LTC Claims Administration Toolbox - Section 4
On Site Reassessment Tool
A. Introduction
This section features a condensed version of the comprehensive On Site Assessment (OSA) tool.
It includes all of the categories included in the OSA but has been modified in order to avoid any
undue inconvenience to the insured (or their representative) by requiring duplicative information.
It is intended to provide the insurer with information sufficient to:
Verify that benefit eligibility triggers continue to be satisfied;
Evaluate if the plan of care continues to be appropriate for the insured’s needs; and
Identify any unreported changes in the Insured’s care providers or level of care changes
B. Discussion
The same 8 categories used in the OSA are represented in the Condensed Reassessment. The
categories are:
Personal
Medical History
ADL
IADL
Falls
Cognitive
Behavior and Emotions
Caregiver
If physical or occupational therapists have been providing services it would be helpful to obtain an
update from the therapists on the insured’s progress and anticipated timeline to achieve
established goals, especially if those goals include independence with ADLs.
C. Condensed Reassessment Tool
The sample Condensed Reassessment Tool included in this section provides LTC insurers with
ideas of what could be incorporated in their reassessment tool. Definitions are broad and must be
tailored to match the definitions of the individual company’s policies if any or all parts of the tools
are used. The simple style of formatting used is purposeful so that the tool can be easily
replicated or reformatted if an insurer is interested in using any of this information in their own
reassessment tool.
The sample Condensed Reassessment tool shown here addresses only those areas related to
gathering functional and cognitive information, as well as other critical pieces of information,
required to verify continued benefit eligibility and to update a plan of care specific to the insured’s
changing needs. It does not include pages that would provide policy information or any
information the insurer might obtain relating to the assessor or the third-party administrator.
D. ADL Assessment
It is important information, as it is used for care planning purposes to ensure previously
established goals remain appropriate and achievable. If the insured is in an assisted living or
skilled nursing facility, the assessor could review the medical record including transfer records if
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On Site Reassessment Tool
applicable, as well as all clinical documentation provided by physical, occupational, and speech
therapists for verification of the self-reported information.
E. Cognitive Assessment
Standardized Tests
The Cognitive section should contain both an objective/standardized screening test and
behavioral and emotional questions related to cognitive function. Insurers will decide which one
of the standardized tests that are available will be used as part of their reassessment in order to
determine an insured’s cognitive status. Examples of objective/standardized tests are the MiniMental State Examination (MMSE, also known as the “Folstein”), the MCAS, Delayed Word
Recall (DWR) or the Short Portable Mental Status Questionnaire (SPMSQ).
Once the insurer has established which test they will be utilizing, the insurer needs to establish
what criteria meets each of the required benefit triggers as defined in their policy. For instance,
establishing the scores of the standardized selected by the insurer’s that identifies severe, mild
and moderate cognitive impairment right on the assessment tool (see tool for example) provides
objective and consistent determinations on this component of the assessment.
Some insurers may wish to include a second generally accepted standardized test in their claim
administrative policy when the documentation received to determine eligibility for benefits is not
clear or conflicts with the primary test that has been obtained. The insurer should establish a
policy with how to proceed if the second test conflicts with the first.
Some insurers may wish to consider other testing which may not be considered “generally
accepted” because they are:
a) new and not widely used in the clinical or insurance communities;
b) are purely propriety in nature; or
c) cannot be easily found in the “common” medical journals or websites.
While many cognitive tests are emerging and may be appropriate for claim determinations, the
insurer should consider the following risks when selecting a “standardized” test for cognitive
evaluation:
a) Is it medically accurate? Consider factors such as sensitivity, specificity, and risk of
assessor error.
b) What is the insurer’s tolerance to customer complaints, litigation and public relations
risk?
c) How suited is the test to procedures, workflows, policyholder skills and vendor
capabilities?
Behavioral/Emotional Questions
The questions used in this section need to be clear enough and include sufficient assessor
instructions to limit interpretive errors by the on-site assessor.
