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Tapping LTC insurance at 93
Old 03-18-2014, 06:49 PM   #1
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Tapping LTC insurance at 93

My 93-year old neighbor lives alone in a one-bedroom apartment in our 55+ apartment complex. She has LTC insurance that would provide a benefit of $105 per day at a nursing home or ALF. Her son worked for Soc Sec so she was able to buy into a good LTC policy for a reasonable price. From what I read, she must require assistance with 2 of 4 life skills (transfer, toileting, eating, and bathing) to be able to claim benefits. I think she is there but how does she prove it?

She is beginning to have issues with safely getting out of bed (especially at night when she needs to get to the bathroom) and safely taking a shower. She is still doing these tasks on her own but they are now becoming risky (risk of falling) activities for her to do alone.

We have been checking out local ALF's but the ones she really likes are slightly more expensive than she feels comfortable paying (wants to leave a legacy of about $100k) so she is looking to be able to tap her LTC insurance.

Has anyone been through the process of tapping the benefits of LTC insurance? Does my friend have to hire help to prove she should qualify for her insurance to pay for help? Her issues with balance have been documented by her PC doc and her cardiologist. She can still feed herself, walk with a cane/walker, and get herself on and off the toilet although she has some issues with urinary incontinence.

She's in great health for someone who is 93 but it's time to get some help. It's no longer safe for her to live on her own. I love her dearly and I want to help her figure out this problem. Any advice?
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Old 03-18-2014, 07:01 PM   #2
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The LTC Insurance company (at least if they are like all of the LTC Insurance companies I have dealt with) has paper work that has to signed by a physician stating which of the activities of daily living, ADLs she is unable to accomplish without assistance. From what you describe your neighbor may not quite be to the point where she qualifies though with a little careful thought you and she could probably figure out what to say to her physician to get him/her to sign the paper work. Perhaps the degree of her incontinence issues and a very little embellishment of her inability to keep herself clean because of it would make the difference in the physician's decision.
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Old 03-18-2014, 07:05 PM   #3
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My goodness, if a 93 year old woman who has been paying LTC premiums for most likely several decades has to prove she needs assistance, what good is LTC insurance? Who would seriously argue that someone who is 93 and asking for assistance is not justified in doing so? Isn't that what she has been paying LTC premiums all those years for?
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Old 03-18-2014, 07:13 PM   #4
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My goodness, if a 93 year old woman who has been paying LTC premiums for most likely several decades has to prove she needs assistance, what good is LTC insurance? Who would seriously argue that someone who is 93 and asking for assistance is not justified in doing so? Isn't that what she has been paying LTC premiums all those years for?
+1

Not sure how long ago she purchased the policy but it's probably been quite a few years.
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Old 03-18-2014, 07:19 PM   #5
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The LTC Insurance company (at least if they are like all of the LTC Insurance companies I have dealt with) has paper work that has to signed by a physician stating which of the activities of daily living, ADLs she is unable to accomplish without assistance. From what you describe your neighbor may not quite be to the point where she qualifies though with a little careful thought you and she could probably figure out what to say to her physician to get him/her to sign the paper work. Perhaps the degree of her incontinence issues and a very little embellishment of her inability to keep herself clean because of it would make the difference in the physician's decision.
I think her physician would be helpful. Maybe it's time to file a claim and see where it goes.

She has a consultation call with a rep from the insurance company on Thursday but I'm thinking she should skip that and go straight to the paperwork. She might do herself more harm than help by being a little too proud to describe her real needs. She takes pride in being independent but some of her anxiety about doing certain tasks is starting to come through.
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Old 03-18-2014, 09:01 PM   #6
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Originally Posted by Buckeye View Post
My 93-year old neighbor lives alone in a one-bedroom apartment in our 55+ apartment complex. She has LTC insurance that would provide a benefit of $105 per day at a nursing home or ALF. Her son worked for Soc Sec so she was able to buy into a good LTC policy for a reasonable price. From what I read, she must require assistance with 2 of 4 life skills (transfer, toileting, eating, and bathing) to be able to claim benefits. I think she is there but how does she prove it?

She is beginning to have issues with safely getting out of bed (especially at night when she needs to get to the bathroom) and safely taking a shower. She is still doing these tasks on her own but they are now becoming risky (risk of falling) activities for her to do alone.

We have been checking out local ALF's but the ones she really likes are slightly more expensive than she feels comfortable paying (wants to leave a legacy of about $100k) so she is looking to be able to tap her LTC insurance.

Has anyone been through the process of tapping the benefits of LTC insurance? Does my friend have to hire help to prove she should qualify for her insurance to pay for help? Her issues with balance have been documented by her PC doc and her cardiologist. She can still feed herself, walk with a cane/walker, and get herself on and off the toilet although she has some issues with urinary incontinence.

