UNUM LTC policy - residency requirements...where to find and how to interpret?

[Tia Suzanne]

Hi! Newbie here-

If a resident of a LTC facility wants to be "home" a lot (especially due to covid) instead of at the LTC, is there a Federal/State law or some Insurance Industry protocol that states how often she needs to stay overnight at the LTC facility to keep her actively on claim and not get denied continuing benefits? There is a major concern that she is not living (overnight) at the facility enough and will be canceled once they notice.

My first guess is that in the policy language it's mentioned, but I'm not sure it states a specific formula anywhere (like 60% residency) or if it is an open-ended metric (subjective).

She's been going home to her family intermittently through this whole COVID mess and now the family is worried that during an annual review (2021) it will come to light that she's been "gone" for a lot of the time.

Fortunately with many of the children in her family on COVID WFH status, they've been able to manage having her at home, but that is unusual. They'll be going back to their own homes (other states) once all the vaccines are administered and won't be at the family home to help out anymore.

In case it matters:

1. She is in Assisted Living due to a serious seizure disorder, resulting cognitive impairment and short-term memory issues. She is very young for an A-L facility.

2. Pre-covid she would leave the facility on her own every day for a walk in town, to run simple errands etc. She can not work or drive due to the combination of her cognitive &memory issues. No physical impairment.

3. The LTC manages her seizure medications and that's the ONLY additional service they provide, other than random monitoring due to her seizure frequency.

So...I guess I'm wondering 'where in the policy' do I look to see where this kind of home vs away calculation would be mentioned?

Thank you!

Identifying anything else that I'm missing here that would affect the policy administration would be super helpful as well.

 

[Arthur Rudnick]

Tia,
According to every LTC contract, the insurance company must be apprised and approve, where the policyholder is receiving care.
This has nothing to do with federal or state laws.
If a policyholder receives care in a facility, the company will pay whatever amount is specified in the policy. If the policyholder is at home receiving care, the company pays the home care amount.
You, or someone in the family needs to contact the company and get everyone on the same page. You also need to read and understand the policy.
Arthur

 

[kpbdy99]

Is it a facility only policy? No home care benefit? It should have a "bed reservation" benefit, but I think on the old Unum policies that capped out at 30 days/year. If the policy doesn't have a home care benefit, there may be an alternate care benefit she could beg off on for a little leeway, considering the circumstances, but as Arthur says, the family needs to be talking with the carrier. You certainly don't want them to discover this six months from now and decide to recoup 6 months' worth of benefits. Where is the agent???

 

[ltcadviser]

As Arthur and Kerry have stated this is a policy specific question. The UNUM policy should provide home care benefits as well as a limited bed reservation benefit. Read the contract. Now, the key will be to update the insured’s written Plan of Care with UNUM if the family intends to provide home care to the jnsured. This updated Plan of Care will need to be reviewed and approved by UNUM.