About Long Term Care
Authored By: Guam Legal Services Corporation
What is Long Term Care?
Long term care can mean many different things but any chronic or disabling condition that requires nursing care or constant supervision can bring on the need for long term care services. Long term care means not only care in a nursing home, it can also mean nursing care in your own home and help with the activities of daily living, such as dressing, eating, bathing and taking medicine.
There are many different services that would fall under the definition of long term care. These services include institutional care, i.e., nursing facilities, or non-institutional care such as home health care, personal care, adult day care, long term home health care, respite care and hospice care.
There are other long term care services that provide people with an option other than nursing home care. These services are defined below:
- Home health care consists of services received in your home, and can include skilled nursing care, speech, physical or occupational therapy or home health aide services.
- Home care (personal care) consists of assistance with personal hygiene, dressing or feeding, nutritional or support functions and health-related tasks.
- Adult day care is for persons living at home, and provides supervision for elderly persons during the day when family members are not at home. It is a method of delivering a variety and range of services including social and recreational, and in some cases, health services, in a group setting.
- Assisted living facilities provide ongoing care and related services to support those needs resulting from a person's inability to perform activities of daily living or a cognitive impairment.
- An alternate level of care in a hospital is care received as a hospital inpatient when there is no medical necessity for being in the hospital and is for those persons waiting to be placed in a nursing home or while arrangements are being made for home care.
- Respite care includes services that can provide family members a rest or vacation from their care-giving responsibilities. It can be provided in a variety of settings including an individual's home or a nursing home.
- Hospice care is a program of care and treatment, either in a hospice care facility or in the home, for persons who are terminally ill and have a life expectancy of six months or less.
Are long term care services covered by Medicare or other health insurance?
Medicare does NOT pay for most long term care services. Individuals should not rely on Medicare to meet their long term care service needs. Medicare does not pay for custodial care when that is the only kind of care needed. Even skilled nursing facility care is covered by Medicare only on a very limited basis.
In order to obtain Medicare coverage of a skilled nursing facility stay, the following five conditions must be met:
- Your condition must require daily skilled care which, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis.
- You must have been in a hospital at least three days in a row (not counting the day of discharge) before you are admitted to a certified skilled nursing facility.
- You must be admitted to the facility within a short time (generally within 30 days) after you leave the hospital.
- You must have received treatment in a hospital for the condition for which you are receiving skilled nursing care.
- You must receive certification from a medical professional that you need skilled nursing care or skilled rehabilitation services on a daily basis.
If the skilled nursing facility stay continuously meets all of the above conditions, Medicare will provide benefits for up to 100 days of skilled care in a skilled nursing facility during a benefit period. In 2003, for the first twenty days of care, all covered services are fully paid by Medicare. For the next 80 days of care, Medicare requires a copayment (the amount you must pay) of up to $105 per day.
If you need skilled health care in your home for the treatment of an illness or injury, Medicare can pay for home health services furnished by a home health agency. You do not need a prior hospital stay to qualify for home health care. Medicare pays for home health visits only if all four of the following conditions are met:
- The care you need includes intermittent skilled nursing care, physical therapy, or speech language pathology.
- You are confined to your home.
- You are under the care of a physician who determines you need home health care and sets up a plan for you to receive care at home.
- The home health agency providing services participates in Medicare.
Once all four of these conditions are met, Medicare will pay for covered services as long as they are medically reasonable and necessary. Coverage is provided for the services of skilled nurses, home health aides, medical social workers and different kinds of therapists. The services may be provided either on a part-time or intermittent basis, not full-time.
Medicare pays the full cost of medically necessary home health visits by a Medicare-approved home health agency. You do not have to pay a deductible or coinsurance for services, however, if you need durable medical equipment, you are responsible for a 20% coinsurance payment for the equipment.
Medicare will NOT pay for full-time nursing care at home, drugs, meals delivered to your home, and homemaker services that are primarily to assist you in meeting personal care or housekeeping needs.
More information on Medicare and changes to the deductibles and copayments under Medicare is available on the web site of the Centers for Medicare and Medicaid Services at http://cms.hhs.gov.
Medicare supplement insurance is designed to fill in some of the major gaps in Medicare coverage, but IT DOES NOT COVER MOST LONG TERM CARE SERVICES.
Other private health insurance that you might already have covers mainly acute conditions and probably does NOT cover custodial care.
Medicaid, a governmental program for low-income individuals and families, is currently the major source of funding for long term care services. In order to qualify for Medicaid coverage, persons must meet certain income and asset tests. Because of the high cost of nursing home care, more than half of those who enter nursing homes privately paying for their care reach this level in less than a year.
How else can I pay for long term care services?
There are other options that you should be aware of that may help you pay for long term care services: -Savings and Investments: A savings or investment plan may help pay for long term care services. A retirement plan such as an IRA or 401K plan may also be available to you. -Life Insurance: A life insurance policy may offer the opportunity for a loan or withdrawal of the cash value. In addition, a person who is terminally ill may arrange for an accelerated cash lump sum death benefit from his life insurance company or for a cash lump sum (called a viatical settlement) from an outside firm. (Note: not all life insurance companies offer an accelerated death benefit option). These cash lump sum benefits are paid in lieu of the policy's death benefit. -Equity in Your Home: If you have built up equity in your home, you could use the profit from the sale of your home to fund long term care costs and move to less expensive accommodations. Another option is a "reverse mortgage," which is a loan based on the amount of equity you have built up in your home. -Other Housing: You may be able to buy into a Continuing Care Retirement Community where the cost includes future access to long term care services. You may also find shared housing with supportive services.
Insurance Covering Long Term Care Services
It is important to realize that insurance policies covering long term care services are a relatively new form of insurance. The services covered under these policies can be significantly different among policies.
Therefore, it is very important to read the policies carefully and compare the benefits to determine which policy will best meet your own personal needs.
Some employers and association groups offer such policies to their employees or members. If you are unable to obtain such a policy through a group, the policies are also sold on an individual basis.