LTC Insurance Claims
Here’s some basic information to avoid common pitfalls.
Understanding your benefits…
Definition of Long Term Care:
Typically, the definition of assistance means hands on assistance with two of six daily living skills, including bathing, dressing, toileting, continence, transferring and feeding or a severe cognitive impairment identified by both standardized testing and functional performance showing evidence of the need for substantial supervision. Level of care needs to be documented in medical records.
Nursing Home Only Policies: Does not cover assisted living or home care. Nursing home only policies cover skilled nursing homes. (However, in rare situations, I have found these policies will cover secure dementia units.)
Assisted Living: May or may not be identified as a benefit. (Should be covered when “custodial nursing home” is identified in policy)
Home Care Only Policies: These policies typically only cover home care in the home setting which typically includes Independent Living in a community setting, but not Assisted Living.
Home Care: May be identified as “Skilled Home Care Agency”, “Home Care Services”, or “home care services” or independent care providers. (Yes, capital letters make a difference, without caps, this means independent providers). This distinction is critical prior to choosing a service provider.
Duration of Benefits:
Pooled Benefits: If you use less than the maximum daily/monthly benefit, the remaining balance extends your policy duration.
Fixed duration: A specific number of years of benefit.
Make sure you know the difference. If you use half your daily benefit for example, you may only receive half your total benefit.
Inflation benefits may have been purchased at the time of issue. This benefit may be included as part of the initial premium or required additional premium during the years. But unless some type of inflation option was initially purchased, the daily or monthly benefit will be the same as when it was purchased.
The elimination period is the deductible period before claims are paid.
Calendar day elimination periods start from the day you meet the criteria for a paid claim.
Service day elimination periods are fulfilled by each day that a paid service is received that meet the definition of benefits paid by the policy. Some policies require only 1 service day to count towards 7 of that week.
If you want help.
If you have questions.
Comprehensive review of your policy
Guidance for self-claims processing
Appeal support services
Lifetime monthly benefit reconciliation for claims
Full claims support – assistance in initiating claim, reviewing all claims documentation, coordinating with home care or assisted living billing and staff and insurance company until claim is paid
Interested in finding out more. Call us or fill out the form below.
“When my parents were about to make a claim on their long term insurance, which they'd been paying premiums on for decades, and I read their policies, I felt like a total babe in the woods. The policies were technical and it seemed rife with tricks & obstacle, and it was so important that the companies live up to their promises and pay what was coming to us. I knew I needed someone to help me and started asking around.
Thank goodness Linda Thalheimer came on my radar. She knows all the ins & outs of the business: how to anticipate & avoid obstacles with the insurance companies, how to advise a home-health agency on the proper way to submit paperwork that the insurance company will accept, and how to push things along when any part of the process gets stuck. Linda is clear, thorough, & tenacious on behalf of her clients, a true professional, while alos being an extremely compassionate person. It was such a pleasure to work with her. Hiring her was one of the best decisions I made and I don't think I could have done it without her. - Jonathan G., Client
“Linda’s help was invaluable to us. My mom had two long term care policies that were written in a technical language that was almost impossible to understand. The family was uncertain on what to do.
“Linda explains how each policy worked patiently and with understanding. Linda handled the numerous telephone calls and paperwork needed for insurance approval. With Linda’s help we received reimbursement for private care that has made a huge difference in our mom’s quality of life and well-being.
“The second policy has allowed for direct reimbursement for dementia and private assisted living. We can’t say enough for Linda’s expertise, knowledge, and sensitivity in handling these long-term care Issues.” - Dan B., Client
“We want to thank you -again- for everything you did to get the insurance benefit paid. I know not everyone is lucky enough to find a person like you that would do all this for the original quoted fee. Here’s the $2,500 difference that you earned, and I hope this actually covers all the work you put into this case.” - Lisa A., Client