I'm trying to get my mom's LTC policy to cover in home care. Why is this so hard?

Call you state's insurance division. they can help you sort out the insurance problem.

My family learned about all this after my mom (with mild dementia) had a stroke and fell down a flight of stairs. She has permanent brain damage and moderate dementia now. Her coverage boiled down to how many ADL's (Activities for Daily Living) she could perform on her own without "Substantial Assistance". When she was unable to perform 2 of those, she became eligible. The policy also defined what "substantial assistance" means.

There is a difference between ADLs and IADLs .

There are 2 sections of the policy that determine if the co. will pay:" Eligibility for payment of benefits" and "Covered Services". Mom's policy defines who qualifies as a caregiver (nurse, cna, etc.) and it cannot be a family member.

If your mom's policy isn't clear, ask for written detailed criteria for those sections. Also, ask for a written explanation of denial. Not just that she was denied, but what criteria did she fail to satisfy.

Good luck. Dealing with insurance companies is so stressful on top of the illness itself.

I agree, It is so stressful of top of the illness itself! It took NINE months for my mom's ltc to finally start paying, thankfully retroactive! We had three doctors certifying her cognitive decline yet the ltc ignored the proof UNTIL I got our state's insurance commissioner involved. It was wonderful having him get involved and finally a listening ear. The reason it worked with the state's insurance commissioner is the fact that a ltc cannot be in business in our state unless they abide by the state's laws. When the Commissioner made a few contacts to the ltc directly, the threat of their ability to do business in our state finally made them comply with the written policy which follows specifically your state's laws or they would not have been able to do business in your state. Look up your state's law if you want specifics on how the policy allows your mom to qualify. Those laws are usually easily found on the web for your state. FYI, don't be afraid of seeking the help of your state's insurance commissioner as that is their job but please do your homework first in gaining some understanding of the way the policy is written and the way the laws are written so you can provide the info of your specifics the commissioner will need.

Hello Again,
My post wasn't clear because a link I included that defines the difference between ADLs (Activities for Daily Living) and IADL's(Instrumental Activities for Daily Living) was deleted. If you google these terms, you will see the difference. My mom's policy only covers deficiency in ADL's. It's very specific.

For the short term, you (or mom) may have to pay for a few hours of aide help until your mom progresses to a more advanced level of care. The LTC policy has a time limit also. My mother's only lasts for 3 years of payouts.

My mother's LTC policy required a diagnosis from a neurologist to activate it. Her policy is one of the better ones in that dementia trumps the requirement of failing 2 out of 6 ADL's. Her policy will cover facility care (snh or assisted living), home care, adult day care, respite care. The premiums are continued until the person enters a facility. Once activated for facility care, it pays for 4 years and it covers 100% up to a certain $$ amount per month. This policy has an inflation rate of 5% a year, meaning that when mom took the policy out, it covered a certain $$ amount that increased 5% each year she paid into it. I hope you have DPOA so you can make financial/medical decisions for your mother. I agree that you need get a copy of the policy and read it. Make an appt. with the insurance agent to discuss it in detail so you understand what it pays and how it works. If they refuse to talk with you then contact your states insurance commission for help. Good luck to you!

Long Term Care is expensive for the insurance company to pay the benefits for. In the case of my mom the insurance company kept denying it even though her three ADLs were certified by the doctor. They (said) that a survey was to her house for her to complete and mail back. I told them she had dementia and couldn't complete that kind of a task. The survey was lost and our process was at a standstill. I called the State's insurance commissioner, told him the story, and his exact words were, "Let's get them." When I told the insurance company what I had done and who the contact person in the commission was it took a matter of a week for the retroactive checks and current payments to start coming in.
Call your state insurance commissioner, get his name, and use it in your next conversation with the insurance company. I predict they will pick up the pace.
Every month they can postpone payment means one less month of benefits.

I am a daughter living with and taking care of my mother who has moderate dementia. I am not able to get a full time job because she needs some watching. I know she could not live alone as she is a risk in everything she does. At the moment she has no long term policy to worry about. I have been through trying to secure the Medi-Cal benefits and have been turned down cause the services she needs are not considered 24-hr. So I have been reluctant to even try to put a long term care policy in place. Question is, should I?

