Help activating long-term care insurance
April 2, 2018 10:52 AM Subscribe
My mom has a generous long term care insurance policy. It has just been necessary for her to move into assisted living . I am looking for help getting the insurance policy to pay.
I am worried that (because they are an insurance company) they will try not to pay. My mom is cognitively impaired but has good and bad days and with no worries now and she is eating three meals a day so she presents as much more with-it than she did a few months ago when she was in her own house.
Are there people who will help you navigate these systems? An elder care lawyer? A social worker? I tired someone who helps keep a friend's mom from getting kicked out of her nursing home (for selling cigarettes singly and picking fights) but they won't only help with getting insurance to start paying.
My mom lives in Massachusetts.
I am worried that (because they are an insurance company) they will try not to pay. My mom is cognitively impaired but has good and bad days and with no worries now and she is eating three meals a day so she presents as much more with-it than she did a few months ago when she was in her own house.
Are there people who will help you navigate these systems? An elder care lawyer? A social worker? I tired someone who helps keep a friend's mom from getting kicked out of her nursing home (for selling cigarettes singly and picking fights) but they won't only help with getting insurance to start paying.
My mom lives in Massachusetts.
The assisted living facility should have people that can help. It is in their interests to get the insurance company paying ASAP.
posted by COD at 11:20 AM on April 2, 2018 [6 favorites]
posted by COD at 11:20 AM on April 2, 2018 [6 favorites]
You can go to a lawyer if they reject the claim, but to get the claim started and have the best possible chance that the claim is accepted immediately, I would start with the executive director/administrator at your mom's ALF.
When I was an Assisted Living administrator (not in Massachusetts), I regularly signed certifications for my residents stating that they were receiving X Y and Z services that qualified for LTC payment. I also often sent a copy of the care plan to explain what those services were. In the case of cognitive impairment, it's usually much more important to be explicit about the services rendered, because it's not as obvious to the outside observer what kind of help she needs (e.g., if she has diabetes it's easy to understand she will need meals planned for her. If she has dementia, LTC might not immediately accept she needs clothes laid out for her/shower items handed to her as part of her care). As long as I signed and sent in the certification on time, my residents rarely had trouble getting their money. The insurance companies accepted my word and my care plan documentation as proof.
If there is a physical exam required to start reimbursement, you should be there for the exam and/or a trusted representative from the facility should be there, to help explain if it happens on a "good day." I would try to shoot for a time of day when your mom is needing the most help, too--e.g. if she is very independent in the morning, but has sundowning and increased confusion in the afternoon, try to schedule the exam later in the day. Her needs should be assessed based on the highest potential level of care for where she is now.
There will be a very explicit section in her insurance documents that explains what they will pay for and what they will not. Also, there is usually a waiting period for the benefits to kick in, and it is then paid retroactively. It's often either 100 days or 90 days.
posted by assenav at 12:55 PM on April 2, 2018 [3 favorites]
When I was an Assisted Living administrator (not in Massachusetts), I regularly signed certifications for my residents stating that they were receiving X Y and Z services that qualified for LTC payment. I also often sent a copy of the care plan to explain what those services were. In the case of cognitive impairment, it's usually much more important to be explicit about the services rendered, because it's not as obvious to the outside observer what kind of help she needs (e.g., if she has diabetes it's easy to understand she will need meals planned for her. If she has dementia, LTC might not immediately accept she needs clothes laid out for her/shower items handed to her as part of her care). As long as I signed and sent in the certification on time, my residents rarely had trouble getting their money. The insurance companies accepted my word and my care plan documentation as proof.
If there is a physical exam required to start reimbursement, you should be there for the exam and/or a trusted representative from the facility should be there, to help explain if it happens on a "good day." I would try to shoot for a time of day when your mom is needing the most help, too--e.g. if she is very independent in the morning, but has sundowning and increased confusion in the afternoon, try to schedule the exam later in the day. Her needs should be assessed based on the highest potential level of care for where she is now.
There will be a very explicit section in her insurance documents that explains what they will pay for and what they will not. Also, there is usually a waiting period for the benefits to kick in, and it is then paid retroactively. It's often either 100 days or 90 days.
posted by assenav at 12:55 PM on April 2, 2018 [3 favorites]
Hey there! I just went through this. I don't know what policy you have - my parents have CalPers which is like a public/private policy. I was overwhelmed and confused and still am a little, but it turns out to not be as complicated as I feared. In the case of CalPERS, they approve over 90% of claims. Here's my recommendations based on my experience but feel free to message me to talk more.
Step 1a) If possible, do talk to a lawyer but only to get power of attorney to speak on behalf of your mom. This will make things much easier going forward, not just with the insurance but with the many other things you will probably have to help with. This should be a relatively cheap, boilerplate thing.
Step 1b) If possible, get a medical doctor to officially provide a diagnosis so that you have something on paper saying your mom is cognitively impaired. You will also eventually need her to release that info to the insurance company.
