Long Term Care Insurance

What is Long Term Care?

Long Term Care is the assistance individuals need when they are unable to care for themselves and need help with Activities of Daily Living (ADLs) – bathing, dressing, transferring, toileting, continence (control of bodily functions), and eating – or they have severe cognitive impairment such as Alzheimer’s disease. The need for long term care can result from an accident, chronic illness or short-term disability, or from advance age. Long term care can include a broad range of services, provided in any setting outside a hospital. It might be help with simple daily tasks like bathing or dressing. It might include skilled care in your own home, an assisted living facility, some other community resources, or a nursing facility.

Understanding Long Term Care

Who Needs Long Term Care

Some Misconceptions about Medicaid and Medicare

Medicaid

Medicaid pays for health services for the very poor of any age. Qualifications for Medicaid vary by state. Being eligible for Medicaid does not guarantee placement in a nursing home. There may be long waiting lists for facility care. Depending on the state and facility, Medicaid patients often receive lesser-quality care than patients who are paying on their own. Under Medicaid, nursing home care is essentially the only option. Home care, assisted living facility care, adult daycare, outpatient services, and alternate caregiver services are not usually reimbursed under Medicaid.

Medicare

Medicare pays for health care for people 65 and over and for those who are disabled. Medicare does not pay for long term medical service such as assisted living or adult day care. Medicare pays only the first 100 days of skilled care, such as physical therapy or nursing, which only accounts for 5% of all long term care costs. You are eligible for the care only if you have been in the hospital for at least three days. The personal care must relate to the treatment of an illness or injury.

Other Exceptions, Limitations and Exclusions and Pre-existing Conditions

Exceptions, Limitations and Exclusions

Most long term care insurance policies will not pay benefits for any confinement, care, treatment, or service(s):

  • That results from attempted suicide or intentionally self-inflicted injury;
  • That results from voluntary participation in a felony, attempted felony, or illegal occupation;
  • That results from a sickness or injury for which benefits are provided under any state or federal worker’s compensation law;
  • Provided outside the United States or Canada;
  • Provided in a government facility (unless otherwise required by law);
  • Provided for the treatment of alcoholism or drug addiction, or in facilities operated primarily for such treatment;
  • Provided in facilities operated primarily for the treatment of mental or nervous disorders or disease, other than Alzheimer’s disease or dementia.

Pre-existing Conditions

You could be declined coverage if you already have the following condition(s):

  • Alzheimer’s Disease;
  • Severe Arthritis with functional limitations;
  • Diabetes which is not under control;
  • Cancer within the past 6 months;
  • Parkinson’s Disease;
  • Stroke within the past 6 months;
  • A Stroke at any time, which has caused functional limitations;
  • Congestive Heart Failure within the past 6 months;
  • Emphysema, if severe or still smoking;
  • Chronic Obstructive Pulmonary Disease, if severe or still smoking
  • Any conditions which require the assistance of another human being for the basic activities of daily living: bathing, eating, toileting, or transferring in and out of a bed or chair.

How Can I Choose the Best Quality Services and Facilities?

Home Care

  • In many States, home care agencies must be licensed. Check with your State health department to see if your State requires it. If so, be wary if an agency is not licensed.
  • Ask if the agency is certified by Medicare. Medicare inspects home health care agencies to assure they meet certain Federal health and safety requirements. Medicare will pay for services only if the agency is Medicare-approved and if the services are covered by Medicare.
  • If the home health care agency is certified by Medicare, you can review its survey report. Call the Medicare Hotline at 1-800-633-4227 and ask to be referred to the Home Health Hotline for your State. You can request a copy of the report from that hotline.
  • Find out if the agency has been accredited (awarded a “seal of approval”) by a group such as the Joint Commission on Accreditation of Healthcare Organizations (630-792-5800); www.jcaho.org) or the Community Health Accreditation Program (1-800-669-9656; www.chapinc.org)
  • Contact your State or local consumer affairs office to see if any complaints have been filed against a home care agency. Also ask about the outcome of any complaint investigations.
  • Whether you work with an agency or hire someone yourself, carefully check the backgrounds of the people who will be coming into your home. Ask for references who have worked with the agency or person. Call them, and ask about their experiences. Would they use the agency or person again?
  • Does the home care worker have the necessary skills and training for your needs? Ask to see training certificates. Make sure the worker knows how to safely assist and care for patients.
  • Does the agency have supervisors who check on the quality of care its workers provide?
  • How does the agency follow up on and resolve complaints?

Nursing Home Care

  • All nursing homes that participate in Medicare or Medicaid are visited about once a year by a team of trained inspectors. They check the home and the care provided and prepare a survey report. You have a right to review the report, which must be posted in the nursing home. Speak to the nursing home administrator to learn more about any problems that appear on the report. Ask if the problems have been corrected.
  • Call your State or local long term care Ombudsman. Ombudsmen visit nursing homes on a regular basis and know about each nursing home in their area. You can ask about the latest survey report and about complaints that have been filed. You can also ask what to look for when visiting local nursing homes.
  • Compare the inspection records of your top choices by visiting the “Nursing Home Compare” Web site: http://www.medicare.gov/nursinghomecompare/search.html. If you can not access the link above, call Medicare Hotline at 1-800-633-4227 to obtain the information you need.
  • Some nursing homes have been accredited by a national group such as the Joint Commission on Accreditation of Healthcare Organizations (630-792-5800). It may be helpful to find out if the home participates in the voluntary process and to learn the results.

What Kind of Services Do I Need?

Help With Daily Activities

  • Shopping
  • Preparing meals
  • Eating
  • Laundry and other housework
  • Home maintenance
  • Paying bills and other money matters
  • Bathing
  • Dressing
  • Grooming
  • Going to the bathroom
  • Remembering to take medicines
  • Walking
  • Other _______________________
  • Other _______________________

Health Care Needs (as recommended by a doctor or other health care provider)

  • Physical therapy
  • Speech therapy
  • Occupational therapy
  • Rehabilitation
  • Medical nutritional therapy
  • Oxygen
  • Care for pressure ulcers or other wounds
  • Alzheimer’s disease care
  • Health monitoring (for diabetes, for example)
  • Pain management
  • Nursing care services
  • Other medical services provided by a doctor or other clinician
  • Other _______________________

Long Term Care Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.