It’s not uncommon for an enrollee to receive benefits, recover, and enter a subsequent benefit period again in later years. Because conditions can change with time, while you are receiving care our care coordinators will review your benefit eligibility and plan of care at least once every 12 months and sometimes more frequently depending on your specific condition.
We may request additional information by: contacting you, your physician, or other persons familiar with your condition; accessing your medical records; having you examined, at our expense, by a licensed health care practitioner; and/or conducting an on-site assessment.
You must inform us of any anticipated or actual change in your condition, care, caregivers, or stay-at-home needs (such as home modifications and durable medical equipment), as soon as you know about or need to make a change. Any requested change to your plan of care must be reviewed and approved by our care coordination staff prior to making the change in order to avoid reimbursement denials or delays.
If long term care eligibility criteria can no longer be documented, you are considered recovered and therefore no longer eligible for reimbursement of benefits for your current claim.
The following are a few reasons why a claimant may no longer be eligible for benefits:
- You no longer meet the benefit eligibility requirements.
- You’ve utilized your entire maximum lifetime benefit.
- We’ve been notified of your death.
