LTC Insurance Claims Information from The LTCpro®
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A 15-minute video introduction
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Part of a longer presentation that includes information on reverse mortgages
and Medicaid benefits originally presented as part of the 2020 Triangle Caregivers Summit.
and Medicaid benefits originally presented as part of the 2020 Triangle Caregivers Summit.
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This page is designed for LTC insurance policyholders or their loved ones to help guide you through what is often a confusing claims process.
If you're just getting started, or if you're stuck, we're here to help! CONTACT US for claims help! |
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The Key Issues Which Cause the Most Problems at Claim Time:
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Are you "BENEFIT ELIGIBLE"?
Nothing happens until you meet the policy's criteria for eligibility which is based on measuring a degree of impairment or limitations, either physically (based on help with the "ACTIVITIES OF DAILY LIVING" - ADLs) or mentally (needing supervision for a COGNITIVE IMPAIRMENT). How the physical help or mental supervision is defined is critical to understand. |
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The "ELIMINATION PERIOD"
This is how long you must wait - or self-pay for professional care services - before benefits are paid. The ELIMINATION PERIOD (EP) doesn't start until you are determined to be BENEFIT ELIGIBLE (see #1 above). Sometimes this can be set at a date in the past when the physical or mental impairment began, in some cases it starts only after you file a claim and the company determines you are eligible. The number of days of the EP is easy to find on the policy's SCHEDULE OF BENEFITS page, but how the days are counted can be complex and the definition is buried in the detailed policy language. There are several different ways EP days are counted, they can be different based on the type of care you need, and they may require that you spend money out of pocket on professional care for a day to count. |
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Care Provider Eligibility
Is your desired care provider even covered by your policy? Nursing Homes (also called Skilled Nursing Facilities) are covered by almost all policies (the exception would be a "home care only" policy). Some older policies that do not have specific Assisted Living Facility (ALF) definitions either will not cover an ALF or you may have to negotiate for payment based on the policy's specific language. If Home Care is covered, the definition of a covered "HOME CARE AGENCY" (or "Home Health Care Agency") is critical; not all agencies are covered depending on the policy's language and how your state licenses (or not) home care services. Very few policies cover individual, unaffiliated caregivers, and even fewer policies will pay benefits for a spouse or other family member to provide care. Before you contract with a home care agency or ALF - especially a "family care home," make sure they are a covered and approved care provider with your insurance company! |
Before starting a claim, make sure you have copy of the actual policy - not a brochure, not a quote, not a summary, not a billing statement. A "schedule of benefits" page may provide some basic information to get you started, but a copy of the entire policy is critical to have when starting and managing a long-term care insurance claim, especially if there are any questions about benefit or provider eligibility.
If you do not have a copy of your policy, request one from your insurance company immediately. You can call the phone number shown on any billing statement or other company information you may have.
CLICK HERE for a list of customer service numbers for the major carriers.
If you do not have a copy of your policy, request one from your insurance company immediately. You can call the phone number shown on any billing statement or other company information you may have.
CLICK HERE for a list of customer service numbers for the major carriers.
NEXT: Benefit Eligibility >
NOTE: This information is for educational, informational purposes only and is not meant to provide specific guidance for any particular policy, policyholder, or claim situation. LTCI claims eligibility is determined by the insurance carrier based on the specific criteria in the issued policy contract and the carrier's own guidelines.
