The US Department of Health and Human Services defines long term care as a “range of services and supports” anyone may need to meet their personal needs either over a long or short-term period. Long term care (LTC) isn’t entirely medical care but rather any assistance you might get related to personal tasks of your everyday life.

Such services aid patients/people live safely and independently even if they can't perform their day-to-day tasks. These personal tasks are also known as Activities of Daily Living (ADLs) and include:

  • Dressing
  • Bathing
  • Toilet use
  • Caring for incontinence
  • Transferring a patient from to chair or bed
  • Eating

Other Common Long Term Care Supports and Services

On top of ADLs, the department’s website also lists down other LTC services and supports, known as Instrumental Activities of Daily Living (IADLs), geared towards assisting patients with everyday activities. These services include:

  • Money management
  • Housework
  • Taking medication
  • Shopping for clothes or groceries
  • Cleaning up after meals
  • Caring for pets
  • Responding to emergencies and other alerts like fire alarms
  • Managing mobile and telephone communications

Who Needs Long-Term Care?

If you have a severe disability or any health condition that requires ongoing attention, you qualify for this type of care services. Your needs for it may also arise as a result of a sudden stroke or heart attack. There are other cases where the need will develop gradually over time as you grow older and your body gets weaker.

It is not easy for caregivers though to determine the type or how much long term care you will need. Here is a list of factors that might lead to an increased necessity for this care in the future:

  • Your marital status– Unlike the married people, single people/patients have increased chances of needing care over time especially when they advance in age.
  • Your gender– Women on average live longer than men. As a result, they have increased chances for needing care in the future than men.
  • Family and health history– Hereditary health conditions and general health history could also call for LTC in the long-run.
  • Your lifestyle– If you have poor dieting and exercising habits, you are likely to need care in the future than the people having balanced diets.
  • Your age– As you grow older, there is a likelihood that you will need this type of care.

Home-Based Long Term Care

Home-based health care has to do with all services - personal, health, and support – that are geared at helping you (or your loved ones) not only enjoy your stay there but also have all the independence you need while at home. Most of this care is either provided at your home or at the home of your family members.

In most cases, home-based care is short-term. For example, it could be about taking care of someone who is recuperating from an accident or an operation. It could also be a long-term service revolving around patient’s care –that is dressing, bathing– just any activity that makes sure you are safe at home. It could also have to do with helping them take their medication.

Who Provides Long-Term Care Services?

These services are provided in different places by different caregivers depending on your personal needs. Most of the time, it is provided by unpaid partners, family members, neighbors or friends. You can also have these services provisions at a community-based care center or in a nursing home. Additionally, you can also engage paid caregivers to provide such services. The caregivers can be found normally, or you could do with healthcare professionals including nurses, homemakers, or even therapists.

Services Provided by Home Health Care Agencies

Some of the services provided by these agencies include emergency systems, homemaker services, transportation services, and companion services.

  • Transportation for the patients

    These could either be paid-for or free services. Transportation services aid people to move to or from shopping centers or medical appointments. You could use the services to move them to any other places in the community. Some community groups and most public transit agencies provide these services. The public transit agencies, however, target people with disabilities.

  • General Home-Based Health Care

    It involves providing medical services for specific health conditions to patients according to physician’s orders. Some of the services a physician might order include; nursing care that helps a patient through the process of recovery –let say, from an accident, surgery or illness. There are other times when such health care services might involve various therapies –for instance occupational, physical or speech. But, if you are over 65 years of age and above, Medicare-approved health care agencies will provide these services to you.

  • Giving the Patient Company

    Mostly these services are offered to those living alone or whose health is growing weaker every other day. Also known as friendly helper services, the service is normally provided by volunteers that pay the patients short visits, with the short visits usually last less than 2 hours. You can as well hire one of the home care agencies adept at providing this care at the homes of your loved ones.

  • Homemakers

    This involves offering your patients the care they need and doesn’t need a nod from your physician. Many of these personal care services include help with dressing or bathing, but homemaker services involve helping people with household chores and meal preparations. These kinds of services don’t need to be Medicare-approved for these agencies to provide them.

