How to file a long term care claim – the 1st step
The first step in how to file a long term care claim for insurance coverage is to contact the insurance company and follow their process for opening a claim. Most long-term care insurance companies post full claim packets online, explaining how to file a long term care claim. Those packets can be downloaded from their websites, which are listed below. Other long term care companies have online claim forms, provide a phone number, or send a packet by mail to help families file a long term care claim.
This process applies to those who purchased long term care policies, either stand alone or as “riders” attached to other insurance, such as life insurance. Medicare, commercial health insurance and employer sponsored health plans typically do not cover long term care costs.
What is needed to file a long term care claim
Typically, when going through how to file a long term care claim, the long-term care insurance company will need the name of the beneficiary, the policy number, the reason for opening a claim and in some cases, an evaluation by a Registered Nurse and/or a form signed by the beneficiary’s physician. They might conduct a phone interview with the person needing care, or ask for proof of a recent diagnosis or hospital stay.
Mild cognitive impairment and how to file a long term care claim
Each long-term care policy has stated rules for when a person can file a long term care claim. For example, in the case of memory loss, defined as mild-to-severe cognitive impairment, the reason will typically be for “constant safety monitoring.” This means the person may be physically very independent, but due to memory issues, must have supervision to avoid wandering or lack of safety in the home.
In the case of mild cognitive impairment, the need for constant safety monitoring is typically enough to satisfy the conditions for starting a long term care claim, even if no other “hands on” services are required.
Activities of daily living needed in how to file a long term care claim
For those beneficiaries who are facing a loss in physical independence due to age, an accident or disease process, the requirement may be that the beneficiary needs help with at least two or three activities of daily living, or ADLs. Activities of daily living often include bathing, dressing, ambulation, transferring, toileting and feeding. The level of assistance required may be just someone “standing by” close in case help is needed up to “full assist,” meaning a caregiver provides hands on assistance to accomplish the ADL.
Getting payment from a long term care claim
In order to get the invoices paid by the long-term care insurance, the care may need to be provided by a licensed home health agency or home care agency, which provides a copy of its license and W9 to the long-term care insurance company, in addition to providing proof of worker’s compensation insurance. In addition, the invoice must be submitted to the long-term care insurance company along with daily chart notes, proving that the care needed was provided.
Some policies allow for private caregivers, but be aware that caregivers are never independent contractors, and they will need payroll taxes deducted, paid sick time, hour and wage laws to be filed and a true payroll check, never cash or a personal check.
Using an assignment of benefits in how to file a long term care claim
An in-home care client may choose to pay for the care directly and be reimbursed by the long-term care company, or the client may want to sign an “Assignment of Benefits” form. This allows the agency to be paid directly by the long-term care insurance company. One question to ask the long term care insurance company is whether they have their own assignment of benefits form. If they don’t, the homecare agency should be able to provide one.
It’s also a best practice for the policy owner to sign a “HIPAA” waiver naming a trusted family member or the staff of a reputable home care agency to talk with the insurance company. That way if any issue comes up, the client may have assistance in clearing up the confusion to make sure the claims are paid properly and on time.
If a client needs a power of attorney or is subject to guardianship, the paperwork will need to be submitted to the long term care company as proof.
Understanding the “elimination period” in how to file a long term care claim
Most claims have an “elimination period”, which is a time when care must be paid for by the client before the insurance coverage starts. Elimination periods may be 120 days, 90 days, 60 days, 30 days, 14 days, or there may not be an elimination period at all.
While each policy may be different, often the first time the person needs care can count towards the elimination period. For example, if someone suffers a stroke and is hospitalized, that first day in the hospital would be day one. Then if the person was transferred to a rehab facility for two weeks, those two weeks will also county towards the elimination period.
One good question to ask the insurance company is whether the elimination period applies to “calendar days” or “actual care days.” For example, a 120 calendar waiting period may allow a client to have care just twice a week for three months. If the 120 days relates to “actual care days”, then the person would need 120 actual days of care before the insurance coverage kicks in.
How At Home Nursing Care helps clients with how to file a long term care claim
At Home Nursing Care, Inc. is very experienced with helping our clients open, process and get coverage with their long-term care policy. Our RNs conduct evaluations, create a full care plan, and supervise the home care being provided. We submit invoices and care notes every other week to the long-term care insurance companies on behalf of our clients at no charge. We take assignment of benefits when requested as well. We are also proudly a BBBForGood designated company, showing our commitment to the community.
There is also a service that can help with how to file a long term care claim. Click here to meet Linda Jahnke and learn about her team.
Here are links to several long term care insurance companies for more information about opening claims. We’ve posted their claims packets when available. We hope this helps as you navigate how to file a long term care claim for yourself or your loved one. Having long term care coverage provides additional choices when someone faces a lack of independence due to age or health related factors, as Medicare typically does not cover long term care expenses, such as caregiving or companion care.
This article, originally posted in 2022, is updated regularly.