LTC Caregiver/Provider Eligibility
NOTE that the concern over provider eligibility is a non-issue in "CASH BENEFIT" or "CASH INDEMNITY" LTC policies as these less-common types of coverage pay the full benefit each month, in cash, no matter who takes care of you, where, or how often. You and your own health care advisors determine how to spend your policy's benefits. A Cash Indemnity policy can pay for care by a spouse, adult child, or any other "informal" caregiver you choose who is appropriate for your PLAN OF CARE.
Most LTC policies are "REIMBURSEMENT" style; they pay back actual, paid and covered expenses up to the policy's daily or monthly maximum benefits amount. Therefore the policy's coverage and provider definitions are critical to understand before you start receiving and paying for services.
Most LTC policies are "REIMBURSEMENT" style; they pay back actual, paid and covered expenses up to the policy's daily or monthly maximum benefits amount. Therefore the policy's coverage and provider definitions are critical to understand before you start receiving and paying for services.
Facility Care
Unless a policy is "home care only", then every policy will cover care in a NURSING HOME (also called a SKILLED NURSING FACILITY). Nursing Homes are highly regulated by both the state and federal governments as they are licensed, equipped, and staffed to provide both high levels of custodial care, but also skilled care that may be billable to Medicare or Medicaid.
Most policies issued since the mid-1990s also cover ASSISTED LIVING FACILITIES, but be very careful if the SCHEDULE OF BENEFITS only says "NURSING HOME". There are nursing home-only policies that do not have assisted living provisions; there are also "comprehensive" policies that cover a nursing home or home care, but they also have no clear assisted living benefit.
Some companies deny coverage for assisted living if it does not specifically name it, refusing to consider assisted living as a type of "nursing home". A few companies have chosen to allow this as a general principle, but others do not. This has been an area of considerable legal challenges over the last few years. The key issue is how a facility or nursing home is explicitly defined by the policy.
Assisted Living should be noted as a covered service on the SCHEDULE OF BENEFITS. The policy's schedule may only refer generally to "Facility" benefits, and you then need to look deep into the policy's definitions to see what it means by a covered "facility".
Unless a policy is "home care only", then every policy will cover care in a NURSING HOME (also called a SKILLED NURSING FACILITY). Nursing Homes are highly regulated by both the state and federal governments as they are licensed, equipped, and staffed to provide both high levels of custodial care, but also skilled care that may be billable to Medicare or Medicaid.
Most policies issued since the mid-1990s also cover ASSISTED LIVING FACILITIES, but be very careful if the SCHEDULE OF BENEFITS only says "NURSING HOME". There are nursing home-only policies that do not have assisted living provisions; there are also "comprehensive" policies that cover a nursing home or home care, but they also have no clear assisted living benefit.
Some companies deny coverage for assisted living if it does not specifically name it, refusing to consider assisted living as a type of "nursing home". A few companies have chosen to allow this as a general principle, but others do not. This has been an area of considerable legal challenges over the last few years. The key issue is how a facility or nursing home is explicitly defined by the policy.
Assisted Living should be noted as a covered service on the SCHEDULE OF BENEFITS. The policy's schedule may only refer generally to "Facility" benefits, and you then need to look deep into the policy's definitions to see what it means by a covered "facility".
CLAIM TIP: If you have an older policy that does not explicitly cover Assisted Living, look closely at the definition of a "Nursing Home", in some cases an ALF may meet the policy's definition. If not, see if the policy includes "Alternative Plan of Care" language that requires the insurance company to negotiate in good faith to cover alternate facilities that are not directly covered. (These alternatives are typically only approved if it can be shown that they would cost less than a covered facility.)
"HOME CARE"
In most policies HOME CARE (or HOME HEALTH CARE) is an all-encompassing term. It is care provided by an agency or individual (if allowed by the policy) and includes services provided by a nurse, home health aide, nutritionist, or occupational, speech, respiratory, or physical therapist. It does not cover services provided by members of your family, or only "companion" care.
HOME CARE also includes custodial care services which may also be referred to as non-medical home care, or private-duty home care.
In a REIMBURSEMENT policy, the definition of a covered home care provider is critical. Not all providers may be covered. Very few policies will cover an "independent" caregiver, even if the individual has a home health aide certification or other professional training. Most policies require that caregivers come from some type of a professional "Agency".
The policy will explicitly define if care must be from a professional agency and what requirements that agency must meet to be a covered provider. Not all agencies meet all the requirements under all policies in all states.
