When asked how much they know about long-term care insurance, many adults reply, “not much.” They are not alone.
In fact, over half of all adults incorrectly believe that Medicare will cover long-term care needs such as a nursing home, assisted living or at-home care.
At the same time, almost all adults state that they do not have the funds to pay for one year of a nursing home, and if they do, it would be very difficult.
Who Pays for Long-Term Care?
This simple answer: You do!
Medicare will cover some skilled care following a hospitalization for illness or injury. Minimal coverage may exist specific to Medicare Advantage, Veterans Program, and Medicaid. For those who have, long-term care insurance—Congratulations! You made a great decision!
Preferred Care at Home of Central New Jersey has help many families navigate the long-term care insurance claim process. Below is the story of Paul, one of our long-term care insurance clients.
Paul has always been a planner and never wanted for him and his wife, Sharon, to become a burden for their children. They purchased long-term care insurance policies many years ago. Paul recently had a stroke and is in the hospital. He will spend at least a month in a rehabilitation facility after his discharge.
Sharon knows she cannot care for Paul alone at home. She knows they have long-term care insurance, but she cannot make heads or tails of the coverage. Thankfully she reached out to us while Paul was in the hospital.
We reviewed the policies with her to ensure she had a good understanding of his benefits. Together we called the insurance company, opened a claim and had care in place the day Paul came home.
Benefit Eligibility
Most long-term care insurance policies use Activities of Daily Living (ADLs) as the key criteria for determining benefit eligibility. Paul’s policy required that he have a cognitive impairment or be unable to perform two of the following ADLs without assistance.
- Bathing: able to get in/out of shower/bath, shave, brush teeth
- Dressing: able to put on clothes and manage buttons/zippers, medical braces, artificial limbs
- Eating: feed oneself from a plate or by a feeding tube
- Transferring: able to walk and get in/out of a bed or chair
- Toileting: able to get on/off toilet and perform personal hygiene
- Continence: able to control bladder and bowel functions or able to care for catheter or colostomy bag.
In Paul’s case, he currently needed assistance with all of the ADLs listed.
We opened the claim, completed the paperwork and scheduled Paul’s assessment by the insurance company’s nurse. The Eligibility Team made their determination within 30 days that Paul met the eligibility requirements.
What Was Covered?
There can be significant differences in long-term care policies. We’ll limit this discussion to Paul’s plan, which included the following:
- No Elimination Period for In-Home Care (immediate coverage)
- 90-Day Elimination Period for Assisted Living Facility or Nursing Home
They would have to pay for the first 90 days without ever being reimbursed. - Immediate coverage for Durable Medical Equipment (hospital bed, wheel chair, walker, etc.)
- No coverage for medical supplies (bed pads, briefs, etc.)
- Lifetime Benefits
- Monthly Benefit Limit of $10,000
Why Choose In-Home Care?
Like most people, Paul wished to be cared for at home. Studies have shown that those who remain at home with in-home care tend to live longer than those who move to a nursing home. Moving to a new environment at this stage of life can result in confusion. They are also exposed to many people who all have the potential to bring communicable diseases.
Knowing his policy did not have an elimination period for in-home care and provided reimbursement for his medical equipment made the decision to choose in-home easy for the family. Our nurse and caregiver visited him in the rehabilitation center, met with the physical, occupational and speech therapists as well as the discharging social worker. We were in place when he arrived and assisted with his transition home.
Paul and Sharon are still part of our Preferred Care at Home of Central New Jersey family. They are able to provide our caregiver with a bedroom in the loft area of their home allowing us to be there if Paul ever needs assistance during the night.
We provide meals, light housekeeping and laundry for both Paul and Sharon. We also assist Paul with all of his Activities of Daily Living as well as home exercises provided by the therapists.
Preferred Care at Home of Central New Jersey
Preferred Care at Home of Central New Jersey would be happy to help you initiate a long-term care insurance claim. It takes time to navigate the process so call as soon as you think you may meet the benefit eligibility requirements. Worst case, you’ll have to wait a bit longer but will have a clear understanding of your coverage. Best case, you’ll start receiving reimbursement for some of your expenses.
At Preferred Care at Home of Central New Jersey, we care for those you care about. Contact us today to discuss your needs.
