Ask the Expert Q & A: Dust off Your Long-Term Care Policy

By Amy Natt

My wife and I have a long term care policy that we bought about 20 years ago.  How can we determine what benefits we have and when we should use it?

This is a great question. Many people purchase policies and tuck them away in a file or safe deposit box. Now is time to revisit that policy and find out exactly your coverage and how to access those benefits. Every long term care (LTC) policy is written differently, and no standard answer will apply across the board.

Start by finding a current copy of the policy and statement of benefits. If you are not able to locate these, call the company to request a new copy. If you chose to have an inflation rider (benefits increase over time), get a current statement of benefits that will reflect today’s dollar amount that your benefit covers.

When you are looking at your policy, here are some things to pay attention to:

  • What types of services are covered? Examples of covered services might be: Nursing Home, Assisted Living, Adult Day Care, Home Care, Care Advisory Services (or care coordination), Informal Care, Initial Care Advisory (or plan of care), Respite Care, and home modification or equipment.
  • What is your elimination period or the time between services being provided and eligibility to receive the benefit?
  • Do you have a lifetime or benefit cap within a certain time period?
  • Is there an inflation rider that has increased your benefit amount over time?
  • What is required for benefit eligibility?  Often a physician needs to certify in writing that you need help with at least two ADLs (bathing, dressing, transfers, toileting, eating) OR that because of significant cognitive impairment, supervision is needed.
  • What criteria must your providers meet in order to be eligible for the benefit? Some policies will outline criteria linked to licensure or certifications. You want to know what type of care and facility setting will be approved for your policy.
  • Is there an alternate plan of care?  Sometimes a claim it does not meet the standard criteria outlined. Due to special circumstances or additional details, you can file the claim through this alternative method for consideration.
  • Who is your point of contact? It is good to identify a current point of contact or benefit representative for when you have questions about your policy.

LTC policies are growing in popularity and often provide more flexibility in care options. They are an excellent way to ensure the care you need will be available when you need it and can be accessed in the way you choose. Not all policies are created equal and some of the older policies may have limited benefits. It is important to read that policy before you need to initiate a claim and review the benefits. If you are unsure or having difficulty deciphering the terms and implications, seek out a third party to help you do a more formal review.  This may be the agent who sold you the policy, a representative of the provider, facility representative, or independent care manager.   This will help you create a realistic plan for the future with accurate financial projections to fund care.