A long-term care (LTC) insurance policy can make a huge difference in helping cover the costs of care in a nursing home, an assisted-living facility, an adult day care center, or at home – but for many caregivers, handing insurance claims for a parent or loved one can be a daunting process. After all, not all policies are the same, and benefits can vary.
To get started, request a copy of the full policy from the insurance company (or employer for group policies). After you have reviewed the policy, we recommend following the five steps below to help you get through the claims process as smoothly as possible:
- Determine what triggers benefits
Most policies pay only if the insured needs help with at least two out of six activities of daily living (ADL), such as bathing or dressing, or if there is evidence of severe cognitive impairment – but the requirements for making a claim vary by policy. In addition, meeting criteria for the LTC benefits is not sufficient on its own; you must have a physician document your loved one’s inability to perform the specified ADLs – or the presence of a cognitive impairment – and formally recommend the appropriate care services. Work with your parent’s or loved one’s doctor to provide the information the insurer needs.
- Find out about home care requirements
If you plan to provide care for your parent or loved one at home, call the insurer to find out about requirements for payouts, especially before you hire a caregiver to come into the home. Some insurers require home caregivers to be licensed or from an agency – and you don’t want to discover too late that the caregiver you hired doesn’t qualify. Some insurers even pay benefits to relatives who provide care without outside support. As a starting place, most insurers have care coordinators who can help you search for caregivers or facilities.
- Understand the waiting period
Most long-term care policies have waiting periods of at least 60 days. Some policies have a zero-day waiting period for home care, but a longer waiting period for assisted living or nursing homes. Others count every calendar day from the time your parent or loved one meets the requirement for needing help with ADLs or for cognitive impairment, even if he or she didn’t receive care every day.
Still others count only the days on which your parent or loved-one received care, which can extend the waiting period. If that’s the case, to speed things up, you may want to have a caregiver come more days over a shorter period, rather than a few days over a longer period.
Regardless of the policy, we recommend filing a claim at the first sign of an issue to ensure that claims are paid as quickly as possible.
- Keep track of all calls and paperwork
This includes all forms you submit and communications with the care providers or facilities and the long-term care insurer to avoid unnecessary paperwork issues. Keep records of all phone calls (including names and dates) and the dates that you, the doctor or the facility sent information – and follow up to make sure all paperwork has been received. When possible, it’s ideal to send paperwork by certified mail that can be tracked.
Also, ask the insurer or your broker if there is anything you can do to streamline the process. Some insurers will arrange direct billing between the facility and insurer, which saves time and hassle.
- Appeal a denied claim
If your claim is denied, as a first step, find out why coverage was denied. It may be a simple error that can be corrected with a quick phone call. If not, find out how the insurer handles appeals for denied claims – and begin taking the appropriate steps immediately. If you are unable to resolve your dispute through the standard process, contact your state insurance department for help.
While most claims are paid without any issues, unexpected challenges with an insurance company can be frustrating. However, diligence (and patience) can help ensure these challenges are met – so that your loved one continues to receive the needed care.