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.

Because of old age, mental or physical illness, or injury, some people find themselves in need of help with eating, bathing, dressing, toileting or continence, and/or transferring (e.g., getting out of a chair or out of bed). These six actions are called Activities of Daily Living–sometimes referred to as ADLs. In general, if you can’t do two or more of these activities, or if you have a cognitive impairment, you are said to need “long-term care.” Long-term care isn’t a very helpful name for this type of situation because, for one thing, it might not last for a long time. Some people who need ADL services might need them only for a few months or less. Many people think that long-term care is provided exclusively in a nursing home. It can be, but it can also be provided in an adult day care center, an assisted living facility, or at home. Assistance with ADLs, called “custodial care,” may be provided in the same place as (and therefore is sometimes confused with) “skilled care.” Skilled care means medical, nursing, or rehabilitative services, including help taking medicine, undergoing testing (e.g. blood pressure), or other similar services. This distinction is important because Medicare and most private health insurance pays only for skilled care–not custodial care.

The Three Levels of Long-Term Care

It is important that you become familiar with the three types of care.

Level #1: Skilled Care

Defined as continuously medically necessary, these cases represent the horror stories about growing old: of people tied to their beds, connected to tubes, suffering from some chronic ailment. But in reality, only one-half of one percent of Americans require this level of care, so unless you have a medical or family history that predisposes you to it, it’s statistically unlikely that this will happen to you.

 Level #2: Intermediate Care

This is care provided under a doctor’s supervision. Only 4.5% of the nursing home population falls in this category.

 Level #3: Custodial Care

All other long-term care patients -- 95% -- receive custodial care, which is little more than room and board. It is based on the mere premise that you’re finding it difficult to maintain one or more of the Activities of Daily Living. Often, Mom is in a retirement facility because she cannot live alone at home anymore, and the kids are unable to care for her.

The result: Mom enters a retirement home. She will find her meals prepared, her room cleaned, and someone to remind her to take her medication. 

Some Misconceptions about Medicaid and Medicare

Medicaid

     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

     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.

Why You Need Long-Term Care

Long-Term Care insurance is an excellent example of how The Rules of Money Have Changed. Many people have not dealt with this subject for the simple reason that, until now, nobody ever had the need.

In ancient Greece, for example, life expectancy at birth was 20. When the Declaration of Independence was signed, life expectancy was still just 23; the median age was 16. Even as recently as 1900, most Americans died by age 47.

These figures are confirmed by the percentage of Americans who reach age 65. In 1870, only 2.5% of all Americans made it. By 1990, that percentage had increased five-fold to 12.7%. Today, 35 million people are over 65 -- and the figures continue to grow.

 We can thank advances in medicine and public health for our newly extended lifelines In 1900, communicable diseases were the leading causes of death, but today, most deaths result from heredity, lifestyle and the environment. That’s why people in the 1940s and 1950s rarely died of heart disease: They were far more likely to die from a contagious disease long before they reached what we would now consider “old age.” 

 Just how long are people living today? Consider: 

• Life expectancy at birth is now age 78;
• people in the fastest growing age group in this country are those over 85;
• if you and your spouse both reach age 65, one of you can be expected to live to age 90;
• 90% of all the people in world history who ever reached age 90 are alive today; and
• Willard Scott won’t wish you a happy birthday unless you are least 100.

Old cars break down more often than new ones, and the same is true for people. As our bodies wear out, we find ourselves requiring assistance with daily life. Called the Activities of Daily Living, insurance companies typically define these as eating, dressing, bathing, toileting, transferring (getting from bed to chair), and maintaining continence. The need for assistance with ADLs is so common, and the cost so large, that:

• more than half the women and about one-third of the men who reach age 65 will spend some time in a nursing home;
• seven out of 10 couples can expect at least one partner to use a nursing home after age 65;
• the average cost of a nursing home is about $73,000 per year;
• half of all older Americans who live alone will spend themselves into poverty after only 13 weeks in a nursing home;
• 56% of couples spend their income down to the poverty level after one spouse has spent six months in a nursing home; and
• two out of five people 65 and over will need long-term care. Half will stay in a facility six months or less, while the other half will stay an average of two and a half years.

These statistics come as a shock to most of us. Indeed, as a nursing home admissions officer once told me, the most common remark she hears when admitting a new patient is, “I never thought I’d live this long.”

 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.

Pre-existing Conditions

     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

For answer to any questions regarding medicaid planning, transfer rules, Long Term Care and many other subjects about Elder Law, please visit the website listed below: https://www.elderlawanswers.com