Does the policy cover a facility, or only a nursing home?
Start with the policy's own name on the front page, because this fork settles the rest. Comprehensive covers a facility and care at home. Nursing facility and residential care facility covers a room but not home care. Home care only pays nothing toward a room.
California helps, and there is a date on it. Insurance Code section 10232.92 makes a policy covering nursing facility confinement cover a licensed residential care facility too, at no less than 70 percent of the nursing facility benefit, and the Department of Insurance draws that line at policies sold after October 2001. It is a California rule, so a policy bought in Ohio in 1994 is a different conversation.
What has to be true before a single dollar moves?
Someone has to certify it, and the test is narrower than a family's sense of need. The Department of Insurance states the rule for tax qualified policies plainly: benefits are payable when the person is impaired in two of six activities of daily living, meaning she needs substantial assistance, hands on or standby, from a loss of functional capacity.
Dementia has its own door. Substantial supervision made necessary by severe cognitive impairment qualifies on its own, none of the six required.
Here are the six. A policy that is not tax qualified adds ambulating as a seventh.
- Bathing
- Dressing
- Eating
- Toileting
- Transferring, in and out of a bed or a chair
- Continence
Will it pay for a six bed board and care home?
A six bedroom house in Van Nuys and a ninety unit building on Wilshire hold the same license, Residential Care Facility for the Elderly. Size is a marketing word here, not a licensing category, and section 10232.92 keys coverage to the license.
A board and care home at $3,500 to $6,000 a month against a larger community at $4,500 to $8,000 a month sets how long a benefit pool lasts.
Take the license number, check category and status on the CCLD Care Facility Search, and give the claims line the licensed name the state shows. A reimbursement claim also wants an itemized monthly bill from that licensee, which an owner run six bed home may never have produced.
- CCLD Care Facility Search, California Department of Social Services, Community Care Licensing Division
- CDSS facility search, California Department of Social Services
How long until money starts, and who pays until then?
The Department of Insurance describes the elimination period as the wait that begins after the person qualifies for care. The clock does not start on moving day.
Counting is where two policies with the same ninety days come apart. One credits every calendar day once the person is certified chronically ill, care delivered or not. Another credits only days when covered care was received, so three home visits in a week credit three days.
Waiver of premium is an option a policy may carry, not a thing to assume. California makes the insurer say which: the outline of coverage has to describe the waiver provisions or state that there are none. Keep paying until that is in writing.
Where in the document does any of this sit?
If the policy has gone missing, ask the insurer for a certified copy of the contract and every rider, since the inflation protection your father paid extra for often sits on a page stapled to the back. The outline California required at the sale is numbered by statute.
| What to check | Where the outline puts it | Why it matters |
|---|---|---|
| The benefit trigger | Section 6, the benefit screens | Two of six daily activities, or cognitive impairment |
| The elimination period | Section 6, waiting periods | The days before anything is reimbursed |
| Inflation protection | Section 8, cost of care against benefits | Without it, an old benefit buys a fraction of a room |
| Facilities the policy will not pay | Section 7, noneligible facilities | Where a six bed home gets excluded |
Where your document disagrees with this table, your document wins.
Who will read the policy with you, for free?
HICAP, the Health Insurance Counseling and Advocacy Program, runs out of the California Department of Aging. Its counselors take long term care questions free, with nothing to sell, on (800) 434-0222.
A denied claim goes to the California Department of Insurance, which takes complaints against insurers on (800) 927-4357. The state prints both numbers in every outline of coverage.
An examiner will ask for the home's license number and status, both on the CCLD Care Facility Search. Skilled nursing is a different license and a different regulator, on Cal Health Find.
- CCLD Care Facility Search, California Department of Social Services, Community Care Licensing Division
- Cal Health Find, California Department of Public Health, Center for Health Care Quality
How is Senior Placement Agency LA paid?
Families pay us nothing. A community that takes in someone we introduced pays us a referral fee, so a policy that pays changes what your family can afford, and a family who can afford more is worth more to us. Weigh what we say about money against that.
Ask us which Los Angeles homes can produce an itemized monthly bill for a reimbursement claim. What the policy covers stays between you and the insurer.
Keep reading
- Assisted living costs in Los Angeles, and the ways families pay
- Board and care homes in Los Angeles
- Board and care or assisted living: how to choose between them
- Does Medicare pay for assisted living?
- VA Aid and Attendance and paying for assisted living
- The Medi-Cal Assisted Living Waiver, and what its waiting list means
- How to check an RCFE license before you move in
- What an RCFE license lets a home do, and where it stops
Bring the policy to the conversation
Read us the schedule page, the elimination period and the facility definition, and we will tell you which Los Angeles homes fit inside those numbers.
Questions families ask us
- Does long term care insurance pay for assisted living?
- Usually, when the policy covers facility care and the person meets its trigger. California Insurance Code section 10232.92 makes a policy covering nursing facility confinement cover a licensed residential care facility too, at no less than 70 percent of the nursing facility benefit. A home care only policy pays nothing toward a room.
- The policy pays a daily benefit. What does that buy in Los Angeles?
- Section 6 of the outline carries both maximums. Multiply the daily one by 30 and set it beside the local range. $150 a day is $4,500 a month, the floor of assisted living here at $4,500 to $8,000 a month rather than the middle. A board and care home at $3,500 to $6,000 a month is where a modest benefit stretches furthest.
- The insurer says the home does not qualify. Is that the end of it?
- Not necessarily. Ask for the denial in writing with the policy language it rests on, then read that language against the home's license record. HICAP counsels for free at (800) 434-0222, and the California Department of Insurance takes complaints against insurers at (800) 927-4357.
- We are not sure a policy even exists. How do we find out?
- Look first, because a forgotten policy usually surfaces as an annual payment to an insurer nobody recognizes. Failing that, ask about VA Aid and Attendance for a wartime veteran or a surviving spouse, and about the Medi-Cal Assisted Living Waiver, which covers care services but not room and board, and carries a waiting list.