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Long-Term Care Fraud and Abuse

Our Nursing Home Abuse Attorneys Assist with Insurance Fraud and Abuse in Long-Term Care Settings 

Long-term care is a term encountered often in nursing homes, assisted living facilities, and other literature about or geared toward the elderly. The definition of long-term care generally covers any sort of permanent or regular assistance with daily activities. These activities of daily living, or ADLs, include dressing, bathing, eating, continence, walking, and getting in and out of chairs or beds (transferring). Assistance with these ADLs is usually provided by a trained or qualified caregiver, therapist, or private duty nurse. As with nursing homes, these settings can lead to fraud and abuse. If you suspect your loved one is being harmed — financially or physically — we encourage you to consult with our California nursing home lawyers. 

Who Needs Long-Term Care?

Any person who has trouble accomplishing activities of daily living on his or her own could require long-term care. According to the U.S. Department of Health and Human Services, approximately 60% of people who use long-term care today are over the age of 65. The natural process of aging tends to create a need for assistance with ADLs, although several individuals with chronic or permanent disabilities, injuries, or other conditions also require and use long-term care.

Is Long-Term Care a Medical Benefit in California?

There remains disagreement in the medical and service-providing community today as to whether or not long-term care is a health benefit. For many people, the need for long-term care results from a medical issue. It is also the case that some long-term care providers are medically trained. Yet, several organizations do not treat long-term care as a medical benefit.

Much of the disagreement about the medical status of long-term care relates to questions of insurance and coverage. For example, Medicare does not generally pay for long-term care.

Because most types of health insurance do not cover long-term care, many providers have begun offering health insurance specifically for long-term care.

Medicare and Custodial Care

Medicare distinguishes between two different types of long-term care: “custodial care” and medically necessary “skilled care.” Most instances of long-term care fall under the former category, and are not covered by Medicare. This is because Medicare only pays for “medically necessary skilled nursing facility or home health care.” According to Medicare, custodial care does not require skilled medically trained personnel assistance.

The fact that Medicare does not cover most types of long-term care can come as a shock to people – especially the elderly – who find themselves suddenly in need of the assistance provided by long-term care. A recent article in the Los Angeles Times states that long-term care in California costs an average of $70,000 a year – a significant expense for individuals living on fixed income or social security.

The growing need for long-term care combined with the fact that long-term care is generally not covered by most health insurance plans has given rise to a variety of plans and offerings specifically geared toward long-term care. These offerings can have complexities and risks associated with them.

Medicaid and Long-term Care

Medicaid or Medi-Cal pays for nursing home care for elder people with limited incomes and assets. Medi-Cal also sometimes pays for home and community long-term care, but eligibility is largely based on income and resources rather than the state of your health. Eligibility for Medi-Cal long-term care coverage is often extremely complicated, and the patient is still often required to pay for services not covered by Medi-Cal.

In general, the resource limit for Medi-Cal eligibility is $2,000 for a single individual. Medi-Cal also operates according to a “share of cost” procedure. This means that if an individual’s net monthly income is higher than the state payment rate ($600 monthly for a person in the community or $35 monthly for a person in a nursing home), then the individual must contribute to a portion of the long-term care bills, with Medi-Cal paying the remainder.

Types of Long-term Care Insurance

Who are some of the top sellers of long-term care insurance?

The following are some of the top-selling companies of long-term care insurance:

  • Columbus Life Insurance
  • Conseco
  • Genworth Life Insurance Co.
  • John Hancock
  • LifeSecure Insurance Co.
  • Massachusetts Mutual Life
  • MedAmerica Insurance Co.
  • Metropolitan Life
  • National Life Insurance
  • Prudential Insurance Co.
  • TransAmerica Life Insurance
  • Woodbury Financial Services

If you or a loved one are encountering potential fraud or abuse regarding long-term care or long-term care insurance and would like a free and confidential consultation with a California elder care lawyer at the Evans Law Firm, call toll free 888-50EVANS (888-891-4906) or 415-441-8669 or by email at

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