She's in great health for someone who is 93 but it's time to get some help. It's no longer safe for her to live on her own. I love her dearly and I want to help her figure out this problem. Any advice?
How lucky she is to have you as a caring neighbor. When I am 93, I hope I will be so fortunate as to have an advocate like you.
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Old 03-18-2014, 09:25 PM   #7
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How lucky she is to have you as a caring neighbor. When I am 93, I hope I will be so fortunate as to have an advocate like you.
+1

Your neighbour/friend is very fortunate to have you looking out for her. The first thing to do is to read the policy. I hope she still has a copy. The policy should make it clear what degree of impairment of ADLs (activities of daily living) is required to trigger payments. Some LTC policies pay up only for residential care, and some pay for care in the home. It must be shown that care is both necessary and prescribed by a healthcare professional. After reviewing the policy, the next step is for your neighbour to discuss her care needs with her doctor. It doesn't sound as if she is receiving paid care at present, but the discussion with her doctor should clarify her options in future scenarios. If the doctor's patients include many elderly people, he or she will be quite familiar with how to apply for LTCI.
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Old 03-18-2014, 09:38 PM   #8
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Perhaps you, rather than the insured should talk to the LTC representative. Ask for a copy of her policy and any forms necessary to make a claim. I wouldn't go into any specifics except, maybe, to say that she needs hands-on help and that you (or a family member) will be going with her to meet with her physician about her needs.

Odds are they can send you all of the material as an e-mail attachment.
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Old 03-18-2014, 10:20 PM   #9
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Easy-peasy. Get the forms from the LTC company, have her take them to her doctor. I've filled out many of those suckers in my life. They have to be filled out exactly right though, so best to know the requirements.
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Old 03-18-2014, 10:23 PM   #10
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+1

Your neighbour/friend is very fortunate to have you looking out for her. The first thing to do is to read the policy. I hope she still has a copy. The policy should make it clear what degree of impairment of ADLs (activities of daily living) is required to trigger payments. Some LTC policies pay up only for residential care, and some pay for care in the home. It must be shown that care is both necessary and prescribed by a healthcare professional. After reviewing the policy, the next step is for your neighbour to discuss her care needs with her doctor. It doesn't sound as if she is receiving paid care at present, but the discussion with her doctor should clarify her options in future scenarios. If the doctor's patients include many elderly people, he or she will be quite familiar with how to apply for LTCI.
I reread the policy today and the important words (going from memory) are 'requires assistance with two ADL's.' In my mind, the problem is how to prove one 'requires assistance' with an activity when one is currently performing the activity...although with difficulty and with real risk of injury.

Given the local demographics, I'm sure her doctor has many elderly patients and would be a good resource.
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Old 03-18-2014, 10:32 PM   #11
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How lucky she is to have you as a caring neighbor. When I am 93, I hope I will be so fortunate as to have an advocate like you.
I really love spending time with her. She's a devout Catholic but she's a Democrat (as am I) so we have fun commiserating about the state of politics in Florida and nationally. She's sharp as a tack and can hear perfectly which makes conversing a pleasure.
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Old 03-18-2014, 10:40 PM   #12
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There are six basic ADLs: eating, bathing, dressing, toileting, transferring (walking) and continence.

Most policies would also have the ability to qualify due to being unable to safely live on one's own due to cognitive deficit, notwithstanding being able to perform any of the ADLs.

If she can't locate her policy and benefits list, she can request that they mail her a duplicate.

Often there is a 30-day waiting period (doesn't pay for the first 30 days). She can likely apply and get a decision before moving to an assisted living facility. If the company has questions concerning eligibility, they will send an assessment nurse to her house.

I'm guessing the policy will reimburse up to the daily benefit rate for room and board (not medications, doctor appointments, transportation).

There are several forms that you have to fill out as things are getting started. Then another form after qualifying. Sometimes you can get different information from different customer service reps on the phone, so best to double check. Keep notes and ask for the employee's name and employee number for each phone call.

Kindest regards.
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Old 03-19-2014, 07:01 AM   #13
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I think her physician would be helpful. Maybe it's time to file a claim and see where it goes.

She has a consultation call with a rep from the insurance company on Thursday but I'm thinking she should skip that and go straight to the paperwork. She might do herself more harm than help by being a little too proud to describe her real needs. She takes pride in being independent but some of her anxiety about doing certain tasks is starting to come through.
That consultation call doesn't look like a good idea and could end up hurting her chances for the policy to pay. See Nords' thread here, he shares the details of his lengthy effort to get them to pay for his father's care.

