Ryan Insurance Strategy Consultants
Welcomes You To Our Long Term Care Insurance Education Site
The Following Information Is Intended For Educational Purposes Only
What is Long Term Care?
Long Term Care is the assistance individuals need when they are unable to care for themselves and need help with Activities of Daily Living (ADLs) – bathing, dressing, transferring, toileting, continence (control of bodily functions), and eating – or they have severe cognitive impairment such as Alzheimer’s disease. The need for long term care can result from an accident, chronic illness or short-term disability, or from advance age. Long term care can include a broad range of services, provided in any setting outside a hospital. It might be help with simple daily tasks like bathing or dressing. It might include skilled care in your own home, an assisted living facility, some other community resources, or a nursing facility.
Who Needs Long Term Care?
About 70% of people age 65 and over will need some type of long-term care services sometime during their lifetimes, says the U.S.
Department of Health and Human Services. (AHIP, “A Guide to Long Term Care Insurance“, © Revised edition, 2003, 2004, 2012, 2013 America’s Health Insurance Plans, Washington, D.C)
By 2020, 12 million older Americans will need long term health care. (AHIP, “A Guide to Long Term Care Insurance“, © Revised edition, 2003, 2004, 2012, 2013 America’s Health Insurance Plans, Washington, D.C)
Family and friends are the sole caregivers for 70% of elderly people and most will be cared for at home. (AHIP, “A Guide to Long Term Care Insurance“, © Revised edition, 2003, 2004, 2012, 2013 America’s Health Insurance Plans, Washington, D.C)
People age 65 or older face at least a 40% lifetime risk of entering a nursing home. 10% will stay more than five years. (AHIP, “A Guide to Long Term Care Insurance“, © Revised edition, 2003, 2004, 2012, 2013 America’s Health Insurance Plans, Washington, D.C)
22% of people over age 85 are in a nursing home. (AHIP, “A Guide to Long Term Care Insurance“, © Revised edition, 2003, 2004, 2012, 2013 America’s Health Insurance Plans, Washington, D.C)
Women, because they outlive men, face a 50% greater likelihood of entering a nursing home after age 65. (AHIP, “A Guide to Long Term Care Insurance“, © Revised edition, 2003, 2004, 2012, 2013 America’s Health Insurance Plans, Washington, D.C)
Some Misconceptions about Medicaid and Medicare
Medicaid pays for health services for the very poor of any age. Qualifications for Medicaid vary by state. Being eligible for Medicaid does not guarantee placement in a nursing home. There may be long waiting lists for facility care. Depending on the state and facility, Medicaid patients often receive lesser-quality care than patients who are paying on their own. Under Medicaid, nursing home care is essentially the only option. Home care, assisted living facility care, adult daycare, outpatient services, and alternate caregiver services are not usually reimbursed under Medicaid.
Medicare pays for health care for people 65 and over and for those who are disabled. Medicare does not pay for long term medical service such as assisted living or adult day care. Medicare pays only the first 100 days of skilled care, such as physical therapy or nursing, which only accounts for 5% of all long term care costs. You are eligible for the care only if you have been in the hospital for at least three days. The personal care must relate to the treatment of an illness or injury.
Exceptions, Limitations, and Exclusions
Most long term care insurance policies will not pay benefits for any confinement, care, treatment, or service(s):
- That results from attempted suicide or intentionally self-inflicted injury;
- That results from voluntary participation in a felony, attempted felony, or illegal occupation;
- That results from a sickness or injury for which benefits are provided under any state or federal worker’s compensation law;
- Provided outside the United States or Canada;
- Provided in a government facility (unless otherwise required by law);
- Provided for the treatment of alcoholism or drug addiction, or in facilities operated primarily for such treatment;
- Provided in facilities operated primarily for the treatment of mental or nervous disorders or disease, other than Alzheimer’s disease or dementia.
You could be declined coverage if you already have the following condition(s):
- Alzheimer’s Disease;
- Severe Arthritis with functional limitations;
- Diabetes which is not under control;
- Cancer within the past 6 months;
- Parkinson’s Disease;
- Stroke within the past 6 months;
- A Stroke at any time, which has caused functional limitations;
- Congestive Heart Failure within the past 6 months;
- Emphysema, if severe or still smoking;
- Chronic Obstructive Pulmonary Disease, if severe or still smoking
- Any conditions which require the assistance of another human being for the basic activities of daily living: bathing, eating, toileting, or transferring in and out of a bed or chair.
Understanding Long Term Care
Many people do not know about or understand all the long-term care options that are available. The following are brief descriptions of the major types of long-term care, the kinds of service you may need, the ways of paying for long-term care and how to find the best services and facilities:
Home care can be given in your own home by family members, friends, volunteers, and/or paid professionals. This type of care can range from help with shopping to nursing care. Another type of care that can be given at home is hospice care for terminally ill people.
