Ask the Expert: Making Sense of Long-term Care Policies

by Amy Natt, MS, CMC, CSA

Q: My husband and I purchased a long-term care policy about 15 years ago. He has recently been in and out of the hospital related to falls, and I think it might be time for us to get some additional help in the home. I pulled out the policy, but it is overwhelming. Where should we start?

A: Long-term care (LTC) policies have gained popularity in recent years. Many people have purchased these plans in hopes of being able to age in place and bring the care they need into the home. There are some great policies and then there are policies that have so many hoops to jump through and criteria to meet that they never get fully utilized. Many people are in the midst of a health care crisis when they need the policy and get easily overwhelmed (and often give up) when trying to apply for benefits.

If you own an LTC policy, you should pull it out now and make sure you understand exactly how it works. Each policy is very different and the company you purchased it from originally may or may not be the current owner of the policy. Each year it is advised that you contact them and request an updated schedule of benefits. Make sure they have your current address and request any updates or changes in writing.

When the time comes to utilize your policy, there is a process that most insurance companies follow. They typically have a claims specialist you can call to inquire about initiating the claim. Here are some basic steps you can start with:

Step 1: Initiating a Claim

Call your long-term care company claims department. Each provider has a process for initiating a claim. It typically involves forms that you will fill out to determine if you are eligible for benefits, as outlined in your policy. Keep a notebook of dates and providers (hospital, therapy services, hospice, home care, etc.) you have used because it is likely they will want this information. If you have an elimination period (be sure to ask this question) those days of service may be counted. It is likely you will have some out-of-pocket expense as you go through this process, so be prepared for that.

Step 2: Establishing Eligibility

The LTC company will want to establish that the insured is eligible to receive benefits. There is language in your policy that states what criteria must be met to become eligible for benefits. For example, you may have to have documentation from your medical provider that you require assistance with ADL care (activities of daily living) such as bathing, dressing, toileting, transfers and ambulation. It is likely the policy will require that you need help with two to three of these tasks. Your policy may also have an option for coverage based on severe cognitive impairment. Documentation to substantiate this will
be required.

The LTC company will likely either arrange for a nurse to visit you and make an assessment, or the LTC will obtain clinical documentation from your doctor or provider. Once eligibility has been decided, then you can determine what types of services and providers your policy provides coverage for.

Step 3: Approving a Provider

The schedule of benefits will outline what services are covered and at what dollar amount. Examples might be home care, adult day care, assisted living or skilled nursing. There are also benefits for equipment and training in some policies, so read those parts carefully. The LTC company will provide the insured with definitions of each type of provider and instructions on what information should be submitted for each provider. They will then verify the provider and let you know if they will reimburse you for the care and the dollar amount. For example, if you are wanting home care and you have a benefit for home care, the policy will state what type of provider is acceptable. It may require that care come from a licensed home care agency, or it may allow for you to use independent providers or caregivers that you choose. There may be other requirements regarding homemaker or companion services.

The fine print is important. Until you go through the process of submitting everything required, you will not know 100 percent that you are going to be reimbursed, so have some money set aside that you can use during the elimination period (days needed before coverage begins). The terminology may be new to you, so ask for a definition sheet. If it is an older policy, some of the terminology may be outdated and you can request an alternate plan of care be created to cover benefits or providers not necessarily included in the original policy language.

Finally, you are dealing with a lot, so if it gets overwhelming, reach out to a professional for help. The LTC company may have a care manager or you can hire a private care manager (visit AgingLifeCare.org). Your attorney or someone with the provider you choose might also be able to help you navigate the claim.

Hang in there! You have paid good money toward this policy and you want to ensure you take full advantage of the benefits it can offer.

Readers may send questions to Amy Natt, an Aging Life Care ProfessionalTM, certified senior advisor and CEO of Aging Outreach Services. She can be reached at amyn@agingoutreachservices.co