A look at how the long term care insurance process plays out.
Having long term care insurance doesn’t solve all the problems associated with requiring extended care. And some people don’t qualify for such insurance, or find it to be prohibitively expensive. But if you do have a policy, it can go a long way toward addressing the financial and emotional challenges of needing help with the basic activities of daily life—or caring for someone who does.
Recently, I had the opportunity to speak with Marilyn Staff, director of care coordination at Long Term Care Partners, which administers the Federal Long Term Care Insurance Program. She has more than 30 years of experience in acute care, home care and long term care. I asked her to explain how a typical claim for FLTCIP benefits is processed. She outlined the hypothetical case of “Mary,” who had purchased a FLTCIP policy prior to retirement and the onset of her need for care.
Mary noticed that her physical health had been declining. As her ability to care for herself had declined, she felt she could use some assistance. She called 1-800-LTCFEDS to understand the process of starting a claim.
Mary was sent a claims initiation kit, outlining the entire process, including the medical documents needed and the timeline. Care coordinators, who are registered nurses, began to work with her and reviewed the documents. She was asked to provide a copy of a durable power of attorney if she had one, in case she needed to delegate some decision-making power to a family member or friend.
Mary completed the documents and forwarded them to the claims department, where the benefit eligibility team, which evaluates claims requests, started its review. Mary initially felt somewhat overwhelmed by the necessary paperwork. She had been told earlier that the claims initiation process typically took 45 to 60 days from start to a decision being rendered. The relatively long time frame is due to medical records requests and reviews.
Mary’s care coordinator suggested she enlist the help of her daughter, who was very involved in her care. Her daughter held Mary’s power of attorney.
Once Mary and her daughter had sent all the required documents, they were able to schedule a visit from a registered nurse to conduct a home benefit eligibility assessment. This visit helps to identify problems a prospective claimant has in performing activities of daily living. LTC Partners also contacted Mary’s health care provider to get her medical records, and to complete a cognitive history for her.
Eventually, Mary was approved as benefit-eligible, and assigned an effective eligibility date. At this time, Mary’s case transferred to a transition team. She was assigned a care coordinator to educate and support her.
Mary’s transition care coordinator called her to advise her about the benefit eligibility approval process and to establish a plan of care. Mary’s care providers needed to be approved by the care coordinator and added to her plan—including the days and hours they would work each week. Invoices submitted to FLTCIP for reimbursement must match the approved plan of care before they are processed.
FLTCIP includes a stay at home benefit that covers care planning visits, home modifications (such as installing wheelchair ramps), emergency medical response systems, durable medical equipment (such as wheelchairs, walkers, or hospital-style beds), and home safety checks. These are covered up to 30 times your daily benefit amount. Caregiver training is also covered at up to seven times your daily benefit amount in your lifetime.
Mary claims were reimbursed without any issues. The transition team typically works with a claimant for two to six months.
Mary successfully graduated from the transition team, meaning she understood how her policy works and was able to submit invoices independently. She then was transferred to a plan of care team. This team of nurses operates as a group, rather than having a one-on-one relationship with Mary. During this time, any questions regarding Mary’s policy, rather than her plan of care, were directed to customer service.
Mary continued to be evaluated periodically through a recertification process that is used to determine that the claimant is still in need of care. Her plan of care team monitored her status and stood ready to help with any alternate plan of care or stay at home benefit requests.
Several months into the claim, the plan of care coordinator began to notice that Mary’s cognitive status seemed to be declining. Mary was informed that the team would reach out more frequently to maintain the proper level of care for her.
Eventually, after an onsite nurse’s review, Mary was diagnosed with dementia. With a durable power of attorney on file, the team began discussing her ongoing care with her daughter.
Mary’s plan of care was updated to include supervision. Her daughter hired a live-in informal caregiver, providing the required documents to FLTCIP. Mary’s case was moved to a specialized expedited review plan of care team, which will monitor and help Mary’s daughter for the rest of the claim. With this team in place, on-site assessments are no longer needed and recertification can be completed based only on medical records. The team makes check-in calls to assess Mary’s status.
As time passes, Mary’s daughter informs her team that Mary now needs a wheelchair and grab bars, and that modifications to her home are required to accommodate the wheelchair. She sends invoices, which are processed and payments are reimbursed. The wheelchair itself is purchased through a durable medical equipment vendor that contracts with Medicare.
For More Information
The Health and Human Services Department has a website with more information about long-term care issues. If you are a caregiver, you can find support and resources at the Family Caregiver Alliance.
Disclosure: Tammy Flanagan is under contract with LTC Partners to provide informational presentations on retirement planning issues.
Photo courtesy Command Care, via Flickr