Community services are support services that can include adult day care, meal programs, senior centers, transportation, and other services. These programs can help people who are cared for at home by their families. For example, adult day care services provide a variety of health, social, and related support services in a protective setting during the day. This can help adults with impairments (such as Alzheimer’s disease) continue to live in the community. And it can give family or friend caregivers a needed “break.”
Supportive housing programs offer low-cost housing to older people with low to moderate incomes. The Federal Department of Housing and Urban Development (HUD) and State or local governments often develop such housing programs. A number of these facilities offer help with meals and tasks such as housekeeping, shopping, and laundry. Residents generally live in their own apartments.
Assisted living provides 24-hour supervision, assistance, meals, and health care services in a home-like setting. Services include help with eating, bathing, dressing, toileting, taking medicine, transportation, laundry, and housekeeping. Social and recreational activities also are provided.
Continuing care retirement communities (CCRCs) provide a full range of services and care based on what each resident’s needs over time. Care usually is provided in one of three main stages: independent living, assisted living, and skilled nursing.
Nursing homes offer care to people who cannot be cared for at home or in the community. They provide skilled nursing care, rehabilitation services, meals, activities, help with daily living, and supervision. Many nursing homes also offer temporary or periodic care. This can be instead of hospital care, after hospital care, or to give family or friend caregivers some time off (“respite care”).
Intermediate Care Facilities for the Mentally Retarded: This is another type of long-term care for the mentally retarded that takes place in home-like settings. They provide a wide variety of services to mentally retarded and developmentally disabled people from youth to old age. Services include treatment to help residents become as independent as possible, as well as health care services.
Learn More: You can learn about long-term care options in your area by contacting:
- The Eldercare Locator (1-800-677-1116, weekdays, 9.00 a.m. to 8.00 p.m., EST). This service can refer you to your Area Agency on Aging.
- Area Agencies on Aging provide information on a wide variety of community-based services. Examples are meals, home care, adult day care, transportation, housing, home repair, and legal services.
- Your State or local Long-Term Care Ombudsman (call the Eldercare Locator,1-800-677-1116, weekdays, 9.00 a.m. to 8.00 p.m. for the number). Ombudsmen visit nursing homes and other long-term care facilities to check on and resolve complaints, protect residents’ rights, and give emotional support to lonely older people. A call to your area Ombudsman can give you information on the most recent State survey (inspection) report of the facility; the number of outstanding complaints; the number and nature of complaints lodged in the last year; and the results of recent complaint investigations.
- “Nursing Home Compare Web Site” http://www.medicare.gov/Nursing/Overview.asp – a Web site created by the Health Care Financing Administration, which runs Medicare and Medicaid. This site helps you locate nursing homes in your area. It also has inspection records for nursing homes that receive Medicare or Medicaid funds. If you can not access the link above, call Medicare Hotline at 1-800-638-6833 to obtain the information you need.
- Hospital discharge planners.
- Social workers (some can be “case managers” or “care managers,” who can help you coordinate long-term care services).
- Doctors and other healthcare professionals.
- Local nursing facilities.
- Volunteer groups that work with older people.
- Clergy or religious groups.
- Family and friends.
What Kind of Services Do I Need?
The first question to ask yourself when trying to decide what type of services are needed for you or for your loved ones is “what kind of services do I need?”. To help find out what kind of services you or a loved one need, check the items below that apply. Keep in mind that these needs may change over time.
Help With Daily Activities
[_] Preparing meals
[_] Laundry and other housework
[_] Home maintenance
[_] Paying bills and other money matters
[_] Going to the bathroom
[_] Remembering to take medicines
[_] Other _______________________
[_] Other _______________________
Health Care Needs (as recommended by a doctor or other health care provider)
[_] Physical therapy
[_] Speech therapy
[_] Occupational therapy
[_] Medical nutritional therapy
[_] Care for pressure ulcers or other wounds
[_] Alzheimer’s disease care
[_] Health monitoring (for diabetes, for example)
[_] Pain management
[_] Nursing care services
[_] Other medical services provided by a doctor or other clinician
[_] Other _______________________
How Will I Pay for these Services?
The second question to ask yourself is “How will I pay for these Services?” Long-term care can be very expensive. In general, health plans and programs do not routinely cover long-term care at home or in nursing homes. Here is some general information about long-term care coverage:
- Medicare is the Federal health insurance program for people age 65 and older and for some disabled younger people. Medicare generally does not pay for long-term help with daily activities. Medicare pays for very limited skilled nursing home care after a hospital stay. If you need skilled care in your home for the treatment of an illness or injury, and you meet certain conditions, Medicare will pay for some of the costs of nursing care, home health aide services, and different types of therapy.
- Medicaid is a Federal-State program that pays for health services and long-term care for low- income people of any age. The exact rules for who is covered vary by State. Medicaid covers nursing home care for people who are eligible. In some States, Medicaid also pays for some home and community services.
