Alternate Plan of Care in Long-Term Care: Definition + How It Works

Updated

Certified Care Manager, Aging Life Care Professional, and National Master Guardian Emeritus

If you have a long-term care insurance policy, it can be easy to miss the clause defining an alternate care plan. Long-term care policies continue evolving to accommodate people’s care and the need for flexible plans. 

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The definition of long-term care is also changing. People live longer, and throughout their lifespan, they may opt for several different long-term care settings based on preference and care requirements. 

Long-term care settings include living at home with home care, assisted living, memory care, independent senior living, and nursing home care. Some long-term care policies cover services (once you meet the criteria) in these circumstances, and others don’t. Review your policy to ensure that it covers services at home if that’s where you intend to stay. 

Definition of Alternate Plan of Care

In health care, a “plan of care” or “care plan” is a standard feature of home health, assisted living, memory care, and nursing home care. In these healthcare settings, a care plan identifies functional needs and provides a plan to address those needs. For example, suppose someone needs assistance with mobility or dressing. In that case, the care plan specifies how often the staff provides that care.

However, a long-term care insurance policy defines a plan of care differently. It’s important to understand a typical plan of care in a long-term care policy. As part of filing a claim for yourself or a loved one, you will request the plan of care from home health, assisted living, and home care agencies involved in care. In some cases, Medicare-covered services can count towards your elimination period. 

Although policies differ, some similarities remain. If you think about any other insurance you have- for your care, home, or health, you must meet the criteria to qualify for reimbursement. The same holds for long-term care insurance plans. Most plans will clearly define what qualifies for reimbursement. Generally, it is substantial assistance in activities of daily living (ADLs) in at least two of these areas:

  • Dressing. When someone needs significant assistance with getting dressed and undressed daily.
  • Eating and Feeding. When someone can’t feed themselves and requires someone else to bring the food to their mouths. 
  • Transferring. When someone needs another person to help them stand and move from a bed or chair. Stand-by assistance does not qualify. The person helping must use hands-on techniques to help you get up.
  • Bathing. Assistance with getting in and out of a shower or tub and help with the act of bathing. If someone is bed-bound, assistance could be bed baths each week to keep the person clean and free from infection. 
  • Toileting. Helping someone get to the toilet and use the toilet. Also, assistance with hygiene related to toileting.
  • Continence Care. Some people are incontinent of urine and or bowels and need assistance with changing Depends and keeping clean. Other people have catheters or colostomy bags and can’t care for those themselves. Consistent continence care helps prevent infections which are much more likely with people who can’t urinate independently.

When you review these activities of daily living, they may not come close to everything your loved one needs to stay safe and functional. That’s where an alternate plan of care can help. Requesting these additional services and equipment is worth pursuing, and your success will depend upon documentation and following the policy guidelines.

When Would You or a Loved One Need an Alternate Plan of Care?

You or your loved one may meet all of the criteria listed above, but you still have other care needs. Medical technology is evolving, and insurance policies can’t account for every device or medical intervention. An alternative plan of care is a broad term used to describe other services not listed in the policy. You or your loved one could have your policy for 10 to 20 years or more, and the policy itself can’t account for every need. 

How Does an Alternate Plan of Care Work?

Consider if your loved one continues to decline and requires more functional assistance through telemedicine, equipment, or home modifications. In that case, your policy might include those benefits in an alternative plan of care. Most people would prefer to stay at home to receive the care they need. Some of the possible services covered under an alternate plan of care:

  • The purchase or rental of medical equipment such as wheelchairs or walkers is deemed appropriate for your needs and ability. Depending on where you live, a device like a Hoyer lift might be helpful if it means the difference between being in bed all day or getting up in a chair. 
  • The payment for care management services through a care management organization to assist you or your loved one with making decisions about long-term care options. A care manager also reviews your plan of care and suggests changes. Care managers can also refer you to local resources and help you apply for any other benefits you qualify for.
  • Caregiver training for someone designated by you who wants to learn how to help you. Some possible training services help with therapeutic devices, changing wound dressings, and repositioning in bed. A nurse could provide the caregiver training, and the insurance company pays for this training. Respite care for a limited time period. For example, if you or your loved one is receiving benefits at home, but your family needs relief, long-term care may pay for a short respite stay in assisted living or time in adult daycare. Request this benefit carefully since it is likely that the policy will only approve a time-limited stay during a defined period.
  • Payment towards an emergency response system (ERS). An emergency response system is a device that alerts emergency personnel for assistance during a medical emergency. Most ERS are monthly rentals, so find one and get pricing to present to your insurance company. 
  • Assistance with telehealth technology. Perhaps you or your loved one is unable to access outpatient medical treatment. A device such as a computer or a laptop is necessary to use telehealth. The long-term care insurance policy may consider the purchase of a device to be a necessary medical expense.

How Can You Get Access to an Alternate Plan of Care?

Long-term care policies explain how to access an alternative plan of care and the services covered under that plan. Read the fine print so you aren’t denied once you apply. Some policies may specify the alternative services, and others may not, but you can always file a request as long as you follow the long-term care instructions. These are the basic steps.

Identify the need

The first step to access the alternative plan of care is to identify your or your loved one’s needs that go beyond the daily paid amount. Make sure the service is something that’s required for safe functioning or to improve health and well-being. 

Contact your physician

Contact you or your loved one’s physician to get an order for the equipment or service. An order from the doctor shows that what is needed is medically necessary. Ask the physician to detail how the alternate service keeps you or your loved one safe.

Contact the insurance company

Your next step is to contact the insurance company to request the alternative service covered under the policy. If you have already received reimbursement from the claim, reach out to the claims person you have dealt with. Upload all of your documentation and anything else the insurance representative requests.

Follow up

If you haven’t received a response in a timely fashion, follow up with a phone call or email. Many long-term care companies are large institutions, and your request could get lost in the shuffle. Try and be persistent and file an appeal if your request is denied. 

Alternative Plan of Care

Insurance of any kind is not pleasant to deal with. However, you want everything you are entitled to regarding your financial and physical well-being. Stay persistent and document all requests for services and equipment covered under an alternative plan of care. Your chances of success will improve if you follow our steps.

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