The long term care insurance (LTCI) claims process and care coordination can be a mystery to policyholders and their financial advisors. It can also be an objection to purchasing LTCI if a client has a negative impression or believes the carrier won’t meet its claims obligation. Even some of the best long term care insurance specialists have questions about the claims and care coordination process. BuddyIns teamed up with our community partner, Amada Senior Care, to answer some of the tough questions around the current claims process and what the future holds as this wave of seniors seeks extended care.
Barry: Let’s start by unpacking the current situation that retirees and seniors are finding themselves in as they enter retirement and age in place. We’ve all heard about the wave of baby boomers entering retirement, and the potential challenges this large aging demographic may impose on our society. As a top national senior care agency, what do you recognize about the situation seniors are facing today?
Thomas: The senior care continuum is incredibly complex. Every administration has been working to address the issue since Roosevelt signed the Social Security act into law and President Johnson signed the Medicare and Medicaid Act. Our aging population presents a public health crisis that affects families, wealth dynamics, economic productivity, hospitals, healthcare systems, and ultimately social and government efficacy.
This large generation of baby boomers aging in place presents several challenges, the largest of which might be the cost to social programs. The government, through Medicare and Medicaid, is the largest payer of healthcare costs, specifically for seniors as they need increased health resources. Senior care and long term care additionally represent exorbitant costs that our government programs aren’t ready to handle. There is increased attention and concern on this issue demonstrated by moves such as Washington’s creation of a public long term care program to shift costs away from their state Medicaid budget, and the dozen other states soon to follow suit. Or the federal government’s attempt to include long term care benefits in the ACA (Affordable Care Act) and multiple proposed fed initiatives being evaluated currently. There is a substantial need for our society to get its arms around what to do with our senior population.
In addition to societal pressure, families are experiencing tremendous challenges to care for their loved ones physically and financially. The reality is that most seniors want to stay at home for as long as possible, and family members end up becoming primary caregivers. It’s estimated that there is a loss in income of nearly $522 billion annually by the nearly 53 million people in the U.S. who care for someone close to them. As a long-time provider of home care services, Amada Senior Care understands how important it is for families to preserve their loved ones’ health, independence, and dignity. Senior care advisors from Amada offices around the country frequently meet with families who have become weighed down by both the physical and emotional exhaustion that occurs when caring for a loved one. At Amada, we provide support not just for the senior loved one but also the entire family.
Barry: This immense societal pressure has certainly been growing for some time. Has COVID made a significant impact on the situation, and in what ways?
Thomas: COVID has absolutely made an impact. It was a collective gut check globally that forced us all to take inventory of what is important. Families lost loved ones, people learned to work from home, many senior care facilities lost 20-40 percent of their residents either to COVID or as they transitioned to care at home. COVID changed how healthcare is being delivered, with far more healthcare services being delivered at home. Ultimately, families were forced to consider other options and many families have chosen to keep their aging loved ones home or make plans for care at home as their loved ones age. A long-lasting impact of COVID will be that there will be more and more care services delivered at home and because there is now a sea change in thinking about what kinds of health care can be accomplished in the home.
Barry: I understand that Amada takes an active role in assisting families during their time of need. Can you explain your process?
Thomas: We take a holistic approach to care as a care advocate for our seniors and their families. We start by conducting a comprehensive assessment of our client’s needs, evaluating the medical, financial, and social needs present for our family. This assessment by our team of senior care advisors identifies support needs with activities of daily living (ADLs) and other needs identified in the client’s plan of care with their health professional, such as cognitive issues, ambulatory issues, etc. This comprehensive needs assessment is necessary to then create a personal care plan for our senior clients that is suitable based on their needs and preferences.
The plan of care for many families includes some level of home care. It might be part-time home care in partnership with the family or full-time, round-the-clock care by our trained caregivers. Most seniors desire to stay in their homes for as long as possible. If care at home isn’t possible because of the level of medical needs present, we have partnerships with thousands of senior housing and elder care communities across the country. An Amada senior care advisor has the knowledge and experience to help the family find the right assisted living or continuous care community or nursing community for their loved one.
Of equal importance in this process is helping our clients afford the type of care that they desire. We are experts in helping our clients financially plan to cover the costs of in-home care. This might include identifying VA benefits, retirement benefits or LTCI benefits that will completely or partially pay for care.
Amada Senior Care began franchising in 2012, thus we have locations across the country with a large network of caregivers providing care to thousands of seniors.
