Understanding Qualifying Medical Conditions for Long-Term Care in Houston, TX


Long-term care in Texas can be considerably expensive. No matter if you or a loved one needs care in a nursing home or assisted living facility, or if they need home health care, the costs average a minimum of $4,000 a month. In some Houston nursing home facilities, this price can easily exceed $6,000 a month.

Even with Medicaid, which provides health insurance to around 14 percent of Texans, or a long-term care policy from a private insurer, you might end up paying for a significant portion of these costs out of your pocket. If you or a loved one has been paying the steep premiums for long-term insurance since buying the policy, the insurance provider should cover the following expenses:

  • Home Care
  • Assisted Living
  • Respite Care
  • Hospice Care
  • Nursing Homes
  • Alzheimer’s Facilities

When filing for disability benefits, one of the most important steps to getting complete, high-quality medical care is understanding your policy’s qualifying medical conditions.

With a Houston disability attorney who has over 20 years of experience, Herren Law will walk you through the fundamental concepts regarding qualifying for long-term care. By calling the Herren Law office in Houston at (713) 682-8194, we can schedule a free consultation regarding your ability to qualify for long-term care.

Eligibility Requirements for Long-Term Care

When buying a long-term care insurance policy, many companies use a process called “underwriting.” This means that the insurance provider will closely examine and review your current health status as well as history. It is important to note that federal law prohibits a company from denying to sell you a health policy based on your health status. Unfortunately, this doesn’t apply to long-term care.

Making a claim on an existing insurance policy, however, holds greater potential for possible denial. This is where the main problem lies for many Houston residents. To be approved for an insurance claim covering long-term care, you need to prove the nature and degree of a physical or cognitive loss to your insurance provider. When making a claim, this proof comes in the form of a written statement from a licensed health care practitioner as well as any medical bills, formal diagnoses, and other documents explaining the severity of a disability.


What are the Activities of Daily Living?

Many insurance provides require at least 2 out of the 6 activities of daily living, also known by its acronym as ADL. These 6 activities include:

  • Bating – getting in and out of the tub or shower, washing your body, washing your hair
  • Continence – maintaining control of bowel and bladder function
  • Dressing – putting on or off clothes as well as braces and/or artificial limbs
  • Eating – feeding yourself from a container with utensils, or feeding yourself via feeding tube or intravenously
  • Toileting – getting on or off the toilet, performing personal hygiene
  • Transferring – getting into or out of bed, chair, or wheelchair

An inability to live independently, defined by the inability to complete 2 out of the 6 ADLs, is a strong indicator for long-term care.

Severe Cognitive Impairment

In addition to the 6 ADLs, severe cognitive impairment is another “benefit trigger” (a condition that initiates a long-term care policy). According to the Centers of Disease Control and Prevention, cognitive impairment is defined “when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life.”

Therefore, impairment is more than memory loss. It is a severe condition that necessitates substantial supervision over a patient. As a qualifying medical condition for long-term care, severe cognitive impairment must be thoroughly documented in medical records. Also, make sure to organize all associated paperwork (this goes for conditions that render a person unable to live independently as defined by the 6 ADLS).

Other Essential Pieces of Information

Before filing a claim for long-term care, thoroughly comb through your insurance policy. It is within the policy that you’ll find essential pieces of information regarding qualifying conditions. For example, most policies have an elimination period that refers to when a policy begins after any “benefit triggers.” In Houston, this elimination period is generally around 90 days, although it could be longer depending on your policy.

Also, qualifying for long-term care might depend on the policy holder’s current level of care. A common reason for denial occurs when a patient receives care from an independent care provider, as opposed to an eligible care provider.

Contact an Experienced Disability Attorney in Houston, TX

Whether it was the sudden onset of a debilitating illness, an accident, or other problems, knowing that a loved one is going to require long-term care is a heart-breaking, overwhelming experience. At Herren Law, we fully understand the emotional turmoil of this situation, and with over 20 years of experience helping over 4,000 people from Houston and the surrounding area, we know how crucial it is to get loved ones the financial backing needed for quality medical care.

If you have questions regarding qualifying medical conditions, or if you need a knowledgeable disability attorney to go through the claim filing process, call Herren Law today at (713) 682-8194 for a free initial consultation.

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