There is no coverage for a nursing condition in the state health law; Civil services in this regard are limited; HMOs provide a good and relatively inexpensive insurance tier, but limited in years; Many people also purchase private long-term care insurance – what is long-term care insurance, what are the advantages and disadvantages of such insurance? And is it worth taking out long-term care insurance?
Let’s start with the simple fact – insurance by definition expresses an overpayment for a service that you may need in the future. Insurance companies make a profit because of size – they insure a large group of people and they pay according to the statistical average, so they should know in the first place what the cost of insurance will be for them, and they charge more (the difference is their profit). The problem – in many cases, the statistics change over time, and this is also what happens in the field of long-term care insurance – the population is growing, the cost of care is growing, and the big question – do insurance companies understand the cost they are planning to pay in the future? Probably so, which is why these insurances are becoming more expensive on a regular basis, which is why insurance companies simply do not pay for long-term care insurance claims and look for various excuses to evade.
And what does that mean – is it worth taking out long-term care insurance? So it is important to explain that there are several types of long-term care insurance. There is long-term care insurance through the health funds which is not bad at all and is relatively cheap (compared to long-term care insurance with insurance companies) but it is limited to a period of 5 years. Insurance through health funds is also good thanks to the approval rates of insurance companies. Simple – insurance companies do not mess with the HMOs, it is no longer as simple as evading payment to an individual. Insurance through the health funds is about to undergo a revolution in which all long-term care insurance will become uniform and their price will increase – see here for an extension.
In any case, in addition to insurance through the health funds, there are insurances from the insurance companies that allow for the expansion of existing insurances both in time and in scope. There are also insurances of the insurance companies that offer financing starting from a certain stage – after 3 years or other periods – this is a kind of guarantee for nursing care financing above a certain amount of self-financing.
Long-term care insurance is important, but is it necessary? Probably not given the risks involved – first, a good chance you will not get the money from the insurance company; Second – the insurance premium may change over the period (what you pay now is irrelevant to what you will pay later). So if so, why is it good? Maybe if the (high) amount you set aside for insurance, you allocate and save on the side for future nursing needs, you will receive an amount that can be no less than the amount that the insurance company will provide you? It’s not really clear, and most people (and rightly so) would not want to take that risk? But, it is important to know that on average you get less than what you pay to the insurance company!
Ultimately it is a cost benefit – how much does the insurance cost, what is the benefit in it, when calculating the benefit you have to understand and internalize that you are not completely insured – both because the insurance companies by definition are erased, and because the situations and critiques change, and no one knows if your insurance today Relevant in 30 years.
Still, long-term care insurance is very popular and expanding – people are just afraid (and rightly so) that they will not have money for this difficult time in life. And beyond that, people are also afraid that they will be a financial burden on their family – nowadays, by law, if the insured does not have funds from providers, they turn to his family to finance his care.
A person can become a caregiver suddenly; It can also happen at a young age due to illness, although most cases refer to the elderly. The costs of caring for a nursing patient reach about NIS 7,000 a month, and even more, if he is hospitalized at home; And much more, if he is hospitalized in a nursing home at a reasonable level and above. In many cases the costs fall on the family members of the nursing patient as well as the care itself.
Who is defined as a caregiver?
It is the state that has defined who a nursing person is, and this definition is binding on the insurance companies and the National Insurance Institute. By definition, a person is defined as a caregiver when he or she is unable to perform at least 3 of 6 basic daily activities on his or her own and needs help and / or supervision. The 6 actions in question are: eating and drinking, walking, getting up and lying down, dressing and undressing, bathing, controlling the closures. Under the definition of a nursing patient is also a mentally debilitated person who requires close supervision (an Alzheimer’s patient or dementia, for example).
The assessment of a person as a caregiver is done through a test called ADL. The test is performed both by the National Insurance Institute for the purpose of granting a nursing benefit and by the insurance companies and the health funds. The test examines the basic actions relevant to defining a person as a caregiver, as noted above. In addition, the test examines the degree of supervision that the person needs and whether he lives alone.
What are the rights to which a nursing person from the state is entitled?
Most of the rights for a nursing person are granted through the National Insurance Institute and the Ministry of Health.
Social Security supports nursing patients staying at home through a nursing benefit, and the Ministry of Health financially supports the hospitalization of patients in nursing homes.
Social Security nursing benefit is given to nursing elderly people over the age of 65 and not to younger people. The worldview of the National Insurance Law in this context is that one should strive to allow the nursing patient to remain in the environment of his home, family and the social environment he is familiar with. Therefore, the National Insurance Nursing Benefit is intended to help finance the costs of the person’s nursing care in his home and it is not intended to assist in the issue of nursing hospitalization.
What is a Social Security nursing benefit?
In essence, a nursing allowance is designed to provide the services necessary for those who need help from another person in order to perform basic daily activities. It is not intended for assistance with household chores only. The National Insurance Institute determines through a nurse or a welfare representative the services to which the elderly person is entitled and which factor will provide them, on the basis of a visit to the elderly person’s home and an assessment of his or her functioning.
