Avoid Being Shorted On Long-term Care Coverage

Among other things, the pandemic has focused our attention on our elderly relatives – are they safe, well-treated, sufficiently housed, properly fed, and receiving adequate health care? One component of this analysis is a strategic look at housing. With finances tight, many families are searching for alternative sources of funding for living expenses and in-home care, including a look at any potentially applicable long-term care (“LTC”) insurance policies.

Many older adults purchased LTC policies decades ago when they were healthy and living in their own homes. Years later, the older adults and their families are evaluating assisted living facilities, nursing homes, skilled nursing centers and memory care units, or a combination of these properties. Not surprisingly, some of the policy language has become outdated over time and laws governing licensing of facilities dedicated to the care of seniors have changed to accommodate more modern amenities, services and treatments. Unfortunately, some families have discovered these coverage discrepancies only after moving a loved one into a facility, making a claim for coverage, and finding out that coverage has been denied for the services furnished by that particular facility.  Don’t let this happen to you!

Here are some tips to help families navigate the complex and multi-faceted landscape of long-term care coverage.

1. Know your coverage

LTC policies provide a host of different coverages, depending on the needs of the insured(s). For example, some policies provide monthly benefits if an insured cannot perform without assistance one or more of the essential activities of daily living, defined as bathing, dressing, toileting, eating and transferring (moving from place to place). Others may cover skilled nursing services such as the administration of medication or daily shots and treatments. Still others cover multiple levels of service – from nursing care to home health care, hospice care, adult daycare and respite care (temporary care while a family member takes a break from caregiving). It is important to know before choosing a facility which services may qualify for LTC coverage.

2. Know your facility

Some policies require as a prerequisite to coverage that the services be provided in a particular type of licensed facility. In Texas, several different types of licenses are available.  If a policy requires that services take place in a facility that is licensed as a “nursing home,” then an assisted living facility, even if licensed as such, may not qualify for coverage.

Similarly, changes in the law over time can complicate coverage. For example, a policy issued in the 1990’s may cover a “personal care facility” instead of an “assisted living facility” because the name was later changed. The Texas statute on “nursing facilities” was not enacted until 1997, so does a “nursing home” licensed in 1991 meet the 1997 (or later) definition of “nursing facility?” Most of these discrepancies can be resolved through a review of the legislative history, but it is helpful to spot these issues if a claim is denied for improper licensing or outdated terminology.

3. Know your caregiver

In addition to the foregoing, some policies demand that care be given by a registered nurse while others permit services to be performed by persons with no medical training at all. Some condition treatment on the presence of a nurse or doctor on the premises, or limit services to those approved by a health care professional as part of an ongoing treatment plan. The variables are endless. It is important to know who will be providing the services, if a treatment plan is required, if the insured needs to be “under the care of a physician,” and if the facility has medical doctors or registered nurses available and on-call 24/7.

4. Match your facility to your coverage

Avoid the frustration of a coverage denial and the disappointment and unhappiness of having to move a loved one from one facility to another by assessing the applicable LTC coverage in advance of moving a loved one into a particular nursing home, assisted living facility, skilled nursing center or memory care unit.  We can assist you in reviewing your LTC policy and using the coverage it provides to generate a list of questions to ask any facility that you are considering.  With some advance preparation and targeted questions, the transition to long-term care can be seamless, economical and beneficial to families and loved ones alike.