Posted on: October 1, 2014 | 0 Comments |
So you think it may be time for your loved one to begin to access their long term care benefits. What makes working with LTC insurance complicated is that there is no real standardization regarding these types of policies. You must be somewhat savvy to ask the right questions and obtain the correct approvals before care is begun to make sure the policy will pay for all services. If you have not worked with the LTC insurance industry, you will need to first become accustomed to their lingo. The following are some terms you will need to understand before calling the LTC insurance provider:
Service Exclusions: Most long term care insurance policies usually do not pay benefits for mental health disorders; although most do pay for Alzheimer’s disease or other dementias. Most also exclude alcohol or drug addiction, attempted suicide, or illness or injury caused by an act of war. Some insurers may say they won’t pay benefits for personal care, such as housekeeping or errands. But you can often get these benefits paid as long as the agency is providing other services that meet the policy’s ADL (Activities of Daily Living) requirements.
Elimination Period: The elimination period or deductible period is the time it takes before the policy will pay. Typically there is a 90-100 day elimination period once the claim has been approved for payment. This means that any services received during this time will need to be paid out of pocket.
Benefit Period: The benefit period tells you how long the policy will pay either as a daily or monthly benefit. Most will have a daily benefit amount, typically 150$/day.
Prior Stay Requirements or gatekeeper provision: Many older policies did not pay benefits unless you spent at least three days in the hospital first. Most policies sold today do not have a prior stay exclusion.
Benefit Triggers: Each policy has its own triggers for determining when the recipient’s physical or mental condition is such that they are entitled to benefits from the policy. Generally, most policies require that at least 2-3 of the activities of daily living require assistance. ADL activities generally include: bathing, dressing, toileting and continence, transferring and ambulating, and eating. Most policies do not require a physical trigger (meaning inability to perform 2-3 ADL’s) if there is a cognitive impairment. If the client has been diagnosed as having Alzheimer’s disease or another dementia such that they require verbal cueing and safety, they are usually considered to meet the benefit trigger for utilizing the policy benefits. Each insurance policy requires different examples of proof of the above disabilities. Some will require a physician to sign off on the inability to perform ADL’s or that there is a cognitive impairment. Some policies will allow a care manager to perform this assessment. Still others require that their company’s care manager must verify the disability.
Once a client’s policy has been activated, you will need to know the limits or the number of days per year for which benefits will be paid. There are some older policies that have a life-time limit. Most policies though, have a lifetime limit of a specific number of years, usually 3-5.
Long-term care insurance is certainly not easy to navigate, but if you know the right questions to ask and information to obtain, it can make the process much easier. In some long-term care policies, there is also a provision that pays for care management and coordination; and DSG services may be reimbursed under this provision in many cases.