- Private Insurance. If you need long-term care now, it is probably too late to be purchasing long-term care insurance.About 70% of people age 65 and over will need some type of long-term care during their lifetimes. (Source: America’s Health Insurance Plans (AHIP), “A Guide to Long-Term Care Insurance”, 2013, page 3). So, if it is not too late, you should be seriously considering long-term care insurance. Insurance companies are becoming more and more aware of the growing need for long-term care. Most insurance companies today offer long-term care insurance policies. These policies may cover services such as care at home, in adult day care, in assisted living facilities, and in nursing homes. But plans vary widely. If you have such a policy, ask your insurer what it covers. If you think you may need long-term care insurance, start shopping while you are relatively young and healthy, and shop carefully.
- Personal Resources. You may need to use resources such as savings or life insurance to pay for long-term care. Most people who enter nursing homes begin by paying out of their own pockets. As their personal resources are spent, many people who stay in nursing homes for a long time eventually become eligible for Medicaid.
Other Resources to Find Help. Your State Health Insurance Program (SHIP) can give you general information about Medicare, Medicaid, managed care plans, and the types of health insurance that can supplement Medicare, including Medigap and long-term care insurance. Counselors also can help you with questions about your medical bills, insurance claims, and related matters. These services are free. To find the phone number of the SHIP office in your State, call the Medicare Hotline at 1-800-638-6833. Or, look at the consumer Web site for Medicare services, http://www.medicare.gov.
|Relative Costs Comparison|
|Nursing||Help with daily activities||Help with health care needs||Relative Costs|
|Home Care||X||X||Low to High|
|Community Services||X||Low to Medium|
|Supportive Housing Programs||X||Low to Medium|
|Assisted Living||X||Medium to High|
|Continuing Care Communities|
How Can I Choose the Best Quality Services and Facilities?
The third question to ask yourself is ” How do I find and choose the Best Quality Services and Facilities?” Here are some tips for choosing the kinds of long-term care people most often use: home care (including home health care) and nursing homes.
- In many States, home care agencies must be licensed. Check with your State health department to see if your State requires it. If so, be wary if an agency is not licensed.
- Ask if the agency is certified by Medicare. Medicare inspects home health care agencies to assure they meet certain Federal health and safety requirements. Medicare will pay for services only if the agency is Medicare-approved and if the services are covered by Medicare.
- If the home health care agency is certified by Medicare, you can review its survey report. Call the Medicare Hotline at 1-800-638-6833 and ask to be referred to the Home Health Hotline for your State. You can request a copy of the report from that hotline.
- Find out if the agency has been accredited (awarded a “seal of approval”) by a group such as the Joint Commission on Accreditation of Healthcare Organizations (630-792-5800); http://www.jcaho.org) or the Community Health Accreditation Program (1-800-669-9656; http://www.chapinc.org).
- Contact your State or local consumer affairs office to see if any complaints have been filed against a home care agency. Also, ask about the outcome of any complaint investigations.
- Whether you work with an agency or hire someone yourself, carefully check the backgrounds of the people who will be coming into your home. Ask for references who have worked with the agency or person. Call them, and ask about their experiences. Would they use the agency or person again?
- Does the home care worker have the necessary skills and training for your needs? Ask to see training certificates. Make sure the worker knows how to safely assist and care for patients.
- Does the agency have supervisors who check on the quality of care its workers provide?
- How does the agency follow up on and resolve complaints?
Nursing Home Care
- All nursing homes that participate in Medicare or Medicaid are visited about once a year by a team of trained inspectors. They check the home and the care provided and prepare a survey report. You have a right to review the report, which must be posted in the nursing home. Speak to the nursing home administrator to learn more about any problems that appear on the report. Ask if the problems have been corrected.
- Call your State or local long-term care Ombudsman. Ombudsmen visit nursing homes on a regular basis and know about each nursing home in their area. You can ask about the latest survey report and about complaints that have been filed. You can also ask what to look for when visiting local nursing homes.
- Compare the inspection records of your top choices by visiting the “Nursing Home Compare” Web site: http://www.medicare.gov/NHCompare/Home.asp. If you can not access the link above, call Medicare Hotline at 1-800-638-6833 to obtain the information you need.
- Some nursing homes have been accredited by a national group such as the Joint Commission on Accreditation of Healthcare Organizations (630-792-5800). It may be helpful to find out if the home participates in the voluntary process and to learn the results.
Long Term Insurance Links
Complete Guide to Long Term Care Insurance
By the Health Insurance Association of America – HIAA
The official government site for Medicare information.
Nursing Home Information
All you need to know about nursing homes and where to find them.
National Hospice and Palliative Care
National Hospice and Palliative Care organization site. At home care with the support of family, friends, and caring professionals.
Retirement Living Magazine
Guide to retirement living online magazine.
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