This is a special guest blog post about long-term care insurance claims by Aaron Skloff, AIF, CFA, MBA.
1. What do I need to know about the long-term care insurance claims process?
In a study funded by the U.S. Department of Health and Human Services (HHS), long-term care insurance policy claimants were asked a series of questions about their experience filing a claim with their insurance company. Only 4 percent reported their claims were denied. Of these denials, the majority stated the reason for the denial was that they did not meet the policy definitions. More than half of these initial denials were subsequently accepted for claim payment.
Qualifying for benefits
Most long-term care policies clearly state that you qualify for benefits if:
- You cannot perform or need substantial assistance in performing two or more of the six activities of daily living (ADLs): 1) bathing, 2) continence, 3) dressing, 4) eating, 5) toileting, 6) transferring
- You have a severe cognitive impairment such as dementia, Alzheimer’s disease, or memory loss
- Your licensed care provider certifies that your care is expected to last at least 90 days
It’s important to note that while traditional long-term care insurance (LTC) policies pay for care based on the criteria above, some combination life and long-term care insurance policies have more restrictive criteria.
Understanding your elimination period
Most LTC insurance policies include an elimination period that operates like a deductible on your homeowners insurance policy. Instead of a dollar amount deductible like on a homeowners’ insurance policy, the elimination period is a time deductible – the amount of time during which the insurance company will not pay for your care. Medicare may pay for your care during your elimination period based on your specific circumstances.
2. What type of support can my long-term care provider or facility offer in filing claims?
Reviewing your claim documentation and recommending needed revisions
Your long-term care provider (i.e., long-term care facility or caregiver service) wants to be sure they provide you quality care and services. If they do, you are more likely to use their services. If the benefits from your LTC policy are integral to your ability to pay for care services then it is in your best interest and the provider’s best interest that your claim is approved.
Have the care provider or facility review your claim documentation and provide recommendations to speed the approval of your claim. It is quite likely your care provider already has experience with your LTC insurance company. Provide them a copy of your policy so the language in your claim documentation matches the policy’s definitions.
For example, one of the largest insurance company’s policy states the definition of “home” as it applies to home care services as, “An individual’s primary residence, including independent living quarters in a continuing care retirement community or similar entity.” In this case, your claim should be very specific, clearly stating that your home care will be provided in a “continuing care retirement community” instead of the more common acronym, “CCRC.”
It should also be noted that in some states specific regulatory language excludes residents of continuing care retirement communities from certain protections that other policyholders receive. For instance, in the state of Vermont, regulation states that “a long-term care insurance policy or certificate shall provide total home health or community care coverage equal to the coverage available for nursing home benefits under the policy or certificate.” However, the very next sentence says, “This requirement shall not apply to policies or certificates issued to residents of continuing care retirement communities.”
Since the state does not apply this protection for policyholders who live in CCRCs, it is even more important for you to find out what your policy provides. If the contract does not specifically mention continuing care retirement communities, then you should speak with a representative of the company for more details and get it in writing.
3. How can I know if my coverage will be accepted by my provider or facility?
Unfortunately, most major medical health insurers have gated plans with lists of medical care providers that are part of the insurance company’s network. As the best medical care providers leave these networks because the insurance companies negotiate their fees down to unacceptable levels, patients are left with weak service providers from which to choose. This same phenomenon is ravaging the Medicare system.
LTC companies, on the other hand, do not negotiate rates with care providers; they simply pay for your care, subject to the limits you contracted with the insurance company when you purchased your policy. Thus, care providers gladly accept payments from LTC insurance companies. Many insurance companies provide Care Coordinators at no additional cost to help you access the benefits of your policy, including alternate care benefits or alternative care.
Also, LTC insurance policies do not place limitations on which licensed care providers you choose, including home care providers, assisted living facility providers, and nursing facility providers. If you currently reside in, or are planning to move into, a continuing care retirement community (CCRC) confirm with your LTC insurance company if your policy classifies CCRCs under your policy’s definition of home care, assisted living facility care, nursing facility care, or all of the above (as your needs change). Some older LTC insurance policies may classify paying for care services in a CCRC as an “alternate care benefit” or “alternative” care.
About the guest blogger
Aaron Skloff, Accredited Investment Fiduciary (AIF), Chartered Financial Analyst (CFA), Master of Business Administration (MBA), is CEO of Skloff Financial Group, a Registered Investment Advisory firm specializing in financial planning, investment management, and benefits for small to middle-sized companies. He can be contacted at www.skloff.com or 908-464-3060.
Thank you to Aaron for sharing his expertise about long-term care insurance claims with our readers!
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