Step 1) I would actually start by calling the insurance provider, saying you're interested in opening a claim, and asking for information on what qualifies your mother to make a claim. For us, it was needing help with 3 activities of daily living. They don't count medication management as an ADL. They do count bathing, dressing, or continence issues. They should be able to provide you with a straightforward explanation of what makes your mother qualify to use this insurance she has been paying for.
Step 2) If you think you can make a case that your mother qualifies based on what the insurance company tells you, recruit the facility to assist with your filing, as mentioned by assenav above. The assisted living WANTS your mom's insurance to pay. That makes her more able to afford to stay there. They will help. I clearly communicated to my parents' assisted living what specific activities they had been approved to cover. I thought this would be helpful when they write up their plan of care, which they share with the insurance company. (Note, I have had to remind my higher-functioning dad to please take advantage of the services he is getting at Assisted Living. He may want to bathe without a standby assist, but I remind him to use the services in his plan of care. When he doesn't he has had problems (near falls etc)
Step 3) In our case, a nurse then came to us to assess my parents and approve or deny the claim. In the case of my mom, she has a documented dementia diagnosis. The nurse made a very cursory assessment but basically because she had this on her medical record, she didn't assess very much. The insurance approved her claim for 9 months before the next review. Her condition is incurable so she will be approved permanently. For my dad, his impairment was not as clear, so the nurse did assess and approve him, but his claim will be re-assessed in 3 months to see if he's still needing help with those ADLs mentioned above.
We also have a 3 month deductible. If your mom stayed in a nursing home recently she may have already met some of the deductible period.
Finally, before you try to hire an advocate, try googling the specific insurance company that covers your mom. Do they have a history of unfairly denying claims? As I mentioned, our company approves most. They were in the news for massively jacking up their premiums, but they do pay out. So perhaps your fears are unfounded.
I know this is all super overwhelming. Again, feel free to reach out with more specific questions.
posted by latkes at 7:17 PM on April 2, 2018 [1 favorite]
Step 1a) If possible, do talk to a lawyer but only to get power of attorney to speak on behalf of your mom. This will make things much easier going forward, not just with the insurance but with the many other things you will probably have to help with. This should be a relatively cheap, boilerplate thing.
Step 1b) If possible, get a medical doctor to officially provide a diagnosis so that you have something on paper saying your mom is cognitively impaired. You will also eventually need her to release that info to the insurance company.
Step 1) I would actually start by calling the insurance provider, saying you're interested in opening a claim, and asking for information on what qualifies your mother to make a claim. For us, it was needing help with 3 activities of daily living. They don't count medication management as an ADL. They do count bathing, dressing, or continence issues. They should be able to provide you with a straightforward explanation of what makes your mother qualify to use this insurance she has been paying for.
Step 2) If you think you can make a case that your mother qualifies based on what the insurance company tells you, recruit the facility to assist with your filing, as mentioned by assenav above. The assisted living WANTS your mom's insurance to pay. That makes her more able to afford to stay there. They will help. I clearly communicated to my parents' assisted living what specific activities they had been approved to cover. I thought this would be helpful when they write up their plan of care, which they share with the insurance company. (Note, I have had to remind my higher-functioning dad to please take advantage of the services he is getting at Assisted Living. He may want to bathe without a standby assist, but I remind him to use the services in his plan of care. When he doesn't he has had problems (near falls etc)
Step 3) In our case, a nurse then came to us to assess my parents and approve or deny the claim. In the case of my mom, she has a documented dementia diagnosis. The nurse made a very cursory assessment but basically because she had this on her medical record, she didn't assess very much. The insurance approved her claim for 9 months before the next review. Her condition is incurable so she will be approved permanently. For my dad, his impairment was not as clear, so the nurse did assess and approve him, but his claim will be re-assessed in 3 months to see if he's still needing help with those ADLs mentioned above.
We also have a 3 month deductible. If your mom stayed in a nursing home recently she may have already met some of the deductible period.
Finally, before you try to hire an advocate, try googling the specific insurance company that covers your mom. Do they have a history of unfairly denying claims? As I mentioned, our company approves most. They were in the news for massively jacking up their premiums, but they do pay out. So perhaps your fears are unfounded.
I know this is all super overwhelming. Again, feel free to reach out with more specific questions.
posted by latkes at 7:17 PM on April 2, 2018 [1 favorite]
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1-888-AG-ELDER
(1-888-243-5337)
TTY: (617) 727-4765
Monday through Friday, from 9:00 a.m. to 5:00 p.m
They'll have info on any caseworker eligibility, the pro bono legal services available to people over 60, etc. But they might not be able to provide active resources until insurance actually rejects the claim. Might be a good idea to contact the insurance directly, if only to gather further information, first.
posted by Iris Gambol at 11:03 AM on April 2, 2018 [1 favorite]