Assisted Living

I have a question. My father has had a long term care insurance that fortunately was able to cover room & board of his assisted living facility. His health suddenly deteriorated after a fall, requiring 2 surgeries and hospitalization for a number of days. He is now being asked to pay $9k+ out of pocket for his assisted living rent while he was hospitalized. The reason given is that his long term care policy doesn’t cover his assisted living room & board whenever he is not physically present at the assisted living facility – even during an unexpected hospitalization. Does this sound right that it can reject those room payments, even though all of his possessions were maintained in his room while he was away at the hospital?.

My mother purchased a Long Term Care policy in 1990, when she was 55 years old. We are currently looking into her moving to an assisted living facility. My mother bought a pretty comprehensive policy which included facility care, home health benefits, adult day care, and hospice care. Her policy pays a set daily amount, has an increasing protection rider (which has long since hit the cap of 150%), has no elimination period, and no maximum benefit days (pays life time).

In reviewing my mother’s LTC policy, the language used for facilities is Convalescent Care Facility, which it defines as “licensed by the state as a convalescent nursing facility, a skilled nursing facility, a convalescent hospital, a convalescent unit of a hospital, an intermediate care facility, or a custodial care facility.”

There are additional requirements, such as primarily engaged in providing services under the direction of a physician or RN, maintaining a daily record of each patient, and administering a planned program or observation and treatment in accordance with existing standards…
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When I contacted the Insurer, SHIP, about coverage for assisted living, the representative informed me that my mother’s policy doesn’t cover assisted living, that it is for a higher level of care, and needs to be a skilled nursing home. She also said my mother’s home health benefit wouldn’t cover care provided by the assisted living facility employees, as home health benefits only cover care provided by a licensed home health agency. (And as we have found, those agencies don’t help with ADL care much.)

I read the policy and called back and informed them that my mother’s policy DOES cover “custodial care” facilities. I was then informed that I would have to check with the assisted living facilities and see if they considered themselves to be a custodial care facility – that it would depend on what the facility considered itself.
This seems puzzling to me – as that is what assisted living facilities primarily are: custodial care (assistance with ADLs). However, they don’t come right out and call themselves that. Additionally, on the Insurers claim forms they list:

 Alzheimer’s/Dementia unit (secured)  Alzheimer’s/Dementia unit (non-secured)  Assisted living unit (secured)  Assisted living unit (non-secured)  Independent living apartment or unit  Skilled Nursing Facility  Intermediate Care Facility

They don’t even have anything listed as “custodial care facility” or “convalescent care facility.”

I am hesitant to rely on the “it depends on what the facility considers itself” advice. It appears that my mother’s comprehensive policy was intended to cover placement in custodial care facilities, which in today’s world is assisted living. But I am also concerned that the company might try to deny a claim under the theory that the facility doesn’t call itself a “custodial care facility.”

Would you advise that I contact the company in writing to clarify that assisted living is covered as a custodial care facility? Or ask them to provide a list of facilities in our area that they consider eligible as “custodial care facilities.”?

My 90 year old mother in law has been paying Genworth for 30 years. The policy was written as a “Nursing Home Policy” as assisted living was not yet in existence. Genworth has agreed that she qualifies for nursing care but refused to accept any of the facilities we have proposed even though they have Florida assisted living licenses with “Limited Nursing Care” and 24 hour nursing coverage. They also refuse to provide us with a list of acceptable facilities so we must submit proposed facilities and then wait 30 days while they do their research and then refuse coverage. All this time we are paying out of pocket for assisted living. There are three facilities in our area that have “Skilled Nursing” but she does not require that level of care and would be out of place in that environment. Are there any other suggestions for finding a facility acceptable to Genworth or strategies to convince Genworth that these excellent Assisted Living Facilities meet the intent and definition of “Nursing Home”?

I could use some help. My Great-Aunt wants to return home to Minnesota (currently in Michigan) and she is 80 years old. Her only remaining family there is her own age and not capable of helping, so living on her own is not a choice. She has a Long Term Care policy but they said they will not cover assisted living home in town because she only has 1 ADL she is unable to perform.

How do I find her more flexible insurance? What are my options?