Health Insurance Options for Individuals Who Require Nursing Care

Health insurance is something that can be used to help cover some of the cost of eldercare. Understanding what you or a loved one may be entitled to is important. It’s equally important to know the limitations of the coverage so no time is wasted pursuing benefits that will never be received. 

If you’re looking at long term planning for yourself or a loved one, knowing the limitations of coverage and understanding ALTCS eligibility is essential.

Elder Care Benefits by Type of Insurance

Time to examine the benefits of specific insurance policies. In doing so, we’ll look at the following areas of coverage:

  • Medications
  • Nursing home care
  • Assisted living
  • Home care
  • Medical equipment
  • Medical supplies

Medicare

Medicare is the primary health insurance coverage for the vast majority of elderly Americans. 

We should point out at this stage, that Original Medicare only pays for medical care and doesn’t cover the cost of personal care. In other words, it won’t pay for assistance to help the elderlu perform daily living activities such as grooming, bathing, eating, and mobility. Therefore, it doesn’t pay for home care or assisted living. 

Medicare does, however, cover nursing home care and some personal care is provided in cursing homes. Medicare also doesn’t cover 100% of nursing home care and only pays for a limited period of time. 

Medicare does offer help with medical equipment, medical supplies, and medication. However, the items must be medically necessary, prescribed by a physician, and be on the list of approved items. When it does pay for such items, it is typically only for 80% of the cost. 

When it comes to helping individuals to age in place, Medicare provides very little assistance. No home modifications will be paid for, however, there is a unique program that Medicare offers in some locations. It is called PACE or LIFE and covers all the medical needs of a participating senior. 

Medicare Supplemental Insurance

Medigap is supplemental insurance that’s designed to help with Medicare’s copayments and deductibles. It doesn’t broaden the coverage, but reduces the out-of-pocket expenses for items and services that are largely covered by Medicare. 

Medicare Supplemental Insurance does not pay for assisted living, non-medical home care or adult day care, unless medical in nature. 

TRICARE for Life and CHAMPVA for Life

These insurance programs are for active military members, retirees and the family members of military veterans who are at least 65 years old. 

The programs function in a similar way to a Medicare supplemental insurance policy in that they simply help to cover copayments and deductibles. Therefore, they provide little assistance towards non-medical eldercare.   

Medicaid

This is an insurance program for very low income individuals with limited financial assets. Unlike Medicare, it offers significant benefits for eldercare including non-medical care. It will pay for unlimited nursing home care. 

Through individual state’s HCBS waivers, it usually pays for some home care, assisted living, adult day care, adult foster care, and medical alert services. 

One of the major challenges is qualifying for the program, as it is reserved for individuals with very limited income and assets. 

The other challenge is service availability. Nursing home care is an entitlement. Anyone who meets the requirements will receive the benefit. Assisted living, home care, and adult day care, on the other hand, usually have a limited number of slots available. Waiting lists are not uncommon.  

Tips on Maximizing Your Insurance 

Know Your Benefits

Health insurance benefits may be difficult to understand, but knowing your benefits is key to getting insurance to pay. It’s not uncommon for insurance companies to decline payment because they don’t see the medical need for a particular item, procedure, medication, or therapy. 

Knowing the benefits you’re entitled to is key, along with being able to communicate the medical reason for it. 

Be Proactive With Your Doctor

You must be proactive in getting your doctor to write very detailed prescriptions. They should include specific reasons why an item, procedure, therapy, brand, or type of care is necessary. 

Provide Additional Supporting Documentation

Try to provide as much supporting documentation as possible. Official letters describing a patient’s needs, statements of medical justification, and laboratory test results can all help your case. There is no such thing as too much information when it comes to insurance claims. 

Make Use of a Patient Advocate

These are third-party individuals or organizations that help patients navigate their way through the health care system. Their focus will be on education, use of health plans, and how best to obtain care. 

There are advocates that charge a fee, but there are also organizations that provide a service free of charge. Examples include the American Cancer Society, the Alzheimer’s Association, or a local Long Term Care Ombudsman. 

SHIPs

SHIPs stands for State Health Insurance Assistance Programs. These are free services provided in each state to help residents better understand and receive benefits from their insurance policies including Medicare, Medicare Advantage, Medicare Supplemental and Medicaid.