LTC Insurance Doesn’t Have to be Complicated

It will depend upon the policy purchased, but services must be for those who are chronically ill or disabled and need assistance with various activities of daily living (ADL), meaning the essential skills one must perform to successfully care for oneself. In most cases, to qualify for LTCI benefits, you must demonstrate that you need help with at least two ADL out of this list of six:

• Bathing
• Dressing
• Incontinence and associated hygiene
• Toileting and associated hygiene
• Transferring to/from a bed/chair
• Eating (lifting a fork when food is placed in front of you)

Many policies will also cover care for those with dementia or cognitive loss. Right at Home can help advocate on your behalf so the process is as smooth as possible.

Filing a claim is a multistep process. The first step is to contact your LTCI provider to open a claim and let them walk you through their process. You should have your policy number, relevant documentation, and other information on hand when you call so you can answer specific questions about your situation and medical condition(s).

Many LTCI policies have an “elimination period” ranging from 30-90 days before benefits begin. During the elimination period, you are responsible for covering your care costs.

Most LTCI policies require specific documentation throughout the claims process, including medical records and assessments detailing the diagnosis or medical condition; physicians’ statements certifying the need for long-term care; proof of care based on the inability to perform two or more ADL, such as bathing, dressing, or eating; and the care provider’s information, including qualifications and licensing (when applicable).

After the necessary documentation has been submitted, the insurer will review the claim and determine if you qualify for benefits. If approved, benefits will start after the elimination period. The timeline for benefit approval and payment varies from company to company.

Claims can be denied for incomplete documentation or not meeting the criteria for care, or the insurance company may dispute the level of care required. It is important to read and understand the denial letter, gather the needed additional documentation or evidence, and file an appeal using the steps in the denial letter. If you believe your LTCI claim has been unfairly denied, you can reach out to your state insurance ombudsperson or consumer protection agency for more information. Right at Home can help advocate on your behalf and help you understand what needs to be done to resubmit your information.

If you think your parents might have a policy, discuss it with them now and make sure you know where it is and how to access it. You should know the carrier and terms before they need to use it. If your parents are unable to help you locate it, check their email accounts and files to see if there is information on a policy. Look through old bank statements to see if they’ve paid premiums. Make sure you also check any pension plans or other legacy retirement benefits packages.