Paying for care
How to use long-term care insurance to pay for home care
A parent bought a long-term care policy years ago, and now it’s time to use it. Most policies cover care at home, but claims stall on the same few things: the trigger, the waiting period, and the paperwork. Here’s how to get through each one.
By Mildred Kiminyei, RN · Published
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Start with the policy itself
Find the policy document and the most recent premium notice. Call the insurer’s claims line, not the sales line, and ask them to open a claim and send the claim forms. Write down the date, who you spoke to, and the claim number.
Ask these questions on that first call, and ask for the answers in writing:
- Does the policy cover home care, and is there a separate daily or monthly limit for it?
- How long is the elimination period, and does it count calendar days or days of paid care?
- Does it reimburse actual bills, or pay a set amount once the claim is approved?
- Does care have to come from a licensed agency? Can a family member be paid?
- Who does the assessment, and what forms does the doctor need to fill in?
- Is the premium waived while benefits are being paid?
What triggers benefits
Most policies sold since 1997 are “tax-qualified,” and they use the definition in federal tax law. Benefits start when a licensed health care practitioner certifies one of these:
- Needing help with at least two of six activities of daily living for at least 90 days: bathing, dressing, eating, toileting, transferring (getting in and out of a bed or chair), and continence.
- Severe cognitive impairment, such as dementia, where the person needs supervision to stay safe.
The insurer usually sends a nurse to assess your parent, or reviews the doctor’s records. Be specific about what help is needed. “Mom can’t get in and out of the shower safely without someone holding her” carries more weight than “Mom needs some help.” Older policies may have different triggers, so check the wording in yours.
The elimination period, and how it really counts
The elimination period is a waiting period, often 30, 60, or 90 days, when the family pays for care before the policy starts paying. It works like a deductible measured in days.
How the days are counted matters a lot. With calendar days, every day counts once your parent qualifies. With service days, only days when paid care happens count. If care is three days a week, a 90-service-day wait takes about seven months to finish, not three.
Some policies waive the elimination period for home care, or count a recent hospital or nursing facility stay toward it. Ask before care starts, because the answer can change how you schedule the first weeks.
Reimbursement or cash benefit
- Reimbursement policy
- The most common kind. It pays back what you spent on covered care, up to the daily or monthly limit, and needs an itemized invoice for every payment. Whatever isn’t used stays in the policy’s total benefit pool.
- Indemnity or cash policy
- Pays a set amount once the claim is approved, whatever the care costs. Families can usually use it more flexibly, including for a family caregiver.
With a reimbursement policy, compare the daily limit to your schedule. At our rates of $40 to $48 an hour, a $200 daily limit covers a four-hour visit in full. An eight-hour day costs $320 to $384, so the family would pay the $120 to $184 above the limit.
The paperwork insurers ask for
- The insurer’s claim form, filled in by the policyholder or whoever holds power of attorney.
- An attending physician statement, filled in by the doctor.
- A plan of care from a licensed health care practitioner, for tax-qualified policies.
- The agency’s state license, if the policy requires a licensed provider.
- Itemized invoices showing dates, hours, and the care provided.
How it works with us
We’re a state-licensed home care organization (license #374700397). We don’t bill insurers directly. We give you an itemized invoice every two weeks to send to the insurer, and the insurer pays you back. If the insurer asks for something else from us, call and we’ll tell you what we can provide.
If the claim is denied
Ask for the denial in writing, with the policy language it relies on. Many denials come down to missing records or an assessment on a good day. You can appeal, send more records from the doctor, and ask for a new assessment. California’s Department of Insurance takes complaints about long-term care claims, and the free HICAP program counsels people on long-term care insurance.
Common questions
Does long-term care insurance cover non-medical home care?
Most policies cover help with bathing, dressing, toileting, and supervision for dementia at home, which is what non-medical home care provides. Check the policy for a home care limit and any requirement to use a licensed agency.
Can we start care before the claim is approved?
Yes, and for many policies the days of paid care are what count toward the elimination period. Keep every invoice. They prove the days of care, and once the claim is approved the insurer may pay back care given after the elimination period ended.
Do you take long-term care insurance?
Families use their policies to pay for our care. We don’t bill the insurer directly. We give you an itemized invoice every two weeks to submit for reimbursement.
Request a free in-home consultation
Tell us what’s going on and we’ll call you back to talk it through and set up a visit at the home. The consultation is free.
If it’s urgent, call instead of using the form.
- (858) 380-9599
- love@pendaseniorhomecare.com
- Office hours: Monday to Friday, 9 a.m. to 5 p.m.
- Care available 24 hours a day, 7 days a week