Common Questions About Long-Term Care Insurance and Claims Disputes [Part I]

Many people are unsure about whether they need long-term care coverage.  These assumptions often are based on an individual being relatively young and healthy.  Although this might seem like a reasonable position, an unanticipated accident can occur at any time or place.  Once an individual actually finds he or she needs long-term care coverage, it is often too late to purchase coverage for living assistance and ongoing medical care.  Some might presume they can rely on Medicare or other programs rather than a long-term care policy.  Part I of this multi-installment blog examines some of the differences in coverage under Medicare, which is a health insurance program for seniors age 65 or over and long-term care policies.

There are three fundamental variations of long-term care, including custodial care, intermediate care, and skilled care.  The extent to which private long-term care policies and Medicare cover these different types of supportive medical services are outlined below.

Custodial Care

This form of care refers to the provision of services to assist in daily care activities, such as eating, cooking, dressing, and bathing.  This form of care does not require a doctor’s order and can be furnished by an individual without professional medical training.  This type of care can be delivered either in a residential facility or in an individual’s home.  Medicare insurance does not provides this form of long-term care.  Medigap coverage is a special form of supplemental health insurance provided by private insurance companies that fill in certain Medicare gaps in accordance with federal guidelines.  However, Medigap coverage also does not provide this type of care. 

By contrast, long-term care insurance provides coverage for personal care.  Depending on the policy, the coverage might extend to meal preparation, light cleaning of a home, laundry services and other types of daily living assistance.  When an individual seeks to purchase a long-term care policy, this form of care will typically be offered.

Intermediate Care

Intermediate care is periodic care that is only required on an intermittent basis whether daily or a couple times per week.  This form of care is provided by skilled providers with medical training under the supervision of a physician.  While Medicare will cover certain types of this form of coverage, it will only be available under specific circumstances.  While a LTC policy will cover physical therapy, skilled nursing care, and speech therapy on an in-home basis, these services will only be available if the policyholder is homebound, and these services are ordered by a physician.  While Medigap coverage will pay for in-home intermediate services, most policies providing this type of coverage only offer an additional $40 for in-home visits to provide this type of care.

Long-term care policies offer more extensive coverage of intermediate services both in-home and in skilled nursing facilities.  Coverage in both locations can be purchased together or in either one of these situations.  Intermediate care often will be available in other settings under a LTC policy, such as adult day-care centers, retirement communities, and assisted living facilities.

Skilled Care

This is the most intensive forms of care which involves 24/7 availability of attention from a skilled medical services provider like a professional therapist or a registered nurse.  This form of supportive care is based on orders from a physician, and it is provided by a skilled health care worker under a treatment plan developed and overseen by a doctor.  Medicare will provide a hundred percent coverage during the first twenty days of each coverage period (i.e., each year) in a skilled nursing facility under the following conditions:

  • The date you enter a skilled nursing facility must be within thirty days of a period of hospitalization.
  • The skilled care must occur within a certified facility.
  • Entrance into a skilled nursing facility must be based on a medical illness or injury for which the individual spent at least three days in a row in the hospital.  A daily co-payment is required for the 21st to 100th day, which was $141.60 per day as of 2011.  Medicare offers no coverage beyond the 100th day.

Medigap coverage can be purchased which will cover the co-payments under Medicare from the 21st to the 100th day.

LTC policies will provide a certain amount of coverage for a designated period for certain types of care in skilled nursing facilities and other settings.  Because only LTC policies cover nursing homes beyond a hundred days, this type of policy can provide a vital form of financial protection if you must spend time in this type of facility.

Our Miami long-term care insurance law firm invites you to contact us if you are having difficulties with your insurance company.  Florida insurance claims lawyer J.P. Gonzalez-Sirgo handles claims against insurance companies in Miami and throughout Florida. The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations.  No Recovery, No Lawyer Fees.  Call 305-461-1095 or Toll Free 1-866-71-CLAIM.

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