Ahh, Insurance company's are hard to pay out. I worked for NYLife and I worked for a home care agency before I started up my own business (unrelated to both). Continual care does often mean 24 hour care in this business though. You're better off finding someone like a college student from craiglist who can help for a little bit of money. Or switch agencies. Some agencies do work with certain insurance companies better. A Family Member HomeCare is well known for working well with insurance companies. Not sure where you are but I think smaller agencies anywhere actually do a better job getting a pay out and offer better quality service than larger agencies.

daughter52~I am sorry to say that I do not think your mother would be accepted because of the dementia. There can be no pre existing conditions when you get a long term health care policy. I applied for a LTC policy and am waiting to hear if I am accepted. My agent said they will call me for a phone interview, may request my medical records. She also said that 50% of the people who apply are turned down. If you are thinking of getting one for yourself, choose a reputable company. Look for a policy that is similar to what I posted above regarding my mother's. Dementia should trump the requirement for ADL's (activities for daily living). A 5% inflation rate a year, covers snh, assisted living, adult day care, respite time, and home health care. Requires a neurologist to diagnose either cognitive impairment or failure of the ADL's. Requires their own nurse to visit and evaluate the care needs of the impaired person, accepted at all licensed and accredited facilities. My mother's will pay for 4 years in a facility, mine...if accepted will pay for 3 years and covers everything above. My brother has one with everything listed above but his premiums are low because he is a government employee. If you or your husband works the the government, talk with HR about a policy.

Middledaughter-There are generally tests done to determine claim eligibility. Can your mother draw a clockface of 3 pm? A simple house/pentagon shape? Her doctor can perform a mini mental and document results. The 1996 federal HIPAA law standardized LTC policy triggers to "severe cognitive impairment" and inability to do 2 ADL's like bathing and dressing w/o standby or hands on help for at least 90 days. Virtually any policy post 1996 will have these triggers. Some policies before then had no timeline and allowed the MD to say it was "medically necessary" to have help, too.
Daughter52-Unfortunately, insurance is only available to buy when you do not already need it. The only thing that might help now is an annuity based on failing health and possibly shorter than normal lifespan. This will make sense only if she has enough money that $50,000 to $100,000 is available with leftover assets to protect. Some use a reverse mortgage for additional income, but the continuous RM gives little. The above mentioned annuity can be bought w/ an RM cash-out and the income will follow her to assisted living, unlike the traditional RM that ceases when you leave home.

I would ask the office of aging in your county for either a social worker or independent insurance agents name. Then ask them to review the LTC policy.
I would ask the insurance carrier for another copy of the LTC policy and any riders which have been added since your mother bought the policy.

There usually is a certain number of "visits" which the policy will pay for a person. If she only needs limited hours a couple of days, it might be worth "saving" the days for when you need someone there more hours each day.

Good luck. The LTC policies aren't perfect but they can be helpful in making it possible for an elder to remain in their home.
Elizabeth

Yes. Long-term care states exactly what long term care means on the policy. It is in a facility with 24/7 hours of skilled nursing care. Day care is paid by the individual out-of-pocket unless there is a rider on her long-term care policy. We all need to expect to pay out-of-pocket for our care since we are not socialistic.

Just an add-on to ferris1's post ... all LTC insurance policies are different and specific as to what they "mean" and what they "cover." My Dad's policy will pay toward in-home care as well as skilled nursing home care in a facility, but like most LTI policies that will pay toward in-home care, the in-home care payments are a percentage of what they will pay for facility care (because the costs are supposed to be lower). For example, I think my Dad's policy will pay 50% of the daily payment rate if he's getting home care (I think the daily pay rate on his policy is up to $150 a day).

Some of the older policies wouldn't pay at all toward the cost of "home care." Some will pay for care provided by family members; some will not. My husband and I have purchased policies that WILL pay if care is provided by a family member, but because we are both probably (with luck!) 20 years away from needing such care, we won't know until then whether the policy actually pays as promised, or even if the company will still be in business by then.

LTC insurance is expensive, but can be a financial live-saver when it comes to dementia. If you don't get dementia, statistically, you're unlikely to get out of an LTC policy what you've paid into it. If you do get dementia, it's likely the insurance company will have lost the "gamble." The companies are notorious for dragging their feet on actually paying, so you either have to advocate on behalf of the patient, or hope that you have someone who will advocate on your behalf.

And yes, it's impossible to get LTC insurance if you already need it. My Dad's policy is modest, because my parents bought it assuming neither of them would need more than 2 years of skilled nursing care at the end of their lives (this is the national average). So it taps out at a couple hundred thousand. With a progressive dementia, this wouldn't pay for more than a couple of years of facility "memory care."

I tried to get my Dad a secondary LTI policy before his dementia diagnosis, but if the applicant is over a certain age, they will do an in-person interview. It is impossible for someone with any short-term memory deficiencies to fake their way through this interview (which includes delayed memory recall questions). The company declined to offer my Dad additional insurance based on his "poor score on delayed memory recall questions" and also on the fact that he had had a knee replacement (insurance companies are also very concerned about mobility issues, as these have a big impact on a person's long-term ability to perform ADLs).

If you have a family history of dementia, I recommend looking into LTC insurance well before you need it.

Thank you PaulaK and others here for your helpful insight. I guess I really knew the answer already. I will have to plug through with home care (me) for as long as I can and then work with medicare and her secondary insurance when the more serious times come. Not looking forward to it. Knock on wood, my family does not have a history per se of dementia. My mother's was due to a stroke. That doesn't mean to say that it can't happen. Good information here