Question: My spouse and I have Long Term Care Insurance, but we are not sure how to use it?

Answer: Long Term Care Insurance (LTCI) is an insurance product that is designed to help a person pay for the care he receives when they are sick. LTCI is not health insurance. It really is care Insurance. To qualify for coverage you must need help with your care.

Generally the LTCI will begin to reimburse for care once help is needed with at least two activities of daily living (ADLs) more than half the time. The ADLs include six activities: walking, dressing, bathing, bathroom, eating, and transferring from chair to bed or the reverse. As we become sick we may need help with these ADLs.

Bathing — either every day or once a week, that is going to meet the criteria.

Eating — this means bringing the food to your mouth, and not preparation.

Dressing — help putting on socks every day, but put on everything else independently that may not meet that criteria, but it could be part of the help you get once you qualify.

Another way of qualifying for payment (reimbursement for care) under LTCI is a diagnosis of confusion/dementia that impairs a person’s ability to function without directions from others. So if you or your spouse have dementia, you could qualify to collect your LTCI benefit even if the need for help is inconsistent. Sometimes people with dementia can use the toilet independently, but can’t find the toilet, so they need help/supervision almost constantly. They may be able to feed themselves, but need prompting to stay focused on eating. They may dress themselves, but wear boots in the house and slippers outside, so they need monitoring or supervision to stay safe.

This change of condition can be an event or catastrophic change, a stroke, a fall where they break a hip, or hit their head. Sometimes this change is more gradual, a slow decline over time making it hard to put a date on when they began needing that much help.

Using this criteria you may find that you might qualify for using the LTCI policy to help pay for care. You will need information like your name, date of birth, policy No., and address. You are going to be asked questions about diagnosis, physician, and what type of help is needed at this time. These questions are sort of a pre-screening for the insurance company. They are trying to get at “why you think you qualify?”

So think about that before you call. What are you getting help with? How often do you need the help? Who is it that helps? Have you been hospitalized recently? When did this need for help begin?

In thinking about these questions, and the answers you give, it is important to run through your answers before you make that call. We like to paint a very optimistic or positive portrait of our self and our spouse. For this purpose you need to be very honest about the needs that you have. How much help is necessary? It is more like thinking of the worse days in the week, not the best days to answer these questions.

So if you feel it is appropriate, pull out the actual LTCI policy and call the phone number listed on the policy. This is how you begin to file the claim. The representative will ask the necessary questions and send a packet of information that needs to be completed promptly and returned to them.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 720-9797 or e-mail at SLM@lutheran-jamestown.org.