Long Term Care
What is Long Term Care
Long term care is the assistance individuals need when they are unable to care for themselves and need help with Activities of Daily Living (ADLs) – bathing, dressing, transferring, toileting, continence (control of bodily functions), and eating – or they have severe cognitive impairment such as Alzheimer’s disease. The need for long term care can result from an accident, chronic illness or short-term disability, or from advance age. Long term care can include a broad range of services, provided in any setting outside a hospital. It might be help with simple daily tasks like bathing or dressing. It might include skilled care in your own home, an assisted living facility, some other community resources, or a nursing facility.
Who Needs long term Care
• 19% of Americans aged 65 and older experience some degree of chronic physical impairment. (AHIP, “A Guide to long term Care Insurance”, 2004)
• About 55% of those age 85 and older are impaired and require Long Term Care. (AHIP, “A Guide to long term Care Insurance”, 2004)
• By 2020, 12 million older Americans will need long term health care. (AHIP, “A Guide to long term Care Insurance”, 2004)
• Family and friends are the sole caregivers for 70% of elderly people and most will cared for at home. (AHIP, “A Guide to long term Care Insurance”, 2004)
• People age 65 or older face at least a 40% lifetime risk of entering a nursing home. 10% will stay more than five years. (AHIP, “A Guide to long term Care Insurance”, 2004)
• 22% of people over age 85 are in a nursing home. (AHIP, “A Guide to long term Care Insurance”, 2004)
• Women, because they outlive men, face a 50% greater likelihood of entering a nursing home after age 65. (AHIP, “A Guide to Long Term Care Insurance.”, 2004)
Some Misconceptions about Medicaid and Medicare
Medicaid pays for health services for the very poor of any age. Qualifications for Medicaid vary by state. Being eligible for Medicaid does not guarantee placement in a nursing home. There may be long waiting lists for facility care. Depending on the state and facility, Medicaid patients often receive lesser-quality care than patients who are paying on their own. Under Medicaid, nursing home care is essentially the only option. Home care, assisted living facility care, adult daycare, outpatient services, and alternate caregiver services are not usually reimbursed under Medicaid.
Medicare pays for health care for people 65 and over and for those who are disabled. Medicare does not pay for long term medical service such as assisted living or adult day care. Medicare pays only the first 100 days of skilled care, such as physical therapy or nursing, which only accounts for 5% of all long term care costs. You are eligible for the care only if you have been in the hospital for at least three days. The personal care must relate to the treatment of an illness or injury. Medicare pays 100% for the first 20 days then you pay $128/day for the next 80 days.
Exceptions, Limitations and Exclusions
Most long term care insurance policies will not pay benefits for any confinement, care, treatment, or service(s):
• That results from attempted suicide or intentionally self-inflicted injury;
• That results from voluntary participation in a felony, attempted felony, or illegal occupation;
• That results from a sickness or injury for which benefits are provided under any state or federal worker’s compensation law;
• Provided outside the United States or Canada;
• Provided in a government facility (unless otherwise required by law);
• Provided for the treatment of alcoholism or drug addiction, or in facilities operated primarily for such treatment;
• Provided in facilities operated primarily for the treatment of mental or nervous disorders or disease, other than Alzheimer’s disease or dementia.
You could be declined coverage if you already have the following condition(s):
• Alzheimer’s Disease;
• Severe Arthritis with functional limitations;
• Diabetes which is not under control;
• Cancer within the past 6 months;
• Parkinson’s Disease;
• Stroke within the past 6 months;
• A Stroke at any time, which has caused functional limitations;
• Congestive Heart Failure within the past 6 months;
• Emphysema, if severe or still smoking;
• Chronic Obstructive Pulmonary Disease, if severe or still smoking
• Any conditions which require the assistance of another human being for the basic activities of daily living: bathing, eating, toileting, or transferring in and out of a bed or chair.