Long Term Care Insurance | Comprehensive Case Management Certification

Hey there everybody, and welcome to this presentation on long term care insurance aspects of case management. I'm your host, Dr. Donnellice Snipes. This presentation is pretty simple. We're going to explore long term care insurance, how it differs from health insurance and why it's important for the case manager to be aware of. A long term care insurance policy helps cover the costs of care that happen when somebody has a chronic medical condition, a disability or a disorder such as Alzheimer's disease. Most long term care insurance policies will reimburse for care in a variety of places, including the patient's home, a nursing home, an assisted living facility or an adult daycare center. It's important to remember that regular health insurance does not cover long term care and Medicare and Medicaid won't either. Medicare and Medicaid may cover short stays at a rehab facility or limited amounts of home health care when the patient requires skilled nursing or rehab. But it's not going to pay for 24 hour care custodial care, which provides supervision and help with day to day tasks like laundry and cooking. If you're a case manager in private practice, you may be able to bill the long term care company directly depending on the policy. Or the long term care policy may provide a bundled payment or a day rate to the person every day that they're eligible for services and that person would pay the case manager directly as out out of their day rate. So it's. There are two different ways that you may be able to get paid for services with someone who has long term care insurance. Benefit triggers. I know insurance has a lot of different terms. Benefit triggers are the conditions that must occur before the patient starts receiving benefits. Most companies look to an inability to perform certain activities of daily living or ADLs in order to determine when the patient can start to receive benefits. A lot of times the person has to have has to be unable to complete three or more ADL's in order to trigger the benefit. Now you might say to yourself, well what if somebody is physically able to do it but cognitively they may not be able to remember how to brush their teeth or you know, take a bath or, or something like that. Well, pay close attention to what the policy uses as a trigger for paying for benefits for a person with cognitive impairment. Because people with Alzheimer's or dementia may be physically able to perform activities, but they're no longer of capable of doing them without help. People with Alzheimer's disease may start having difficulty dressing themselves. You know, they forget how to put their pants on or what order to do it in mental function tests may substitute as benefit triggers for cognitive impairments. So if the person can physically get dressed, as long as they've got somebody, you know, telling them what to put on first, second and third, you know, then obviously they can still physically do it, but cognitively they may not be able to do it. Same thing with taking a bath and remembering to check the water temperature and you know how to turn on the, the shower spigot so it's not coming out of the bathtub faucet. It's important to ask whether the patient must require someone to perform the activity rather than just stand by and supervise. In order to trigger benefits. In order to submit a claim, it's important to gather a certain amount of information. You don't want to, you know, have to go through calling back 3, 4, 5 times. The information needed may vary based on the long term care insurance company. So find this information on the certificate of coverage or look on the back of the person's insurance card, call the 1-800number and ask the insurance company for these details. What do I need in order to submit a. In order to submit a claim? Benefits vary by policy and may cover a percentage of every service or be more like a bundled payment and simply pay the patient a set dollar amount per day regardless of how many or how few services are used. So as a case manager, if you can go in there and, and reduce service utilization or set it up so the people providing services cost less. For example, a CNA is going to cost that comes in once a day or even all day long is probably going to be cheaper than being in a long term care facility where they've got 24 hour care from registered nurses. Maximum benefit limit in years is another issue that you want to be aware of. The maximum benefit limit may be 1 year, 3 years, or even the remainder of the policyholder's lifetime. So just like with health insurance, there may be a maximum lifetime benefit. Another maximum benefit trigger, if you will, may also be the total amount paid. So read through the policy, find out if the maximum benefit is in years or in dollars in order to help the person plan for their care. Because they may know that they're going to need services, you know, indefinitely. And, and we want to try to figure out how to ensure that they are able to get their needs met even after they've met their maximum benefit. If it's a maximum benefit in years, you know, obviously if you can speed up their recovery process, that's ideal. If they are not, if they don't have a condition that is going to recover, for example schizophrenia or Alzheimer's. It's important to recognize that, that utilization of the long term care insurance may want. The patient may want to push that off for as long as possible if they know they've only got, for example, three years of coverage. If you know that there's a total dollar amount like they'll pay $250,000 for a particular condition for that patient, then it's going to be important for the case manager to help clients how to figure out how to efficiently, effective and effectively get their needs met for the least amount of dollars possible in order to draw out the length of time that they're able to access benefits. A final term that is really important to know because a lot of patients really don't know about it, is the premium waiver clause. Once a claim is filed and approved and approved premiums are waived and no longer have to be paid, that can be substantial. Some of the long term care insurance policies may be charging, you know, a couple hundred dollars a month. People can do a lot with a couple hundred dollars a month. This premium waiver may take effect once the first benefit has been paid or after the benefits have been paid for a certain number of days. Another issue that it's important to