Although each Long Term Care Insurance Policy can be different most use common language and definitions. It is important for the policyholder to be familiar with these terms to help ensure their policy remains active and pays what it is worth. There is a lot to consider when reviewing your Long Term Care Insurance Policy. This is why we recommend having someone familiar with Long Term Care insurance Policies review yours. It is absolutely free to have Scott Strachan, one of our owners and an RN, review your policy for free.
Max Daily, Max Weekly, and Max Lifetime Benefit:
These outline what your policy pays on a daily/weekly/ and lifetime basis. While relatively straightforward it is important to know the details of these. For example, if your policy pays for 365 days. That may be defined as 1 calendar year from when care started, or it may be 365 days of care. That is a big deal when you are only requiring just a few days of care per week.
Another example is if your policy pays a maximum of $100.00 per day. If the policy is time limited and you only use $50 of service for a day you may be leaving money on the table that you are entitled to.
Some policies have what is called a “Restoration of Benefits”. With a restoration of benefits, you may use some or all of your available benefits. However, if you do not use or require benefits for a period of (usually 180 days) then your policy restores or resets to its original limits.
Elimination Periods are often compared to the deductible on Car Insurance. When involved in an Auto Accident you are responsible for paying for a portion of repairs through your deductible. With an Elimination Period, you are responsible for paying for care while your elimination period is met.
It is important to know how long your elimination period is, and how your Insurance Company measures the time of your elimination period. Many policies have elimination periods of 0, 30, 60, or 90 days. Some policies allow the elimination period to include time spent in a rehab facility. Others allow an elimination period to accumulate over an extended period. The most restrictive policies require the elimination period days to be within a certain time frame. For example, 90 days within a 180 day period. This requires a client to have care close to 4 days of care /week which many don’t need or want.
Some policies recognize days of service based on a week. If you have 3 days of care it could potentially count as a full week or 7 days, thus more quickly meeting your elimination period.
Some policies will waive an elimination period when you work with a case manager assigned by them to ensure you genuinely need care on an ongoing basis.
ADL’s or Activities Of Daily Living:
Policies will require a trigger for them to be active, in most cases it is the requirement of a certain level of support with a certain number of ADL’s (Some policies also include a Cognitive Impairment Provision). Your policy will define what they recognize as an ADL. They will also define the level of support required.
The most common ADL’s are:
Bathing, Dressing, Eating, Toileting, Continence, and Ambulation.
Most policies require assistance in 2 out of 5 ADL’s to be in effect. Policies may go a step further and define the level of assistance required with each ADL. These levels of assistance are defined as:
Hands On or Active Assistance: What this means is that an individual needs physical assistance each (and often) every time. This is more difficult to qualify for because if you don’t have care every day you must be prepared to answer how those tasks are done. For example, if someone lives independently and states they require hands-on assistance with ambulation, and they only receive care 3x/week. Their Insurance company may want to know what they do when a caregiver is not there if they are dependent on help for that ADL.
Standby or Passive Assistance: Standby or Passive assistance typically means that an individual may be able to complete tasks, but they require monitoring, prompting, or some help, but not necessarily all of the time. This allows a caregiver and policyholder the ability to be as independent as possible but receives help when necessary. It is also much easier to qualify for when accessing insurance benefits.
Should you have any questions do not hesitate to contact Abby Services. We are happy to review your policy for free and help make sure you have access to the In-Home Caregivers you need and maximize what you receive from your policy.