Health insurance is a big problem for self-employed individuals. Many are uninsured because they can’t afford to pay the premiums. Anyone without health insurance always takes a risk. For the self-employed, they are the business. A major illness not only affects their health but it could cause them to lose their livelihood. What options are available for individuals in this situation?
Medicare insurance, the federal health insurance program for individuals aged 65 and older, can be confusing. Three very helpful websites are: www.medicare.gov, www.aarp.org, and www.ssa.gov. Some individuals think they are eligible for Medicare when they retire but it is not based on work status *(with the exception of certain medical issues) but rather age. You should file several months before you turn 65. The open enrollment period each year is January 1st to March 31st with an effective starting date of July 1st.
The American Association of Homes & Services for the Aging (AAHSA)
Provide free consumer tips for finding home and community based services, assisted living facilities, nursing homes, and continuing care retirement communities.
1-202-783-2242
The American Association of Retired Persons (AARP)
Provide brochures and other information on long term care and housing options.
1-888-687-2277
With long term care it’s essential to understand the difference in formal and informal care. Care is given by many types of individuals and in many locations. Medicare, major medical and long term care policies define what’s covered and what’s not. Formal care can be provided by volunteers or paid individuals and is usually associated with a medical facility or some type of service organization. Informal care is provided by family members, friends, neighbors or volunteers, and in some situations they receive payment for their services.
Examples of formal long term care providers include: home care agencies, assisted living facilities, community services, hospice, church and service groups, adult day care centers, senior citizen centers, and state aging associations. The services vary by community, city and state. Most states have departments of aging and many of the state/city services fall under this. The local senior citizens center is always a good place to inquire about the types of care available in your community.
Medical insurance and long term care policies define the types of care covered and the types of acceptable facilities. With major medical/hospitalization coverage the usual choices are hospitals, doctors offices and other type treatment facilities. But long term care can take place in many different environments and facilities. Before you purchase a long term care policy make sure you understand this and exactly what your policy covers.
Nursing home is the term most of us are familiar with. We define it as place we never want to live or never want to put a loved one. But they provide a critical service in our society. The types of home vary by the kind of care given and the state they are located in. Medicare defines a skilled nursing home as a facility with registered nurses on duty 24 hours a day, a doctor on call at all times and it must have ambulance service to a local hospital. To be certified by Medicare, they require additional staffing and services in addition to the above requirements.
Types of care or level of care can be confusing to the average person. Insurance companies often base their payment amount, as does Medicare, on the type of care the patient needs. Typically these terms are used to differentiate the care given by a medical specialist as opposed to lesser skilled aides. Usually skilled care is covered by insurance whereas many types of custodial care are not covered, unless they are provided in conjunction with skilled care.
The American College of Medical Quality defines skilled care as “the provision of services and supplies that can be given only by or under the supervision of skilled or licensed medical personnel. Skilled care is medically necessary when provided to improve the quality of health care to patients or to maintain or slow the decomposition of a patient’s condition, including palliative (soothing intense emotions) treatment. Skilled care is prescribed for settings that have the capability to deliver such services safely and effectively.”
An individual needing assistance with physical or emotional needs over an extended period of time is defined as needing long term care. Typically this is due to a terminal illness, disability, sickness, injury or old age. Help is needed in the areas that a normal, healthy individual takes for granted.
The areas they need help with can include personal things such as bathing, dressing, or eating. If the individual remains at home help might be needed with household chores, yard work or laundry. Often individuals needing long term care are no longer able to drive and need transportation for doctor visits, to purchase groceries, or run errands. Sometimes it is difficult for these individuals to read or write and they require assistance with bill paying, letter writing or managing their personal affairs. Depending upon the illness, they might also require medical treatment, nursing visits or therapy.
Before deciding if you need long term care insurance coverage, you must first define long term care. It’s a term that’s misunderstood by many individuals. Some people mistakenly believe that long term care needs are covered by their major medical. Usually they are not covered by group or individual health plans. Others believe that Medicare or Medicaid covers this type of expense. Medicare offers some coverage but there are rules and limitations. Medicaid is administered by the state and typically an individual must be impoverished (no longer own their home and have a very small amount of liquid assets) to qualify. VA covers some costs of long term care but indefinite care is only covered when 70% of the disability was service connected.
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