Long-Term Care Insurance Best Practices: Clients & Claims. Bill Comfort, CSA, CLTC, LTCCP

Transcription

1 1 Long-Term Care Insurance Best Practices: Clients & Claims Bill Comfort, CSA, CLTC, LTCCP Marketing to LTCI Policyholders LTC insurance = private-pay ability Market your care services first Understand the ins & outs of coverage Don t over-promise Not all policies are the same for HC Use your expertise to gain trust Old Problems Here Today (Policies issued before 1993) 3-day prior hospitalization Limited benefits (NH only) Assisted living not covered Not known HC only paid at skilled level (HHC model) NH stay required before HHC Alzheimer s excluded Problematic eligibility Medically necessary LTC Insurance - Basics NOTHING happens until benefit eligible Have to meet the deductible period Designed to pay policyholder NOT designed to pay providers Client can assign benefits (AoB) Care provider must be covered by policy definitions Working with Alternate Plan of Care (APoC) Must have a written Plan of Care Benefit Eligibility Nothing happens until benefit eligible Functional Disability : Physical Activities of Daily Living (ADLs) OR Mental Cognitive Impairment 1

2 Mental Cognitive Impairment (Some older policies use medical necessity ) 6 Activities of Daily Living 1. Bathing 2. Dressing 3. Transferring 4. Toileting 5. Continence 6. Eating Lose 2 of 6 Watch out for: Only 5 ADLs (or lose 3) Hands-on vs. Stand-by Provider must chart stand-by activities Caregiver training Cognitive Impairment Measured loss of short and/or long-term memory Awareness of person, place or time Standardized testing HIPAA (post 97), TQ: Severe requiring Substantial Supervision (=Continual) 24/7 Not necessarily professional, family counts Who Decides? Older contracts: Physician, insurer - F2F assessor HIPAA (TQ) Since 1997: Licensed Health Care Practitioner Doctor, nurse (RN or LPN), or licensed social worker Whose?! Incorporated into claim standards for older policies. It s insurance The company always gets to review Plan of Care HIPAA requires written Plan of Care Written into contracts since 1997 Has become a general claim practice for all claims Who writes? LHP On your staff? May be insurance company care coordinator 2

3 On your staff? May be insurance company care coordinator Insurance company can t directly contest Client in charge of his/her caregiving options May request every 30-days May drive/limit benefit payments Working with Plan of Care MUST match services & schedule MUST update when caregiving changes Often requested every month Looking to see if services/billing match plan If don t match, may not pay or delay until new plan in place Working with Plan of Care Problem: Early stage Alzheimer s You re there 2-4 hours/3-4 days a week Plan of care only addresses your services Basic eligibility requires 24/7 supervision Company denies claim not eligible Solution: Make sure plan addresses ALL caregivers including family & informal Spousal supervision 4 Key Benefit Elements 1. Elimination Period 2. Benefit Amount - Home Care Benefit 3. Benefit Period 4. Inflation Increase Option Elimination Period The policy s deductible Does not run unless benefit eligible Stated as # of days 30, 60, 90, 100, 180 Not based on $ spent, based on receiving care How counted? (HC Issues) Calendar days any caregiver Service days paid & covered services Very problematic: HC 3 days/week = 7.5 months to get to 90 Hybrid/crediting 1 paid day/week = 7 days 0-day 3

4 0-day Benefit Amount Daily or monthly E.g., $100/day or $3,000/month Reimbursement Most common Pays up to max per day or month Indemnity Pays full benefit regardless of expenses Professional or Cash Home Care Benefit Typically expressed as % of NH benefit 50%, 75%, 100% (Newer: 150%) May be none read the policy Look out for skilled-care-only in older contracts WHO is covered? Licensed agency (state or Medicare) Non-medical agency (IF meets policy definition) Independent Trained, certified aide Free agent Home Care Definition Is HC covered? How much? Home Health Care is not important, definition is Look out for skilled-care-only in older contracts WHO is covered? Contract language is critical Licensed agency (by state or for Medicare) Non-medical agency (IF meets policy definition) Independent Trained, certified aide Free agent Home Care Agency Home Health Agency is not important Definition of agency is Must read the policy look for cross-references Must be licensed If not defined, try to send your business license as a home health agency. (or Medicare, etc.) You re stuck 4