  • Taking Care of Emergencies

    Emergency services are geared towards responding to emergencies –medical and any other emergencies that might arise. Many care customers will wear either a bracelet or necklace and these devices have buttons that you can push in case of an emergency. As a result, it helps you call for assistance in case of any emergency at home. If your parents or loved ones are living alone, they make the right candidate for these services. These services are normally charged on a monthly basis.

Long Term Care Insurance

By the time you hit 65 years, chances are you will need paid LTC. Unfortunately, if you pay this out of your pocket, you will be forced to part with about $140,000 annually. This is a huge financial risk you may have to bear.

However, only about 7.2 million Americans have long-term care insurance which covers the costs of assisted living, costs of nursing home care or in-home care. You might want to insure today against such risks.

But, before you get there, here some of the things you need to know about this type of insurance today:

  • You need a plan, but you might not need insurance

    According to industry research by Life Plans, most long term care premiums cost about $2,700 a year. As a result, the high cost puts the coverage out of reach for most ordinary Americans. If you have few assets, you can rely on Medicaid to cover these costs. But, if you are flush enough with money, you can plan to pay your care in future out of pocket.

    If you are only spending less than 4% of your total saving for your living expenses each year, you can comfortably go without LTC insurance, but you need to weigh factors other than cash. Do you have a person whom you can rely on to help out in case you needed care? What about home equity you can make use of? Does your family have a history of dementia that increases the risk of needing care in the future?

  • People and insurers alike are shunning traditional policies

    Traditionally, LTC insurance was about paying an annual premium to an insurance firm while you get financial assistance in case you needed any help in your day to day activities. But, the insurance terms of today are characterized by a daily benefit of $160 that covers nursing home fees, up to three years’ worth of coverage and a three-month waiting period before you can start claiming your benefits. Unfortunately, these policies usually have a troubled history where insurers hike premiums or register huge losses. Today, very few insurers are selling long term care insurance.

  • You can consider investing in “hybrid” policies

    Unlike the traditional long term care insurance, the hybrid policies don’t end up hiking your premiums. “Hybrid” policies enable you to lock in your premium upfront. Besides, you get your money back in case you don’t end up needing care in your old age.

  • Traditional policies are way much cheaper

    If you want cost-effective coverage, traditional long-term care insurance is the way to go. But, you should not expect a refund in case you never needed any help. But, “hybrid” policies are usually 2-3 times more expensive compared to old-school policies for the same benefits. You will have to pay extra for that guarantee of getting all of your money back. If you are planning to use the premiums as your savings, again the “hybrid” policy makes more sense.

  • Smart shopping for your cover pays off

    If you want this insurance, you can start looking in your 50s. Speed is critical, otherwise; premiums may rise, or your health condition worsens to the point of ruling out any robust coverage. The more you delay, the more expensive it will be. For instance, you are likely to pay 8% to 10% more if you are 65 years and above.

Note: Don't seek your coverage from a single insurer. For the best deal, look for an independent agent selling insurance policies from different companies. They have extra expertise and will also give you a wider choice of policies to choose from.

How Long Term Care Insurers Deny Benefits

It can be quite heartbreaking if you or your loved one bought LTC cover years ago, have paid your premium ever since but cannot get the benefits when you need them. Unfortunately, these cases happen more often.

The policies of the 90s are much different from what we are experiencing today. As a result, most of the people who started paying their premiums then might have problems when it comes to claiming their insurance benefits.

At those times the industry was lax, and the laws that governed the policies were poorly written. Besides, there were few cases of assisted living facilities and they were not usually covered in the policies. While the LTC insurance policies written 10 years ago provide comprehensive insurance coverage, today's scenario is entirely different. For you to qualify for these benefits today, for instance, you have to prove inability to perform two or more Activities of Daily Livings.

Here is a round-up of some reasons why insurers delay or deny benefits:

  • No prior hospitalization

    This is especially common among the older long-term care policies. It requires that the policyholder had a nursing home stay, hospitalization confinement or both before claims are paid.

  • Ineligible care provider

    If you are in an assisted living facility or nursing home, the operator must have certification that proves to the insurer that the facility is an “eligible care provider.”

    The policy may also require that the facility has appropriate care and personnel. Before you place your loved one in a facility, be sure to find out whether it meets the criteria of their policy. Otherwise, you might run into problems with their insurance cover providers.

