When looking to file a new claim, there are five basic long term care questions to ask your insurance company

People who purchase long term care insurance usually pay premiums for years before an event or diagnosis leads them to open a claim and to the five long term care questions to ask.

There are different processes set by each insurance company for how to open the claim, and we have details about that here, but often the first step is to call the insurance company prepared with long term care questions to ask.

When calling, be sure to have the name of the policy holder, the policy number, and be ready to fax or email a power of attorney form, if needed. Often, a family member will call with the policy owner near by. That way the insurance company representative can get verbal permission from the policy holder to share information about the policy initially.

In planning to set up long term care at home or considering moving into an assisted living community, you’ll want to know the amount of insurance available and how long it’ll take to access it. That’s where the five long term care questions to ask are helpful.

A daughter helping to ask long term care questions
Daughter and elderly mother with long term care questions

1st of Long Term Care Questions – What is the elimination period?

When the long term care policy was first purchased, the buyers were likely given several options to consider with varying elimination periods, costs and benefits. The elimination period is the time from when care starts and the client pays, to the time when the insurance company starts paying.

Most policies have an elimination period of 120 days, 90 days, 60 days, 30 days or 14 days. Others have no elimination period at all. In order to budget and plan, the length of the elimination period is one of the important long term care questions to ask.

However, you don’t want to only know the length of time, but also how it is calculated. For example, some policies name a 60 calendar day elimination period, meaning 60 calendar days must pass from the first day of care. But, care does not need to be provided on all of those 60 days.

In this scenario, a client may have care three days a week for two months, and that will satisfy the elimination period.

If the elimination period is defined as “days of care provided”, then the client will need to have care on 60 days, whether that takes two months, four months, or six months, before the insurance benefit starts.

In conclusion, the first of the long term care questions to ask is “What is the elimination period?” Then follow up with “Is that elimination period based on calendar days or actual days of care?”

daily weekly monthly planner
Daily, Weekly, Monthly Planners

2nd of Long Term Care Questions – What is the daily, weekly or monthly benefit and what are the limits?

Most policies vary in terms of what the daily, weekly, monthly or overall benefits will be. Those options were picked when the long term care insurance policy was purchased, but clients typically can’t remember what they selected.

Therefore the second of the long term care questions to ask is, “What is the daily, weekly or monthly benefit”? This will help the client schedule care that fits into their budget if they need more than is covered by the long term care insurance.

At Home Nursing Care has billed long term care companies with every benefit imaginable. Some clients have a limit of $90 to $300 per day. Other clients have a limit of $5000 per week, and still others can use the benefits any way they choose, until they hit a maximum of $9,000 per month.

Some of the most generous policies, which are not really sold anymore, offer “unlimited benefits”, meaning the person may have $300 a day to spend for the entirely of their life, but that’s now rare. Far more common is a total amount set in the insurance policy, whether it’s $100,000 total, or $800,000 total.

activities of daily living
Aide helps with a transfer, an activity of daily living

3rd of Long Term Care Questions – How many ADL’s (activities of daily living) are required?

Finding out how many ADL’s or activities of daily living are required to receive reimbursement from a long term care insurance policy is the 3rd of the long term care questions to ask.

When a client has an accident or illness, under a long term care policy, there are certain supports that must be provided in order for the long term care company to reimburse the care.

The activities of daily living that are most often listed for long term care insurance companies include: Bathing, Dressing, Ambulation, Transfers, Incontinence Care or Toileting, and Feeding, which is help bringing food or drink to the mouth, not simply meal prepping.

Most policies require two to three activities of daily living be needed by the client in order to justify the long term care insurance claim.

There is one exception. When a person has mild cognitive impairment, the person will qualify for long term care insurance coverage just by virtue of needing “constant safety monitoring.” That’s because many seniors who are diagnosed with dementia can still bathe, dress or walk independently, but they don’t have the ability to reason or use proper judgement, making it unsafe to leave them alone.

