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FAQs #13

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Q13. My mother has had several strokes and needs 24 hr care. We have her at home with us and it seems to work well. We have a wonderful and skillful caregiver for Mother who we pay privately. We know that Mother has had a long term care insurance policy for several years and we would like to access these benefits. Someone told us we could be reimbursed for the aide if an R.N. is supervising her. Do we just submit a claim to the insurance company?

A13. Nancy Driskill:
>Unfortunately, most long term care or home care insurance policies require that the providers are associated with a certified agency. They also require that there be a doctor's order for the home care, that the care be judged necessary and appropriate, and some include the proviso that there be actual hands-on assistance with bathing, feeding, dressing, and toileting. In other words, companionship and oversight are not covered. And the most relevant issue for you: your private provider can not be paid with insurance benefit dollars, even if she may be working under the supervision of an R.N. Care Manager. If you are committed to keeping this private provider with whom your mother has established a relationship, you might consider supplementing her services with the approved and billable services of an agency.


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Donna Burrill:
>It's been my experience that when in doubt file a claim. This is a perfect situation to call the policy's agent and get himher to review coverages with you and submit all the necessary paperwork. If you want to investigate this on your own, these policies are written for older citizens and therefore use very straight forward language. First, check to see if the policy has home healthcare coverage and is not just a nursing home policy. Older policies pay benefits if the insured's physician says care is necessary and the insured needs assistance with 2 or 3 of these Activities of Daily Living (ADL's): bathing, dressing, eating, toileting, continence and transferring (io. getting in and out of bed) or have deterioration in intellectual capacity. Your mother's policy may only reimburse care provided by an employee of a bonafide home healthcare agency, and therefore, you'd need to replace the current care giver (possibly) or augment her time with another provider. Many insurers will pay for layperson care if care is necessary and sufficient to meet the patient's needs because it will be less expensive. The key is the policy is meant to pay for effective care that's necessary.

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Donna Burrill:
>It's been my experience that when in doubt file a claim. This is a perfect situation to call the policy's agent and get himher to review coverages with you and submit all the necessary paperwork. If you want to investigate this on your own, these policies are written for older citizens and therefore use very straight forward language. First, check to see if the policy has home healthcare coverage and is not just a nursing home policy. Older policies pay benefits if the insured's physician says care is necessary and the insured needs assistance with 2 or 3 of these Activities of Daily Living (ADL's): bathing, dressing, eating, toileting, continence and transferring (io. getting in and out of bed) or have deterioration in intellectual capacity. Your mother's policy may only reimburse care provided by an employee of a bonafide home healthcare agency, and therefore, you'd need to replace the current care giver (possibly) or augment her time with another provider. Many insurers will pay for layperson care if care is necessary and sufficient to meet the patient's needs because it will be less expensive. The key is the policy is meant to pay for effective care that's necessary.

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Heidi Rizzotto
A Little R&R Home Care
1966 W. 15th Street, Suite 6
Loveland, CO 80538
970-667-1067

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Home Care Services : Non-Medical

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