Read the policy's requirements for a HOME CARE (or "HOME HEALTH") Agency to be considered a covered provider before you sign a contract and start receiving services. Typically the agency can work with you and the insurance company to determine this.
DO NOT simply take the agency's word that they "take insurance" or will be covered because they've had other clients with the same insurance company. Most carriers have many different LTC policies issued over the year that can have significantly different policy language for home care. Coverage is based on your policy, not on the company overall.
Some older policies require that to be covered, a Home Care Agency be explicitly licensed by the state. But some states don't require a license if the agency only provides "custodial" and not "skilled" care. Unless there is some type of "if licensing is required by the state" exception language, you may find that a strict licensing requirement limits the options for home care agencies.
HOME CARE is not covered by all policies. If it is, it should be clearly shown on the policy's SCHEDULE OF BENEFITS. If not explicitly shown on the policy's Schedule, it is likely not covered, but further examination of the policy language may be required.
When offered, HOME CARE services may be covered as part of the main policy, as an option or rider attached to a facility policy, or as a separate policy.
In most policies HOME CARE (or HOME HEALTH CARE) is an all-encompassing term. It is care provided by an agency or individual (if allowed by the policy) and includes services provided by a nurse, home health aide, nutritionist, or occupational, speech, respiratory, or physical therapist. It does not cover services provided by members of your family, or only "companion" care.
HOME CARE also includes custodial care services which may also be referred to as non-medical home care, or private-duty home care.
In a REIMBURSEMENT policy, the definition of a covered home care provider is critical. Not all providers may be covered. Very few policies will cover an "independent" caregiver, even if the individual has a home health aide certification or other professional training. Most policies require that caregivers come from some type of a professional "Agency".
The policy will explicitly define if care must be from a professional agency and what requirements that agency must meet to be a covered provider. Not all agencies meet all the requirements under all policies in all states.
Read the policy's requirements for a HOME CARE (or "HOME HEALTH") Agency to be considered a covered provider before you sign a contract and start receiving services. Typically the agency can work with you and the insurance company to determine this.
DO NOT simply take the agency's word that they "take insurance" or will be covered because they've had other clients with the same insurance company. Most carriers have many different LTC policies issued over the year that can have significantly different policy language for home care. Coverage is based on your policy, not on the company overall.
Some older policies require that to be covered, a Home Care Agency be explicitly licensed by the state. But some states don't require a license if the agency only provides "custodial" and not "skilled" care. Unless there is some type of "if licensing is required by the state" exception language, you may find that a strict licensing requirement limits the options for home care agencies.
HOME CARE is not covered by all policies. If it is, it should be clearly shown on the policy's SCHEDULE OF BENEFITS. If not explicitly shown on the policy's Schedule, it is likely not covered, but further examination of the policy language may be required.
When offered, HOME CARE services may be covered as part of the main policy, as an option or rider attached to a facility policy, or as a separate policy.
CLAIM TIP: It is critically important to make sure the home care provider you want to use will be covered by your policy BEFORE you sign a contract and begin receiving services.
"HOMEMAKER SERVICES"
Activities such as meal preparation, housekeeping, laundry, using a telephone, shopping, and driving/traveling outside the home are considered Homemaker Services. Help with HOMEMAKER SERVICES alone does not qualify a person for benefits to begin, but once BENEFIT ELIGIBLE most policies will pay for HOMEMAKER SERVICES.
Usually HOMEMAKER SERVICES are covered if provided by the same aide who is in the home to provide the physical ADL support or cognitive supervision. A few policies reimburse for a separate Homemaker depending on if that person is from a professional agency or is independent.
HOMEMAKER SERVICES are also often referred to: INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)
Activities such as meal preparation, housekeeping, laundry, using a telephone, shopping, and driving/traveling outside the home are considered Homemaker Services. Help with HOMEMAKER SERVICES alone does not qualify a person for benefits to begin, but once BENEFIT ELIGIBLE most policies will pay for HOMEMAKER SERVICES.
Usually HOMEMAKER SERVICES are covered if provided by the same aide who is in the home to provide the physical ADL support or cognitive supervision. A few policies reimburse for a separate Homemaker depending on if that person is from a professional agency or is independent.
HOMEMAKER SERVICES are also often referred to: INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)
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* NOTE: This information is for educational, informational purposes only and is not meant to provide specific guidance for any particular policy, policyholder, or claim situation. LTCI covered caregiver/provider eligibility is determined by the insurance carrier based on the specific criteria in the issued policy contract and the carrier's own guidelines.