  • Inability to pay claims as a result of cognitive impairment

    Sometimes, due to old age or cognitive impairment, the policyholder might forget to pay the premiums. Fortunately, some states allow up to five months before a policy can lapse due to missed payments. But, to your defense, you can get physicians statement that demonstrates that your parent has cognitive issues. That way, the insurer will reinstate the policy.

  • No benefits for personal care

    There are those insurers who won’t pay personal care “benefits” like errands or light housekeeping duties a caregiver must run for the policyholder. But, as long as the policyholder meets all the policies ADL requirements, there is no sufficient reason for denial of claims.

How to Get Your Benefits Paid

Here some tips you need to know to get your long term care claims paid:

  • Read the policy keenly before submitting any claim. That way, you will be able to characterize your claim properly. As a result, you will avoid characterizing your claim in a way that would prejudice your ability to get your claims paid. In case you can't find the policy, feel free to ask the insurer to send one.
  • Get a statement signed by your parent that authorizes you to act on his behalf in case policy disputes arise. This doesn't have to be from the attorney, you need a simple statement that is signed. If your parent has dementia, unfortunately, it would be too late for you to do that.
  • Prepare ‘daily care notes’. Some insurers require ‘daily care notes' before they approve your claims. If you are planning to hire an aide from a home health care agency, make sure they are keeping the notes.
  • Don’t be boxed by the boxes on the form. When it comes to filling your insurance claims, feel free to include more information than what they are requesting for. You can’t be limited by the amount of information you need to substantiate your claim. You can attach any information –including info from caregivers or your physician. Sometimes you might be required to submit your physicians ‘plan of care’, or “certificate of necessity of treatment.”
  • Find better ways of communicating your grievances. If they still can’t pay your claim, put in writing and send the protest letter to the insurance company. But, always avoid resolving your claims issues over the phone. A claim denied letter leaves little room for ambiguity that the way a phone call does. In other cases, the insurer might make unpractical demands. For example, there are those that might need the power of attorney for you to represent your parent. With that kind of paper trail, you are sure nobody can challenge or change what was agreed upon.
  • Make sure you are at home when the LTC insurer dispatches someone to your home to determine whether to pay benefits or not. Your parent might fail to tell the interviewer what he or she is unable to do by themselves –such as feeding, dressing, or bathing himself. As a result, it could lead to denials of your claims.
  • Request to be a third-party designee– that way, you will be receiving a copy of any lapse notices. So, in case, your parents fail to make their payments, you will always know what to do.

What if Things Go South?

One Julia Klimenko thought she was prudent when she invested in a long-term care insurance policy. She believed that the policy would help pay for the care she would need in her old-age. But, today, she’s telling a different story. She wishes she could have rather banked her money instead of investing in her health care premium plans. She’s already 69 and is forced to pay nearly quadrupled monthly premiums. She has the option of either lowering her premium (and thus cut her policy benefits), pay the increased cost of premiums or drop the insurance altogether.

Although the therapist is ready to pay the increased costs of premiums, she's not sure how much more premium price hike she's willing to take. Dropping her insurance is not a choice either because it means she'll have lost a lot of money. Besides, if she decides to pay less, the insurance won't cover what she needs.

She is not alone in this bandwagon of LTC insurance frustrations. Today, most insurers have botched different aspects of insurance policies that they sold to consumers in the early days of the Long Term Care industry.

For instance, New Yorkers who bought this type of insurance from Genworth, were hit with a 60% premium increase in October. As if that is not enough, Genworth asked Pennsylvania state regulators to allow them hike premiums by 130% for some policyholders. That can be scarier, if not heartbreaking. But, don’t despair –you can get help

Long Term Care Insurance Denial Attorney Near Me

If you have been subjected to ridiculous LTC premium increase or improperly denied a claim, you could have a legal case. You don't have to accept the fact that your claim has been denied. Get advice from an attorney experienced in bad faith insurance claims. Unfortunately, not all attorneys get the nuances of how the insurance industry operates.

Stop Health Insurance Denial, a highly celebrated Los Angeles law firm, boasts of a team of highly experienced bad faith litigators who can assist you to get your claims paid when they are improperly denied. Contact us today at 310-695-5241, we’ll be glad to try and help you get your claims paid.