5 as a home health agency. (or Medicare, etc.) You re stuck if licensure is required by your state. This is where you have opportunity (NOT an Alt Plan of Care) Get a letter from the state stating not required Quote exact policy language back Alternative Plan of Care (APoC) Contract language that allows the client to negotiate for services not specifically covered A facility-only policy will NEVER pay for HC APoC can only be used for an alternate facility 3-way agreement: 1.Client 2.Physician 3.Insurance company Ins. company can veto any request Client and Physician should make initial request w/reasons Generally only approved if lower-cost than a covered service, or covered service not available Benefit Period How long benefits last once begun Expressed as number of years or days 2, 3, 4, 5, 6 years Unlimited/lifetime option (no longer available) Most policies BP is a multiplier 3 years x 365 days x Benefit Amount ($100) = $109,500 pool of money NOT a time limit. Benefits can stretch beyond Inflation Rider Increases benefit amount each year Automatic, built-in, or Purchase option Increasing premiums Actual benefit more than shown on original policy Client should call to confirm current benefit Percentage Fixed, 5% most common, new 3% options Variable, e.g., tied to CPI Compound Increases each previous year s benefit Simple ( Equal ) Increases based on % of starting benefit Claim Time When to file ASAP 5

6 When to file ASAP Start the EP, no penalty ID conflicts with carrier early Time to prove caregiver/facility credentials Family issues Intrusion of 3 rd parties Desire to save benefits for later Unaware of policy or process Existing frustration with insurance company Claim Timing Elimination Period Deductible have to file (& be eligible) to start Reimbursement Client pays for care Submit bills to insurance company Company reviews Benefit paid to client Best case: 1 st $ in 4-5 months Claim Time The agent May be gone Could be defensive May be helpful Medical privacy issues (HIPAA) Assignment of Benefits (AoB) Assigning benefits to HC provider Client decision Or guardian, power of attorney Not always recommended for HC Multiple providers? Who gets the assignment? Conflict of interest Fiduciary responsibility Do it ONLY if claim already established, client is benefit eligible, HC provider approved and a month or two already paid. Practical for facility Daily charge = or more than benefit Assignment of Benefits (AoB) Client decision only gives up right to payment Or guardian, power of attorney OK to accept IF: 1.You have a signed service agreement 6

7 OK to accept IF: 1.You have a signed service agreement Client must understand he is responsible: During EP If ins. company doesn t pay If charges for care exceed the benefit amount 2.Client is benefit eligible 3.Your agency is an approved provider 4.(EP has been satisfied) Waiver of Premium Most policies waive or forgive the premium payments when on claim Most waive AFTER benefit payments begin (after the EP), some start 90 days after benefit payments begin Some do not Some do, but only if in a nursing home If client stops paying premiums, she risks losing coverage Role of HC Agency Assist in review of contract Work with agent/insurance company 1. Definition of benefit eligibility triggers 1997>: Certified by Licensed Health Care Practitioner Doctor, Nurse, Licensed Social Worker 2. Covered services Provider definitions 3. Benefit amounts Respect stage of care and continuum needs Working with Problems Read the actual contract Admin standards may be stricter than contract language Develop plan of care to coordinate with coverage Hire 3 rd -party social worker, RN care coordinator (Meets LHP definition) Have the appeal letter come from the client (policyholder). CC: the Dept of Ins. Quote exact language from policy w/page reference Call a lawyer; recommend client do so File formal complaint with DoI, CC: ins. company Marketing Ideas Speak to groups of agents, financial planners, accountants, lawyers Educate them on home care Your role in caregiving For your clients AND their families 7

8 Your role in caregiving For your clients AND their families Be careful of individual quid pro quos Advertise your expertise But don t offer to take insurance Help with claims 30 Bill Comfort, CSA, CLTC Bill@ComfortLTC.com 8