Services provided through Social Security:
Funding of weekly care hours in the nursing home – up to a maximum of 18 hours of weekly care.
Visit to a day center for the elderly – up to a maximum of 6 days a week.
Supply of disposable absorbent products.
Personal distress button.
Not all services are provided as part of the benefit, but only services with the value of the benefit determined according to the patient’s condition and the degree of his dependence on others to perform operations. You can convert nursing care hours and receive one or more of the three additional services offered. The amount of Social Security nursing benefit also depends on the patient’s monthly income (excluding income from Holocaust survivors’ benefits from abroad).
Nursing benefit services can be converted into money if the patient employs a “foreign worker” or an Israeli caregiver or close family member for at least 6 days a week, at least 12 hours a day.
Approval for the employment of a foreign caregiver is given by the National Insurance Institute and only when the person in need of nursing can perform most of the routine daily activities. The salary cost of a foreign caregiver close to the patient is about NIS 3,500 per month The National Insurance Fund finances a maximum of NIS 2,950 out of this, and the difference is covered by the patient and his family. The older the foreign worker, the higher his salary will be, and he will also receive it, if the family wants him to stay. Fees from both the therapist and the patient, but today it is also possible to do this independently.
If it is a nursing patient in a wheelchair, the cost of preparing the house must also be taken into account (adjusting the doors of the rooms and toilets to the width of a wheelchair; installing a ladder in a house with stairs, etc.). Sometimes it is even necessary to change the place of residence accordingly. There is also the possibility of financial assistance in this case from the state.
Assistance from the Ministry of Health to a patient hospitalized in a nursing home
Ministry of Health: The Ministry of Health helps fund hospitalization in nursing homes with which it has an agreement. The amount of assistance from the Ministry of Health (known as a geriatric “code”) is granted according to the person’s nursing level and according to the income test (including that of his spouse and children). Hospitalization in the cheaper nursing homes costs about NIS 9,000, and it reaches up to NIS 18,000 and more in the expensive institutions. The cost of nursing care in a mid-level nursing institution can amount to about NIS 140,000 per year. Some families sell the parents’ apartment, which they were supposed to inherit, in order to finance the maintenance of their foster parents in a reasonable nursing home (better than those who make headlines due to neglect and beating hospitalized …). And what happens if the nursing patient’s spouse is still alive and living in the apartment? After all, then it is not possible to sell the apartment, and the burden is even greater.
The Ministry of Health has a budget for subsidizing hospitalization through “codes”, which it issues to nursing patients over the age of 65. The amount of “codes” it can approve is limited and therefore only a few receive the full subsidy. The maximum code value is NIS 9,500, and it depends on the income test of the elderly person and his family members. The subsidy is transferred to the nursing home only after the elderly person has participated in the financing as much as he can (old-age pension, pension income, and even NIS 24 for his home that becomes vacant). After submitting the application.
In addition to various discounts and exemptions granted to the elderly in general, the Ministry of Economy in some cases provides assistance in financing hospitalization in a special institution for the mentally debilitated.
What is long-term care insurance?
Similar to the state health insurance, where the health basket is comprehensive, but does not provide a satisfactory answer to all diseases and all medications, the rights and assistance that the state provides to the nursing patient are not sufficient.
That is why long-term care insurance comes to meet the real needs. Long-term care insurance provides the insured with a monthly benefit over time, depending on the insurance he has purchased, regardless of the insured’s financial situation. There are two main types of insurance – long-term care insurance (group) for HMO members and long-term care insurance for insurance companies. As with any insurance – the insured pays a monthly premium in exchange for the insurer’s commitment to a specific and defined coverage of the nursing expenses.
Both the private long-term care insurance and the HMOs define a person as long-term care on the basis of the ADL test. It should be noted how the insurance company representative interprets the examinee’s ability to perform any action; If the subject can perform only 50% of the operation and less, it should be considered that he is unable to perform the entire operation.
The advantage of long-term care insurance through the health funds is cheap
HMO long-term care insurance is group insurance operated through private insurance companies, with each HMO having the insurance company with which it works; Clalit with Dikla, Maccabi and Leumit with Clal, and United with the Phoenix. There are differences in the terms of the policies, both in terms of coverage and compensation periods and in terms of the premium, and a health statement is required.
It was recently announced that the Insurance Supervision Authority intends to make the long-term care insurance policies for HMO members uniform and identical in terms of conditions, including amounts and periods of compensation. The reform on the subject is expected to take effect from the end of 2015.
The big advantage of HMO nursing insurance is that it is cheap because it is group insurance. The disadvantages are that the premium and insurance terms can change over the years, the compensation period is usually limited to 5 years. Hostility but also to injury while flying or a nursing condition following a birth defect.