I think a valid HIPAA release from your neighbor would help so the physician and insurer will let you be part of the dialog. Then the insurer should provide you with specific forms they need and which type of physician (family Dr. or specialist) can certify the need for assistance. You should also find out if they have the option of asking for a second opinion, and if so, your neighbor would benefit the most from having you along as part of that visit.

+1 @ others that your neighbor is fortunate to have you by her side.
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Old 03-20-2014, 02:58 PM   #14
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She had her phone call and it's pretty clear that if she is living on her own, she ain't going to qualify. Wanting additional support does not count towards making a claim!

We both knew the likely outcome of the discussion, but she was still a little down and frustrated. I told her that it wasn't all bad because she would probably be staying nearer to me for a little longer and that was good news! That made her smile and laugh which was good to see.
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Old 03-20-2014, 03:11 PM   #15
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There are six basic ADLs: eating, bathing, dressing, toileting, transferring (walking) and continence.

Most policies would also have the ability to qualify due to being unable to safely live on one's own due to cognitive deficit, notwithstanding being able to perform any of the ADLs.

If she can't locate her policy and benefits list, she can request that they mail her a duplicate.

Often there is a 30-day waiting period (doesn't pay for the first 30 days). She can likely apply and get a decision before moving to an assisted living facility. If the company has questions concerning eligibility, they will send an assessment nurse to her house.

I'm guessing the policy will reimburse up to the daily benefit rate for room and board (not medications, doctor appointments, transportation).

There are several forms that you have to fill out as things are getting started. Then another form after qualifying. Sometimes you can get different information from different customer service reps on the phone, so best to double check. Keep notes and ask for the employee's name and employee number for each phone call.

Kindest regards.
The Waiting Period is 90 days and she must require 'substantial assistance' with two ADL's. I think she said her daily benefit is up to $125. Her booklet is titled 'The Federal Long Term Care Insurance Program.'
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Old 03-20-2014, 03:41 PM   #16
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At this point she should consider whether or not the policy is worth the premiums, this appears to be a facility only policy (btw, you can look at the Feds LTC policies website on line - I didn't think they approved any facility only policies). In my building, at least, none of the women who need assistance at her age lived much longer than 90 days. I know of only one woman in my Mother's circle who lived significantly longer than 90 days.
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Old 03-20-2014, 04:11 PM   #17
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At this point she should consider whether or not the policy is worth the premiums, this appears to be a facility only policy (btw, you can look at the Feds LTC policies website on line - I didn't think they approved any facility only policies). In my building, at least, none of the women who need assistance at her age lived much longer than 90 days. I know of only one woman in my Mother's circle who lived significantly longer than 90 days.
I called her and she is pretty sure she has the Comprehensive Option. Her booklet has Comprehensive Option and Facilities-Only Option listed on the front. She says she had to pay a little extra to get that benefit.

Your point is a good one though. She said one of her comments to the rep on the phone was, "So why am I buying this insurance?"

My MIL lived to nearly 95. The whole cycle of falling ill (from virtually perfect health) and dying was about 90 days. She was hoping to go in her sleep one night and 30 days over 95 years was almost overnight.

Edit: She called back and confirmed she had Comprehensive.
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Old 03-20-2014, 05:33 PM   #18
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I suggest she meet with her physician and determine if she can 'fail' any of the ADL's. Then she should hire help for 90 days. It seems to me that substantial assistance with bathing and dressing would be indicated, those are where she is at greatest risk of falling. She may need an assessment of her balance by a PT to buttress the need.
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Old 03-20-2014, 05:43 PM   #19
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I suggest she meet with her physician and determine if she can 'fail' any of the ADL's. Then she should hire help for 90 days. It seems to me that substantial assistance with bathing and dressing would be indicated, those are where she is at greatest risk of falling. She may need an assessment of her balance by a PT to buttress the need.
Yes, definitely bathing but getting out of bed (transferring) is probably her second although I'm sure a case could be made for dressing also.

During her phone call, the rep asked who helped her when she fell. She responded that she had to get herself up because no one else was there to assist her. The rep basically said, "Well, there you go! You don't need any help!"

She has been mulling over hiring in-home help and has interviewed a caregiver who helped a friend of hers before her passing. I guess it's time to pull the trigger.
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Old 03-20-2014, 05:48 PM   #20
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I suggest she meet with her physician and determine if she can 'fail' any of the ADL's. Then she should hire help for 90 days. It seems to me that substantial assistance with bathing and dressing would be indicated, those are where she is at greatest risk of falling. She may need an assessment of her balance by a PT to buttress the need.
The other problem is she doesn't complain about much to her PCP. She is concerned her PCP will not back her up because the PCP comments, "I wish my mother was as independent as you!"
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