The Insurance Buying Guide: What Does LTC Insurance Cover?
Long-term care insurance provides four principal types of benefits:
- skilled nursing care;
- intermediate care;
- custodial care; and
- home health care.
Skilled nursing care is care provided under the direct supervision of a licensed physician. The care is provided on a 24-hour basis and is administered by registered nurses and/or physicians.
For example, Sarah, age 77, has had serious surgery. Sarah is well enough to be discharged from the hospital, but she needs skilled nursing care for a period of time due to the surgery. She is admitted to a nursing home.
Intermediate care is nursing care for individuals who do not require the degree of care that a hospital or skilled nursing facility provides, but do require some medical care under the direction of medical personnel. Intermediate care is administered under the supervision of a registered nurse, but also may be administered by a licensed practical nurse or physical therapist.
Example: Sarah slowly recovers from the effects of her surgery and is now able to take care of herself to a small degree. However, she is still in need of frequent medical care. Sarah's care may be downgraded to intermediate care.
Custodial care is primarily for the purpose of meeting essential daily living requirements. This type of care may be administered by volunteer workers, licensed practical nurses and therapists.
Example: Due to the seriousness of Sarah's surgery and her age, she is never able to fully recover and needs daily help with such things as walking, bathing, dressing and feeding herself. Although recovered from her surgery, she may be in need of continued custodial care.
Generally, LTC policies provide benefits for each of these levels of care. The policy may require that the care be provided by a state- or Medicare-approved nursing facility.
Home health care is intermediate and/or custodial care provided in a home setting. The home health care benefit provided by LTC policies is usually 50 percent to 85 percent of the regular skilled nursing care benefit. Some policies now allow you to select whether to receive institutional or home care. To qualify for home health care benefits, you usually need to be certified by a physician as unable to perform two or more of the activities of daily living.
Home health care benefits include visits to the patient's home by a registered nurse, the services of practical nurses, physical therapists, etc. More liberal LTC insurance policies may even pay for home care provided by family members. However, this is specifically excluded from coverage on other policies.
In recent years, there has been a shift in LTC insurance claims. More and more, LTC insurance policyholders are filing for home health care and adult day care benefits -- rather than skilled nursing benefits.
Basic LTC Benefits| Level of Care | Type of Care | Administered By |
| Skilled | Administration of medication, changing surgical dressings, therapy, general rehabilitative and custodial care | Administered By Doctors, RNs, practical nurses and therapists |
| Intermediate | Therapy, general rehabilitative and custodial care | RNs, practical nurses and therapists |
| Custodial | Assistance in walking, practical bathing, dressing, eating and daily living requirements | RNs, nurses and general therapists |
| Home | Intermediate and/or some custodial care | RNs, practical nurses, social workers and therapists |
Adult day care almost always is provided as an optional benefit on an LTC policy. An adult day care facility provides a structured environment, where the adult receives medical care and participates in a variety of health, social and related support activities for a few hours each day. Such care includes transportation to and from the facility, as well as meals.
Hospice care may be a standard or optional benefit. A hospice is an organization whose primary purpose is to provide comfort and an acceptable environment for the terminally ill. Coverage for hospice care will include home visits by social workers, as well as registered nurses. It also includes in-patient services in a hospice. Typically, a hospice will keep a terminally ill patient comfortable in his or her last days, but it does not provide life-saving or life-prolonging treatment.
Often, as part of the hospice benefit, respite care may be provided for family members who are responsible for the care of the terminally ill patient. Respite care provides a break in the day-to-day routine and care of the terminally ill. For instance, a patient may be admitted to the hospice to give the family "a temporary rest" for a short period of time. Following the respite, the patient returns to the home and the care of the family.
