By Steven Buttice, Founder and President Living By Your Design, Inc.
Taking time to help a parent with their insurance questions and claims can seem overwhelming, especially when you are dealing with insurance questions of your own. Life today is active, especially for women aged 45 – 55 who care for both their parents and children. These are the people caught in the “sandwich generation”.
Mom planned ahead; she purchased LTC 15 years ago, but filing a claim is not like filing a medical insurance claim. Mom not only had to be receiving coverable services, she had to meet the claim “triggers”. The policy stated that to be eligible for benefits, she had to either need assistance with 2 activities of daily living or need 24-hour substantial supervision because of a cognitive impairment. Logically, it was the safety/supervision issue that was the trigger she was able to meet. She is able to dress, bath, and do the other thing by herself. So, how is the need for 24-hour substantial supervision proven?
A consultant suggested that a diary and related paperwork be kept on mom for when she didn’t seem to process situations or when she put herself in situations that were not safe. She even had an auto accident 5 months ago. So, that information and medical report was also kept in this diary file along with other situations. After the accident, it did not appear she was safe to drive, so the car was never replaced. All of this information was given to mom’s doctor and mom went through a thorough exam. Mom’s situation was also discussed with the facility. While she has a lot of freedoms, there is security at the facility and a large enclosed courtyard where mom can go outside most anytime she wishes.
So, when claim was made, mom’s portion of the form was completed. Her doctor and facility both completed forms and included information regarding the need for substantial 24/7 supervision for safety from their observations and the diary. Yesterday, mom received her first check.
Now, it’s time to work on your family’s health insurance. Your insurance company may have sent you a letter stating they are discontinuing your current plan. So, where do you start? You will find the process much easier and with a better outcome if you secure the advice of a local ACA certified health insurance expert.
Ask questions such as who is in the network of doctors? Is this a PPO (can go outside of the provider network, but the plan pays better in network)? Or is the plan an HMO, where you pay 100% of all costs out of network? Are my medications covered? Are services provided at my doctor’s office covered in the doctor’s office co-pay? Are the major specialty groups that you may go to in-network?
All of this is complicated, especially when caring for your family and parents. Therefore, get professional help. Your premiums will be the same whether you use an ACA agent or enroll on your own. The results could be significantly different.
Whether you are planning for your parents or yourself: start early and seek professional help. Start early; do not wait for a crisis.
For more information, contact Living By Your Design, Inc., focusing on the issues of the elderly: legal, financial, free guidance for residential placement, and healthcare issues. Call: 309-285-8088. Website: www.LivingByYourDesignInc.com. Location: 809 W. Detweiller Dr., Peoria, IL 61615.
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