Argh! Navigating an insurance provider’s policies can be challenging to say the least. It is not easy to decipher how things work, or how to set things up for the long term with the patient’s interests in mind. Here is what I learned and what you need to keep in mind:
Hospital Social Worker can be your best friend.
I didn’t even know that my mother’s insurance covered at-home care services. The hospital social worker gave me a high level explanation and then, took the initiative herself, to get the forms filled out with the necessary signatures from my mother and the doctors. I know that was part of her job, but seriously, God bless her for doing it! Without her I would have been lost. Looking back, I wish I had spent more time with her understanding how this would work once it got set up and my mom was home. In any case, I learned it myself… and so can you.
Every insurance policy is different. I knew this. But from my experience reviewing policies for Mom and others (some family members have asked me to review policies for their parents given how much I learned through the process), I have learned one big watch out: Some policies only cover in-home care immediately after a hospital visit but not on an on-going basis. This “immediately after” could mean 3 weeks or 3 months, but it’s never on an on-going basis. So, it’s important to understand if your loved one’s primary or secondary insurance covers this on an on-going basis and their process for evaluating a patient’s needs – i.e. how many hours a week of at-home care through an aide will be approved based on the patient’s condition and need. It’s also important to understand timing. In some cases, once a request is filed, the insurance can take up to 30 days to review and another 30 days to start the aide services. That means it can be two months from when you first request it to when an aide shows up at home. So, apply early. You can do this with the help of the social worker while your loved one is still in the hospital.
The insurance will usually send their own RN to review the patient’s needs and evaluate how many hours per week of support they need. Make no mistake, they are stingy. It’s their job to ensure their company isn’t paying more to support someone than is absolutely necessary. They also evaluate from a (minimum) need perspective vs an (ideal) quality of life perspective. In the end, they want to manage their costs. They’ll look at multiple factors and enter all the info into their computer system which will spit out a Needs Level and recommended hours/week range. For example, a patient who lives alone may get more hours for the same condition than someone who lives with their family.
A quick note on Appeals. They exist! I was pleasantly surprised that I could appeal a decision by the insurance. First step, understand what they are for and how the process works. If the insurance allocated (say) 20 hours/week of aide services for your loved one, but you truly believe their conditions, including pre-existing conditions, warrant more help (say 30 hours/week), you may have the option to file an appeal. Second, make sure you file the appeal within the said timeline and provide all the details needed. Third, you are your loved one’s best advocate. So, take the time to think through and paint a picture for the reviewer on the other end (who are human beings in the end) on why more hours are needed. For example, one can simply list that your loved one has Osteoporosis or one can add an extra line to say that this fact combined with the fact the patient is a fall risk, increases likelihood of fractures and long stints in rehab, which the insurance will have to cover ultimately.
Renewal of Benefit
Typically, the insurance will approve aide benefits for 3 or 6 months at a time. To renew, you may need to get documentation from a PCP to attest to the fact that you need on-going in-home care. Make sure you stay on top of these periodic check-ins with the PCP, who will require the patient to come in and assess their physical capabilities, and progress on health conditions before sending a request directly to insurance. But it doesn’t end there. In addition to the PCP notes, the insurance will send their RN as well on a regular basis to establish for themselves what hours/week are warranted and you go through the same process mentioned above.
While setting up in-home care for your loved one can take time, diligence, and patience, remember that you are the best advocate for your loved one and setting things up well will save you time, energy later and ultimately, be the most beneficial for your loved one.