LTC Claims are not “Give Mes”

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A Look at Long Term Health Care

This morning it feels like a weight has been lifted from your shoulders. The worries about mom’s changing judgments and wandering around parts of Peoria the past few months were pretty scary, but she didn’t seem to think it was a problem. It is very relieving to know she is safe today at a local assisted living facility. What’s more, her long term care policy (LTC) is paying for her care.. Life today is active, especially for women aged 45 – 55 who care for both their parents and children. These are the people caught in the “sandwich generation”.

Mom planned ahead; she purchased LTC 15 years ago, but filing a claim is not like filing a medical insurance claim. Mom not only had to be receiving coverable services, she had to meet the claim “triggers”. The policy stated that to be eligible for benefits she had to either need assistance with 2 activities of daily living or need 24 hour substantial supervision because of a cognitive impairment. Logically, it was the safety/supervision issue that was the trigger she was able to meet. She is able to dress, bath and do the other thing by herself. So, how is the need for 24 hour substantial supervision proven?

A consultant suggested that a diary and related paperwork be kept on mom and times when she didn’t seem to process situations or when she put herself in situations that were not safe. She even had an auto accident 5 months ago. So, that information and medical report was also kept in this diary file along with other situations. After the accident, it did not appear she was safe to drive, so the car was never replaced. All of this information was given to mom’s doctor and mom went through a thorough exam. Mom’s situation was also discussed with the facility. While she has a lot of freedoms, there is security at the facility and a large enclosed courtyard where mom can go outside most anytime she wishes.

So, when claim was made, mom’s portion of the form was completed. Her doctor and facility both completed forms and included information regarding the need for substantial 24/7 supervision for safety from their observations and the diary. Yesterday, mom received her first check.

Coordinating care for your children and parents simultaneously is not easy. What can you do to manage this? Three words of advice: Plan, Plan and Plan. Legal, financial, residential, mental and physical healthcare elements must be addressed prior to a crisis. A sandwich generationer should guide their parent through these issues and the primary issue of safety, while being careful not to take all control away from a parent. Once again, it is important to start talking, making suggestions and guiding early, do not wait for a crisis.

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Steven A. Buttice is the president of Medical Reimbursement & Management Services, Inc., a firm specializing in issues affecting seniors, including seminars and consultation on Medicare Plans, Long Term Care and other types of insurance, claims issues, and sales/service of insurance products since 1984.

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