When insurers ask Behavioral/Emotional questions as part of the cognitive assessment, they
need to establish clear procedures to rate or score these questions for the purpose of determining
how the responses would indicate poor judgment, deficient deductive and abstract reasoning, and
or indicate threat to safety and health. This is critical to minimize subjective interpretation by
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On Site Reassessment Tool
assessors and reduce variability across assessors responsible for determining if the benefit
triggers have been met.
Certification for Tax Qualified (TQ) Policies
If the insurer will be asking the on-site assessor to evaluate the ongoing eligibility for TQ
certification, there should be clear instruction and clarification of terms used in this certification
process to limit assessor variability. Therefore the insurer needs to establish what meets each of
the required benefit triggers as defined in their policy and include this information in the
certification document.
The cognitive section of the TQ certification document should be written in a manner that clearly
shows that certification requires that the insured have both “severe” cognitive impairment AND
require “substantial supervision,” the latter being defined by the IRS as meaning continual.
An example of assessor instructions to include in a certification document for TQ certification
follows. If an insurer’s definitions are different from above or the insurer’s triggers differ, the
instructions and actual certification would be altered from those below to reflect the differences.
The example reflects the use of the MMSE as the standardized test:
TQ certification requires that the claimant have BOTH “severe” cognitive impairment AND
to require “substantial” (IRS defined as CONTINUAL) supervision to protect the claimant
from threats to their health and safety.
•
•
Severe cognitive impairment is demonstrated by an MMSE* score of 0 to 10 or a
score of 11 to 23 in conjunction with behavior problems consistent with severe
cognitive impairment such as those in the “behavioral questions” section that
pose a threat to the claimant’s health and safety.
SUBSTANTIAL supervision requires that the supervision be CONTINUAL.
Intermittent or periodic supervision such as only a daily medication reminder or
telling a claimant they have a doctor’s appointment are not continual or
continuous in nature and are therefore not generally considered “substantial” in
nature.
Examples of certification statements based on MMSE* scoring:
A. I certify this claimant has a SEVERE cognitive impairment as documented by either an
MMSE score of 0 - 10 alone or an MMSE score of 11 - 23 in addition to known behavior
problems consistent with severe cognitive impairment AND requires SUBSTANTIAL
(defined as continual) supervision to protect this SEVERELY cognitively impaired
claimant from threats to their health or safety.
Yes ______ No _______
B. I certify this claimant requires SUBSTANTIAL (IRS defines as CONTINUAL) supervision
to protect this SEVERELY cognitively impaired claimant from threats to their health or
safety. SEVERE cognitive impairment is documented by either an MMSE score of 0 - 10
alone or by an MMSE score of 11 - 23 in addition to known behavioral problems that
threaten their health or safety.
Yes ______
No _______
* If using a test other than the MMSE, substitute the appropriate scores to both the Scoring
Section on the actual cognitive test used in the assessment and in the actual certification
statement.
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On Site Reassessment Tool
F. Fall Risk (Frailty) Assessment
The terms “frail” or “fear of falling” are often used when describing why an insured requires
assistance with ADLs. The definitions of “frailty” describe things such as “a freestanding
syndrome marked by loss of function, strength, and physiologic reserve and increased
vulnerability to falls, sickness and death” or “inactivity, weight loss and decline in functionality
(grip strength, walking speed, exhaustion, etc.).” Some definitions also include depression,
isolation, “a lack of drive,” or “loss of interest in activities, family or friends.”
A Fall Risk Assessment provides valuable insight into possible causes for falls resulting in injuries
leading to the inability to complete ADL functions. A Fall Risk Assessment, when combined with
the other information collected in an assessment, provides a complete picture of the insured’s
physical and emotional status and contributory environmental factors that put them at risk. This
additional information is incorporated in the POC and becomes key in promoting independence.
For those who have come on claim as a result of an injury due to a fall, the information gathered
from the Fall Risk Assessment can help prevent a return to claim if the cause of the fall can be
addressed through the POC.
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