prevention program that includes periodic digital video and telehealth consults with healthcare providers, costs an additional $1000/year (current rate may vary) with a five year minimum term of participation.

If the participating Sharing Member lives another five years of MINDFUL, quality years then the investment in the prevention program will have produced tremendous economic and non-economic payouts. The economic benefit includes continued monthly social security and any other retirement benefit payments. The non-economic benefit of five additional mindful, quality years with family and friends is priceless.

Terms and Conditions of Prevention

Option If you select the Prevention Option (PO) the following becomes part of this LTCBP. The Effective Date and specific Terms of the PO appear on the LTCB Schedule of Benefits.

While this LTCB remains in force, We will :

• Provide periodic digital video and telehealth consults with healthcare providers trained in achieving and enforcing the lifestyle modifications demonstrated to modulate the pathologic changes of Alzheimer’s Disease. Optimizing a ketogenic diet and restorative sleep, promoting brain stimulation and physical exercise under strict supervision may reverse or delay the onset of Alzheimer’s Disease.

There is a five year minimum term of participation in the program while you are a Sharing Member of the LTCBP. If for any reason Membership in the LTCBP is terminated, all additional Sharing Contributions for this PO are cancelled.