recognize with this premium waiver clause. The claim has to be filed and approved and then do they. Does it kick in as soon as the first benefit is paid or does it kick in after, after the person has received benefits for 15 days or some other number of days? Oh, I guess there is a couple more terms that we're going to talk about. The elimination period, like a deductible on health insurance. This is usually a period of time instead, instead of a set amount of money during which care costs will have to be paid out of pocket before coverage kicks in. So if someone has an injury or has surgery and is in long term care or is in care for an extended period of time. I had a friend who was in a terrible motorcycle accident and broke both of his legs. And he was in a long term care facility for months after his surgeries, plural, he had multiple surgeries. His long term care insurance didn't kick in until after he had been in the long term care facility for two weeks. So he had to pay for that first two weeks out of pocket. Invoices from current care providers must also be submitted to ensure these days of care count toward the waiting period needed to begin benefits. If you're not in a long term care facility or a rehab facility where all your services are being kept in one chart. If you're getting home care, for example, you may need to have invoices from every single person who's providing services to demonstrate the number of day, number of days that you have been receiving services. Many policies will not cover care needs that result from drug and alcohol abuse like detoxification or residential addiction treatment or mental health disorders like crisis stabilization. Now, long term care may apply to people with. You may be able to get a policy for somebody with schizophrenia, for example, but what it won't cover is urgent like, like I said, like crisis stabilization after a suicide attempt. Et. These services like detoxification, residential treatment or crisis stabilization are however often covered under their health insurance policy. It's important to know what type of care the long term care policy covers for any individual. Just like health insurance, it varies from policy to policy. So does the policy cover in home care and what level of services qualify? Does a CNA who drops in three days a week just to check meds, does that qualify? Or does it have to be somebody who is there providing custodial care a minimum of eight hours a day? Does it have to be an lpn? You know, very similar to what we talked about with the level of care guidelines with health insurance. Long term care insurance also has the requirements of or or stipulations about what will be covered and what won't be. Does the policy only covered skilled nursing care or our custodial care services included too? This can be a big difference. I have a patient right now whose mother is infirmed and her hip has gone bad and she's waiting to get her hip replaced. She is pretty much immobile now, so she needs custodial care services. She's got dogs that need to be let out. She can't get up to go to the bathroom to get her own food. You know, she's pretty much bedbound so she needs these custodial care services. However, she doesn't have long term care insurance, so she is struggling to figure out or the whole family is struggling to figure out how to make that happen. But some of your long term care policies will only cover what they call skilled nursing care. Sometimes that may be in home where you've got a nurse in the house, or it may be at a nursing home or rehab facility. If care is going to be provided in a facility, is the specific facility that you're looking at an eligible provider under the policy? Are they credentialed with that policy? Some policies may cover home modifications or even pay certain family members to provide care for the policyholder. In Florida, for example, certain if certain conditions are met, then Medicare sometimes will pay for a family person, a family member to be the custodial caregiver. So it is important to look at not only the long term care insurance, but also if the person has Medicare, look at the Medicare guidelines to see if it will be covered under that. Or if they have Medicaid, look to see if it's covered under that. As I said in the last presentation, Medicare and Medicaid generally only cover custodial type care on a short term basis, such as, you know, after a hip replacement or something they may cover. Is crucial to know which services are included in a person's long term care plan and which services are not. That way you don't have a person you know partake of services and then end up finding out it's not covered. Five Documents needed to file a long term care insurance claim the policyholder statement. Also known as the claimant statement, individual statement, insured statement or care support history. This set of forms will require basic information about the policyholder, explanations regarding the reason for submitting the claim, including which activities of daily living are a problem and how long assistance will be required. So generally as it sounds like this is completed by the policyholder or the family, or sometimes the policyholder or the family with the case manager. Not all policyholders or families feel capable are of completing some of these forms. They can be very overwhelming. Number two generally and almost always you're going to have to have an attending physician statement that verifies the medical necessity of care. Sometimes insurance companies will require supporting documentation like office notes or test results. The third type of document is called the Nursing Assessment and Plan of Care. Sometimes this can be completed by the case manager, especially if the case manager is a nurse or a social worker. The assessment may include demographic information, medical history and the care plan or service plan. And this is really where the crux of the case management stuff happens, where the case manager is the single point of contact and helps identify what services are needed, when they're needed. They get input from the doctor, from the physical therapist, from whomever about the services are needed that are needed. And then they determine, you know, how are we going to organize this, in what order do these services need to be arranged? And the case manager will often facilitate linking the clients with those services. The person completing this form is also usually the single point of contact who will gather all of the other forms, submit the packet