If your parent or spouse has a long-term care insurance policy, it may cover some or all of the cost of in-home care. But policies vary widely, and understanding the details before you file a claim can save time and prevent denials.

This article explains what to check in a long-term care insurance policy and how to navigate the claims process.

What Long-Term Care (LTC) Covers

Long-term care insurance is designed to pay for long-term care services, including:

✓In-home care (personal care, homemaking, companionship)
✓Assisted living
✓Nursing home care
✓Adult day care

Most policies cover in-home care, but the specific terms vary. Some policies cover care only from licensed agencies. Others allow independent caregivers. Some have daily or monthly benefit limits. Some have lifetime caps.

What to Check in the Policy

Benefit Amount

✓What is the daily or monthly benefit amount? This is the maximum the policy will pay per day or month.
✓Is the benefit amount fixed, or does it increase with inflation?
✓How does the benefit amount compare to the actual cost of care in your area?

Benefit Period

✓How long will the policy pay benefits? This may be stated in years (e.g., 3 years, 5 years, lifetime) or as a total dollar amount.
✓Is there a lifetime maximum?

Elimination Period

✓The elimination period is the waiting period before benefits begin. It is similar to a deductible. Common elimination periods are 30, 60, or 90 days.
✓During the elimination period, you pay for care out of pocket.
✓Some policies count the elimination period in days of care received, not calendar days. This means if your loved one receives care 3 days a week, a 90-day elimination period takes 30 weeks to satisfy.

Qualifying Conditions

✓Most policies require that the insured person need help with at least 2 activities of daily living (ADLs): bathing, dressing, toileting, transferring, continence, or eating.
✓Some policies also cover cognitive impairment, such as dementia, even if the person can still perform ADLs.
✓The need for care must be expected to last at least 90 days.

Care Provider Requirements

✓Does the policy require care from a licensed agency?
✓Does it allow independent caregivers?
✓Does it require a care plan from a health care professional?
✓Does it require ongoing assessments?

Exclusions and Limitations

✓What is excluded? Common exclusions include care needed due to self-inflicted injury, war, or certain pre-existing conditions.
✓Are there any specific limitations on in-home care?
✓Does the policy cover all levels of care, or only skilled care?

Premium and Lapse Status

✓Is the premium current? If the policy has lapsed, benefits may not be available.
✓Have premiums increased over time? Some policies have rate increases that can make them expensive to maintain.

How to File a Claim

Step 1: Gather Documents

✓The original policy document
✓Any riders or amendments
✓The premium payment history
✓Your loved one's medical records
✓A doctor's statement about the need for care

Step 2: Contact the Insurance Company

✓Call the claims department (the number is usually on the policy)
✓Ask for a claim form and instructions
✓Ask what documentation is needed
✓Ask about the elimination period and when benefits will begin

Step 3: Get a Care Assessment

✓Most policies require a care plan from a health care professional
✓A doctor, nurse, or care manager can assess your loved one and document the need for care
✓A care agency can also provide an assessment

Step 4: Submit the Claim

✓Complete the claim form
✓Include all required documentation
✓Keep copies of everything
✓Follow up regularly until the claim is approved

Step 5: Understand the Ongoing Requirements

✓Most policies require periodic recertification of the need for care
✓Keep records of all care provided, including dates, hours, and services
✓The insurance company may request updates or assessments

Common Challenges

Claim Denial

If the claim is denied, you have the right to appeal. Common reasons for denial include:

✓The insured person does not meet the ADL requirements
✓The elimination period has not been satisfied
✓The care provider does not meet the policy's requirements
✓The documentation is incomplete

If your claim is denied, request a written explanation, review the policy, and consider consulting an elder law attorney who specializes in long-term care insurance claims.

Premium Increases

Some long-term care insurance policies have had significant premium increases. If the premium has become unaffordable, options include:

✓Reducing the benefit amount or benefit period
✓Increasing the elimination period
✓Contacting the state insurance department for assistance

Policy Lapse

If the policy has lapsed due to non-payment, benefits may not be available. Some states have reinstatement provisions if the lapse was due to cognitive impairment. Check with the insurance company and the state insurance department.

Tips for Success

✓Read the policy carefully before filing a claim
✓Keep detailed records of all care, communications, and documents
✓Follow up regularly with the insurance company
✓Get help if needed from an elder law attorney or care manager
✓Start the process early because it can take weeks or months

A Final Note

Long-term care insurance can be a valuable resource, but navigating the policy and claims process can be complex. Take the time to understand the policy, gather documentation, and follow the process carefully. If you need help, a care provider or elder law attorney can guide you.

If you would like help understanding how long-term care insurance works with in-home care, Healthy at Home offers a free care assessment. We can help you understand what documentation is needed and how to get started.

Using Long-Term Care (LTC) for Home Care: What to Check in Your Policy