Barry: Wow, care advocacy sounds like so much more than just care coordination or care advice. For those of us looking for help, what should we look for when choosing the right care advocate?
Thomas: A senior care advisor should certainly address all physical, health, and emotional needs as well as financial needs. Additionally, does the advisor ask the right questions about the senior’s unique situation? Does the home care agency employ its own workforce of trained caregivers? What is their process for vetting caregivers or the assisted living communities they recommend? What is their experience working with LTCI claims management and advocating with brokers on behalf of senior clients and their families? Can the senior care advisor show a proven process for filing LTCI claims or successfully working with the VA to acquire funding to pay for in-home care services?
These are a few of the many questions that should be asked when choosing the right care advocate and partner to provide care services for your loved one. Amada has earned critical acclaim for our home care services, primarily because we employ our caregivers and have established a culture of compassion and gratitude for the work of our caregiving team that extends to the value and dignity of the seniors they care for. Home care agencies that contract independent caregivers don’t have the same influence or control over the quality of care provided by their network. We have also worked with clients who have LTCI for over a decade and have become leading experts in working with insurance carriers to file, process, and get approvals from every long term care carrier in the market. We have found this to be pivotal in ensuring that senior policyholders receive all the long term care benefits they are due.
Barry: This comprehensive approach to care is certainly valuable to the families you serve. Tell us more about how you provide support for families with LTCI.
Amada: The process begins with re-educating clients on the benefits available in their LTCI policy. We’ll contact the insurance company on the family’s behalf, collect information, complete and file the claim forms, and even continue to manage the payments if the client wants us to. A critical component of the claim process is providing an RN or medical professional to meet the client in their home and complete a medical assessment as well as a plan of care that is submitted upon filing the claim. Once the claim is approved, our team will automatically collect and file all paperwork as well as maintain the client’s eligibility status by managing recertifications.
As client advocates, Amada senior care advisors have worked with most insurance carriers and have filed tens of thousands of LTCI claims on behalf of clients. That gives us a unique perspective that is based on real-world cases. We work hard to share our experience with others, like BuddyIns, to help educate financial advisors and consumers about the long term care claims process.
Barry: How do you foresee the LTCI claim’s process changing as more and more seniors age and become benefit eligible?
Thomas: There was a little more than $12 billion in LTCI benefits paid in 2022, and that number is expected to grow considerably over the next decade. Additionally, there are an estimated 73 million baby boomers that will all be over age 65 by 2030. This block of aging baby boomers has represented a majority of LTCI policyholders over the last several decades. As many carriers are transitioning from not just collecting insurance premiums to now paying significant claims benefits, it’s foreseeable that there will be additional scrutiny on the claims process.
Applying even more pressure to the situation is the predicted shortage of geriatric specialists, care managers and caregivers. Seniors will desperately need advocates to not only help them navigate their LTCI claims but also to navigate the complexities of the senior care environment. It’s expected that home care services, quality caregiving, and senior advocacy all will be in short supply and incredibly valuable. This demand is already being felt by non-medical, in-home care providers as they struggle to hire enough caregivers to meet the growing need.
Barry: Is home care right for everyone?
Thomas: Home care isn’t right for everyone, but it is ideal for many. Data from AARP’s Home and Community Preferences Survey* shows that 77 percent of adults 50 and older want to remain in their homes for the long term—a number that has been consistent for more than a decade. Most seniors intend to stay home and age in place. The challenge for many is that without a plan to make staying at home possible, their desire isn’t possible. For seniors who can’t afford to stay home or have complicated medical needs that make aging at home untenable, there are a range of options for them to consider.
Barry: You’ve highlighted how complex our healthcare system is and the challenges that seniors face. Whose job is it ultimately to make sure our seniors are cared for?
Amada: It’s our job to serve seniors, it’s the job of family members, and it’s the job of our communities. The complex needs of many seniors and families require an all-hands-on-deck approach. That being said, we have recognized how valuable and critical the impact of LTCI is for families that have prepared ahead. We are huge proponents of LTCI and the higher quality of life and superior care that it delivers to many seniors who, without it, wouldn’t be able to afford the personalized care they need to stay healthy and happy at home.
Organizations that advocate for and educate consumers about the need for long term care planning are an invaluable resource. The movement to ensure consumers are educated and have all the information they need to make the best senior care decisions for their families will continue to grow and serve more people. And that’s a positive development no matter how you look at it.