For example; In Clalit Health Services, a 25-year-old joiner will pay starting at NIS 1.5 for the first year of insurance, while a 65-year-old will pay about NIS 100. Those who join under the age of 18 (usually attached by their parents) will pay zero shekels per month. At Maccabi Silver – there is no payment for those who join up to the age of 17, for those aged 18-29, about NIS 5 per month, for those aged 60-65 – NIS 61 per month. In the Maccabi Gold route, which also has high coverage, the rates are tens of shekels higher for the elderly.
The health insurance of the HMOs does not have a qualifying period (a period of paying a premium without compensation, even if during which the insured became a long-term care) but there is a waiting period of 60-90 days until the financial coverage is received. The compensation is made in exchange for receipts, and there is no compensation, for example, for the hours of care of a family member in the nursing patient.
Today there is also a problem with long-term care insurance in the transition from one fund to another, an issue that you have applied uniform insurance to all funds, should also deal with. While the transfer between the HMOs is free, joining the HMO’s long-term care insurance is conditional on filling out a health declaration and an underwriting process. There are situations in which the insured is in a worse health condition than when he was insured in the fund from which he transferred, and he may not be admitted to the long-term care insurance for the members of the HMO to which he moved or be required to pay a premium due to his health condition.
Personal / individual long-term care insurance
Since the HMOs ‘long-term care insurance is also limited in its coverage and during the years of coverage, many of the HMOs’ long-term care insureds add another insurance layer – private, which is provided by the insurance companies. The majority purchase insurance that will begin from the moment the HMO’s insurance ends; For example, if you are insured with a health insurance fund for NIS 5,000 per month for a period of 60 months, the majority purchase similar coverage for another 5 years in private insurance. There are also those who buy, mostly affluent people, full coverage of private long-term care insurance without the first tier of HMOs.
Personal / individual long-term care insurance is a personal insurance policy between an insured and an insurance company. Today, it is possible to purchase personal long-term care insurance that provides lifelong insurance coverage, and it can also be limited in years.
The premium is determined by the age of joining the insurance (the younger you join, the lower the premium) and changes at a fixed rate each period. In individual policies, it is possible to accumulate rights over the years of payment, so that even if you stop paying after a few years, the insured retains some of his rights through settlement values. Joining long-term care insurance is conditional on the insured’s health declaration, usually written.
The insurance policies of the private insurance companies differ from each other in terms, the amount and types of coverage, the period of coverage and more, and therefore the rates are also different. It should be noted that women pay more because their life expectancy is higher than that of men.
Joining at the age of 30, a man – NIS 50 to 65 per month, a woman – NIS 70 to 110 per month.
Joining at the age of 50, a man – from 190 to 350 shekels per month, a woman – 230 to 350 shekels per month.
The amount of the premium may differ in the policies of different companies, as stated. You should check the policies of different companies before deciding to join one insurance company or another.
One third of insured claims are denied
The Supervisor of Banks published a year ago findings that insurance companies pay on average only 66% of the long-term care insurance claims submitted to them, including only partial payments. According to the inspectorate, the situation with the HMOs’ long-term care insurance was only slightly better.
why is it happening? Because as with any commercial insurance, insurance companies find every excuse why not pay – failure to properly disclose the health statement, failure to meet the conditions of defining the insured as long-term care and more. As stated, in Israel a person who is unable to perform at least three out of six daily operations is considered nursing, and then he is entitled to receive the insurance premium. The Supervisor of Insurance claimed in its announcement that some of the companies interpreted the rules in a way that benefited them when they took advantage of situations in which a person is only able to perform part of the operation – for example, getting up from sitting to sitting but not from sitting to standing. The inspection regulations stated that “anyone who is unable to perform a substantial part (at least 50% of the operation)” will be considered as unable to perform the operation at all. ” They divide each action to give an action and give a score for each sub-action.If the score has accumulated to more than 50%, the insurance companies have determined that the person is able to perform the same action daily, even if he is unable to get out of bed after going from lying to sitting, or can bathe Only his upper body.
In light of the difficult findings, the Supervisor of Insurance, Dorit Salinger, issued a clarification according to which an insurance company is required to examine whether an insured is able to perform a substantial part of any action on his own and not to examine the accumulation of sub-actions. Pay attention to the conditions for determining the functional assessment both in the terms of the policy, and when making a claim, when the insurance company will send a representative on its behalf to perform a functional assessment.
In general, it is advisable to check in the policy all its terms, what the exceptions are, what the premium is and how it varies from period to period, what is the compensation period, and whether there is a difference in the compensation amounts between staying at home and being hospitalized. Take with you someone who has taken out such insurance, or someone who is knowledgeable about it.
Qualifying period and waiting
Most personal long-term care insurance policies have a qualifying period of 3 months, from the date of purchase of the insurance, in which the insured pays the monthly premium but is not entitled to benefit from the insurance payments if he has become long-term care during this period. In addition, there is also a waiting period, usually of 3 months, from the day it was defined as nursing, until the actual start of receiving the payments.