for reimbursement and ensure efficient utilization of resources. Number four, the provider statements are statements from the individual providers about the services that have been provided, the medical necessity of those services, and the person's progress or current status. And finally, number five, the authorization for Release of Information as required by HIPAA permits the insurance company to collect health care documentation in order to process the policyholder's claim. So the per the client signs an authorized authorization for release of information and which enables their doctor and the insurance company to effectively communicate back and forth. The policy or their legal representative must sign the release of information. If someone's signing the release of information on the policyholder's behalf, a sixth form, the copy of the power of attorney or guardianship should also be included. Long term care costs are an important part of any long range financial plan, especially for patients with chronic conditions or who are getting older. They recommend 50s and beyond. I'm 50. I don't know that I'm quite ready to go there yet, but I do recognize that there could come a time that I may need long long term care insurance. So it is something to discuss with clients if they don't have it yet, about whether they may need to get it. It's something to discuss with family members. Maybe the client that you're working with, you know, they can't get it because they've already got a pre existing condition, but their family members may start recognizing the benefits of long term care insurance and may want to consider that if they think that they may need it in the future. Private pay well, not everybody has long term care insurance. Let's just face it, there's a lot of people, like I just said, who may stave off getting that long term care insurance and then oops, it's too late. Situations in which a case manager might be beneficial which may not be covered by any insurance include after the death of a spouse or a partner. When my mother passed, my stepfather was pretty much non functional. He was forgetting to eat, he was forgetting to drink water. He was, you know, just pretty much in a daze. He was also having difficulty just doing, you know, day to day activities and remembering cognitively. He was a mess, which you would expect, don't get me wrong, but he benefited from a case manager that assisted him in figuring out, okay, what do we need to do? And helped him transition to the apartment in the over 50 community that he was transitioning to. They were trying to transition before my mother passed, but that didn't happen. So there was a lot to do with getting the house ready to sell. Selling the house Getting, you know, everything in order after my mother passed with bank accounts and her Social Security and everything else, there's a ton of stuff that needs to be done. Who knew when somebody passes away? So a case manager can be very helpful here to serve as a navigator. Through this process, Case managers can also be used to extend independent living in the person's home. My grandmother dug her heels in and she did not want to go into long term care. However, she was starting to develop some pretty significant dementia. My uncle used to go by every day, check in on her, but it got to the point where she needed more than he could provide. So a case manager was able to step in and help identify services that, that she qualified for under Medicare and extend the amount of time she was able to stay in her home before she finally, ultimately did have to transition to a long term care facility. Postpartum depression is another time when case management can be really helpful. In those early days of having a baby in the house, you know, seems like they have to go to the pediatrician like every single week. That's not how often, but it seems like it. The person's not getting a whole lot of sleep. With postpartum depression, they may be experiencing other symptoms that are going on. And a case manager can be very helpful at helping the new parent or the parent with the new new child navigate these early days and months to make sure that they're accessing any and all services that are available, like respite care and support groups and those sorts of things. Same thing, sort of thing in addiction recovery. People who discharge from residential often are told, in addiction recovery, they have to change people, places and things. They have to really kind of start reinventing a lot of aspects of their life and this can also be overwhelming. Case managers are super helpful in addiction recovery while the person is in residential, helping them identify where they're going to live if they're not going back to their home, but also making sure that they are making and keeping their doctor's appointments and going to their support group meetings and whatever else is on their treatment list. Now, with postpartum depression and addiction recovery a lot of times, and even extending independent living and after the death of a spouse or partner, all of these are relatively time limited. But a case manager can be a super helpful navigator that can help people who are feeling overwhelmed or who may be in crisis in some way navigate a really challenging situation. If you want to look at doing private pay case management work, consider registering with the Aging Life Care association and other condition related associations. So for example, if you want to work with early steps, you know, obviously get, get signed up with them. If you want to work with families with children with developmental delays, if you want to work with families that have a member that has diabetes, you know, you may consider registering with the diabetes association in your area and or contacting the endocrinologists in your area that would be working with people with diabetes. So there are a lot of different ways you may be able to reach out and connect with people. If you're trying to establish a private pay case management practice. Long term care insurance may cover case management services on a fee for service basis provided there's documentation of medical necessity. It can also cover case management services if the person is getting that day rate that bundled payment and the the person, the individual says you know what I think I am going to pay for case management services out of this day rate. Long term care insurance covers services that are not covered by health insurance, Medicare, Medicaid or workers compensation.