At Abby Services we have helped many residents in Fort Myers, Cape Coral, and the surrounding area find excellent private duty home health caregivers. One challenge is when a client has a long term care policy. Often these policies were established years ago and clients can be unclear about coverage benefits or requirements of the policy. That is why when a client has a question about their policy, or benefits, they should schedule a complimentary appointment with one of our owners and RN Scott Strachan. Although the meetings can take a while to thoroughly review a LTC policy, and fully explain the its triggers and benefits, it is important to understand the what you are entitled to under a Long Term Care Policy. More important than understanding your Long Term Care Benefits is how to actually access those benefits.
Even when you are armed with accurate information, and thoroughly understand your policy, some insurers have been known to act inappropriately. Here is an article I found with a quick google search:
A class action lawsuit filed by a Florida nurse registry claims that Transamerica Life Insurance Company’s (Transamerica) long-term care insurance policies improperly deny coverage by requiring a level of certification for home health aides that exceeds state requirements, and that Florida law does not allow Transamerica to deny coverage meeting those state requirements.
According to a complaint filed in the District Court for the Southern District of Florida on January 21, 2011, American Nursing Resources Inc. (American Nursing) arranges home health care services for clients, regularly receives insurance-benefit assignments from its clients, and bills insurance companies directly for its services.
American Nursing alleges that its home health aides have provided services to Howard Boteler since October 31, 2009. Mr. Boteler assigned American Nursing his benefits under a long-term care policy issued by a predecessor of Transamerica. American Nursing alleges that when it attempted to collect benefits under the policy, Transamerica denied its claim on the basis that the services were not provided by a “Home Health Aide” as defined in the policy. According to the complaint, the policy provided for reimbursement for the services of a “Home Health Aide” if the aide was: (1) eligible for reimbursement under Medicare; (2) employed by a state-licensed or accredited home health care agency; or (3) employed by a provider of home health care services accredited by the National League of Nursing, American Public Health Association, or the Joint Commission on Accreditation of Hospitals.
American Nursing alleges that, by its definition of “Home Health Aide,” Transamerica effectively requires a nurse registry such as American Nursing to either: arrange for the provision of basic services by nurses or other individuals with a level of certification greater than that of a home health aide; become eligible for reimbursement under Medicare; or be licensed as a “Home Health Care Agency.” American Nursing alleges that this violates Florida statutes governing long-term care insurance, which provide that a long-term care policy cannot: require services to be performed by an individual with a higher level of certification than the services require; require services to be provided by a licensed home health agency when they can be provided by a nurse registry; or require that services be required by by Medicare-certified agencies or providers. See FLA. STAT. ANN. § 627.94071.
The complaint alleges that, “Defendant cannot define ‘Home Health Aide’ and implement its Policy in a manner which violates Florida law by excluding or discriminating against nurse registries as covered home health service providers for basic services. … To do so, violates the Florida Statutes and Rules which by law are incorporated into Defendant’s Policy and give rise to an action for breach of the Policy.”
American Nursing seeks, for itself and on behalf of similarly situated providers, damages for breach of contract and an injunction preventing further denial of benefits on these grounds. American Nursing has defined the class narrowly to include only Florida licensed nurse registries which, from January 1, 2006, through January 21, 2011, were assignees under a Transamerica long-term care policy and had a claim for benefits for home health-care services provided in Florida denied on the basis that the services were not provided by a “Home Health Aide” under the policy. The class is also defined to include any Florida-licensed nurse registries currently named as assignees under such a policy. The case is American Nursing Resources, Inc., v. Transamerica Life Insurance Company, No. 0:11-cv-60146 (S.D. Fla.)
This situation just occurred with a State Farm Long Term Care Insurance Policy a client has. I am helping them to work through the Insuror’s confusion and hopefully State Farm will do the right thing. This is the information I shared with State Farm that was referenced in the article.
The article references Florida Statute 627.94071 which covers insurance contracts and rates:
627.94071 Minimum standards for home health care benefits.—A long-term care insurance policy, certificate, or rider that contains a home health care benefit must meet or exceed the minimum standards specified in this section. The policy, certificate, or rider may not exclude benefits by any of the following means: