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Managing Long Term Care Claims

Key Items to be Aware of as You Start Your Claim

You or your family member have been paying premiums to the insurance company for decades, and now it is time for them to pay you. We have helped scores of people start their long term care claims and then provide the ongoing care and documents that are required to receive reimbursement. Here are ten key items you want to be aware of:

  1. If you don’t have a copy of the policy and any associated riders, contact the insurance company for those documents.
  2. Does it have an elimination period (where you have to pay out of pocket for the services)? If so, what satisfies it (i.e. some policies require a minimum number of visits per week and a minimum number of hours per visit in addition to a defined period, like 30 or 90 days, while other policies may count the whole week if you get 1 or 2 visits that week).
  3. What needs must the client have and must be documented at each visit (e.g. most policies require the client to need assistance with two Activities of Daily Living (ADLs) or have cognitive impairment)? ADLs are mobility, eating, hygiene (including bathing), dressing, and toileting. It is rare for a policy to cover home making activities only (i.e. meal preparation, cleaning, laundry, etc.). If the person doesn’t get assistance with those ADLs at the visit then the policy won’t pay for that visit.
  4. Make sure you understand the allowances per period; some policies have a daily allowance while others have a weekly or monthly allowance. Make sure you understand the lifetime allowance also.  
  5. Make sure you understand the duration of the policy.  Make sure you know if you can start and stop the claim, and if you can, does it require the elimination period to be satisfied again?  Does the policy go by visit days or calendar days (e.g. a 2 year policy may be for 730 days that can be used over a much longer timeframe).
  6. Is the benefit an indemnity amount, where regardless of the expense of care you will get paid out a certain amount (e.g. the daily care may cost $200, but the policy may pay a daily amount of $300)?
  7. The insurance company may send an RN to do an assessment and will typically want to see doctor’s orders validating #3.
  8. The home care agency will have to do an assessment to meet state requirements; this may need to be done by a RN, depending on the state and the care needs.  This assessment and the corresponding Plan of Care that is created will need to be sent to the insurance company.  We will send those documents for you.
  9. A copy of the invoice and the notes will need to be sent to the insurance company for each visit.  Some insurance agencies also use a third party telephony system for the caregivers to log in and log out; that can replace sending invoices and notes.  We will send those to the insurance company weekly for you.
  10. Overall I see that most people wait too late to use their policies. As a result they only utilize a fraction of the coverage even though their lives and the lives of their families could have had a higher quality if they had started their claim earlier.

When you are at the point where you or your family member need care you want to work with a trusted agency. Our focus on providing quality care truly sets us apart locally and nationally. Click here to learn more about us, and click here to understand the type of care we provide.

Thank you and call us for more information! 704-879-2394

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