Once it’s determined how many ADL’s are needed, then care notes should reflect that those services are being provided each shift. Otherwise the long term care company may not reimburse for days when the ADL charting is missing. At Home Nursing Care is expert at creating a plan of care, keeping electronic charting of care provided and billing long term care insurance, saving our clients time and frustration.

It’s important to note, while other services such as errands, light housekeeping, help with meal prep, incidental transportation to doctor’s offices, are important needs for seniors, those services alone do not trigger coverage under a long term care insurance claim. Avoid trying to open a claim because, “Mom can’t drive anymore and can’t get to the store,” or “Dad is just not cooking anymore and needs help making meals.” In those scenarios, the claims are often denied. However, having an in-home caregiver plan, shop and prepare meals helps seniors maintain strength and improves nutrition.

RN Assessment
RN Assessment of Client at Home

The 4th of Long Term Care Questions to Ask – Will the LTC agency send an RN for an assessment or will an agency’s RN assessment suffice?

In order to start a long term care claim, some insurance companies will use a nursing service to call the client or visit the home and assess the diagnosis and need for assistance with ADL’s or constant safety monitoring. It’s helpful to have paperwork available, such as the recent discharge summary from a hospital or nursing facility, or any paperwork from a doctor listing the diagnosis.

If the RN calls the client, it’s a good idea to make sure another responsible person is there to monitor the call. At Home Nursing Care had a situation once where the nurse talked to a client with mild cognitive impairment who was convincing that he didn’t need any help at all. That’s despite the fact he certainly needed constant safety monitoring and kept leaving the stove on or forgetting where he was while driving. While fixable, the situation created some confusion at first.

Other long term care companies will rely on the RN assessment from the homecare or home health agency being hired by the family, saving time and the extra step.

During an RN assessment, the nurse will evaluate the client and will mark which ADL’s are needed and to what extent. Some people may need what’s called “stand-by assistance”, meaning a caregiver is ready and available right nearby if needed. Other levels of need include “hands on” assistance or “total dependence.” Even stand by assistance with two to three ADL’s is enough to trigger coverage in a long term care policy.

A good homecare agency will use the RN Assessment to create a client centered plan of care, so that the client’s needs, wants and goals are met. Caregivers follow that plan of care each shift, and chart the care they are providing.

signed doctors order
Doctor Signs Attestation of Care Needs

The 5th of Long Term Care Questions to Ask – Is a signed statement from the physician required?

Most policies want as much documentation as they can get to limit fraud when it comes to long term care policies, so they often require the client to get a signed statement from the attending physician or primary care physician attesting to the client’s condition and need for assistance.

Long term care insurance companies typically have their own forms, many of which are available online and easy to download and fax or deliver to the physician. You can find links to several companies and their claim process here. We recommend calling the physician’s office ahead of time and explain they will be getting a form to fill out related to a long term care claim being initiated.

It’s important to use a physician who is aware of the client’ s needs. Sometimes, elderly clients don’t visit their physician regularly. There is also the issue of physician retirements or merging physician groups, leaving a client unsure where to go.

Medicare will often cover visits from a House Call Doctor. Ask the agency you will be using for a referral, if needed. Or check with the client’ s medical insurance for an in-network physician who is accepting new patients. You can search for a reputable and experience agency by zip code through the main state association, CAHSAH.org.

Once these steps are taken, the insurance processing should go smoothly. Care notes and invoices must be submitted together on a regular basis, typically by fax, email or through a portal. Clients may decide to pay for care directly and be reimbursed by the long term care insurance company. Of they may sign what’s called an “assignment of benefits”, meaning the agency will be paid directly, with the client only paying for extras such as miles, groceries, or care that goes beyond the policy limits.

Some long term care companies will periodically check in with the client, mainly to ensure that the need for care has not changed.

Having a long term care policy, while it may have been expensive, can lead to more choices and freedom when it comes to care, as Medicare does not typically cover long term care needs, especially when someone needs 24 hour care.

Those are the five long term care questions to ask when it comes time to open a claim.