It is one thing to own a Long-Term Care Insurance policy - it is another thing to use the benefits when you need long-term health care. Is the claim process complicated? And do you know the process for filing a claim?
That’s what we’re here to help you navigate. The good news is, filing a Long-Term Care Insurance claim is easier than you may think!
Claims are also reliable and lucrative for those with policies. In 2023 the top insurance companies paid over $14.1 billion in Long-Term Care Insurance benefits to policyholders - much of it paying for in-home care services.
This number has grown steadily over the past decade, and promises to continue climbing as more people discover Long-Term Care Insurance and utilize their policies to pay for qualifying care.
Ready to fully understand the process? We’ll start with what can trigger a claim benefit, then walk you through the process of filing a claim.
Benefit Triggers
The policy language is straightforward if you own a tax-qualified Long-Term Care Insurance policy. Most insurance companies have an outstanding track record for prompt, responsible claims payments.
To be eligible for the payment of benefits under all provisions of a Long-Term Care Insurance policy, you must meet the following requirements:
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You must be chronically ill; meaning you are unable to perform at least two activities of daily living without substantial assistance from another person who is physically present with you for a period that is expected to last at least 90 consecutive days due to a loss of functional capacity -
OR
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You require substantial supervision to protect yourself from threats to health and safety due to a severe cognitive impairment.
Most insurance companies will require a written plan of care from a licensed health care practitioner prescribing the services you will need.
Paperwork Required for an LTC Insurance Claim
Most insurance companies will need paperwork completed. In some situations, an assessment may be required. The process of getting benefits from your Long-Term Care Insurance policy begins with submitting claim forms to the insurance company.
There is usually never a good reason to delay submitting a claim.
Most LTC Insurance policies have an elimination period, a deductible based on days rather than dollars. Some companies offer zero-day elimination periods; however, 90 or 100 days are common.
This elimination period is only calculated once per lifetime. If you trigger a benefits claim and have previously exhausted the elimination period, this period is not reapplied to a later claim.
Remember, health insurance, including Medicare (and supplements), will only pay for up to 100 days of skilled services. The days paid by health insurance or Medicare will count against your deductible.
RELATED: Doesn't Health Insurance Pay for Long-Term Care? What About Medicare and Supplements?
Get Free - No Obligation Assistance with LTC Insurance Claims
LTC NEWS has arranged for free, no-obligation help and assistance with completing the claims process to assist you no matter what insurance company you - or your loved one - has in place - no matter who sold you the policy in the first place.
LTC NEWS can even help if you or your loved one does not own Long-Term Care Insurance but needs help finding quality care and developing an appropriate plan of care.
You can also find contact information from major insurance companies with Long-Term Care Insurance policies in place.
Learn more - Filing a Long-Term Care Insurance Claim | LTC News.
Most insurance agents and financial advisors who sell Long-Term Care Insurance have little or no experience processing claims. Many Long-Term Care Insurance specialists do have this experience and can be helpful.
Filing a Long-Term Care Insurance Claim
If you don't want to get help with the process, you should know these steps when processing a Long-Term Care Insurance policy claim.
The first step to filing a long-term care insurance claim is to contact the insurer to obtain all necessary claim forms. These forms can be mailed - sometimes emailed - and should be completed fully. On occasion, you’ll be able to submit these forms through an online portal, and download any additional forms that may be needed throughout the process.
Be sure to have the policyholder's complete information (full name, social security number, and policy number).
If you are helping the policyholder, you may need to have a medical power of attorney or have a signed HIPAA form allowing the insurance company to communicate with you during the process.
Keep detailed records as you may have to speak with the claim's department employees a few times during the process. Note when you called and to whom you spoke and what was discussed.
Never mail an "only copy" of any form or document. Keep a copy for your records.
Most providers will bill the insurance company directly; however, some will not. Discuss with the provider. Many providers today understand Long-Term Care Insurance and are very happy to help you through the process.
Once the claim is approved, there are usually few problems going forward. It can take anywhere from 3 to 5 weeks to process a claim - much of that time waiting for medical records. Be proactive and ask the doctor to process the requested information right away.
Seeking help, whether through LTC NEWS or elsewhere, will make this process much easier.
Filing LTC Insurance Claims: Frequently Asked Questions
How do I apply for Long-Term Care Insurance?
Many reputable providers exist that provide Long-Term Care Insurance, and a trained specialist will be able to guide you through policy options.
For any policy, there will be paperwork to fill out, benefits to determine, and an underwriting process to determine eligibility. For more, check out our guide to applying for Long-Term Care Insurance.
Can providers deny an LTC Insurance claim?
No. Any claim that meets the benefit triggers outlined in the policy must be honored. As a reminder, benefit triggers revolve around activities of daily living (ADLs) and being able to perform them.
Most policies use the inability to perform two or three out of six ADLs as a trigger for benefits. These ADLs include bathing, dressing, eating, transferring (moving to or from a bed or chair), toileting (including personal hygiene), and continence (including personal hygiene.)
Policies can also be triggered via cognitive impairment that requires substantial supervision.
A related question we often get is whether or not companies can cancel a policy. Again, no, they cannot, so long as you continue to pay your policy premium.
Additionally, premiums are based on when you acquired the policy. As you age or if your health declines, premiums can’t increase for these reasons.
What happens if I use up all of my benefits?
While rare, it’s possible to exhaust Long-Term Care Insurance benefits of a policy.
Some plans do offer unlimited benefits. However, these are rare, and also come with higher premiums than most other plans.
If your spouse has a policy with unused benefits, it may also be possible to share the benefits of their policy.
A specialist specifically trained in providing Long-Term Care Insurance guidance can help to ensure that you have the requisite coverage based on your financial assets, family history, age and risk tolerance.
How much does a Long-Term Care Insurance policy cost?
A typical range for policies is $1,000 to $2,000 per year. This range can seem large, but it’s possible to narrow in on a specific cost based on your age, gender, health and benefits of your policy.
For example, from our article on cost of long-term care insurance, one policy approximating a monthly premium for a married 55-year-old man, where the policy doesn’t have an inflation rider, is roughly $50/mo., give or take depending on what company you go with. That policy cost can more than double with a 3% compound inflation rider, though, highlighting how easily policy pricing can change with seemingly small adjustments.
The more important figures, though, are the hundreds of thousands of dollars a well-structured policy can save you in long-term care costs.
Factors like your age, gender, health status, marital status, and benefit options all affect the cost of a policy. Speaking with a specialist who can represent several providers is the best way to compare policy options and choose the one that’s right for you.
Confidence as You File Your Long-Term Care Insurance Claim
The best Long-Term Care Insurance policy is the one that pays benefits when you need care in the future. The process can be easier if you understand the steps and seek professional help. LTC NEWS can even provide you with free, no-obligation assistance with this process.
If you have a policy, don't delay in making a claim for benefits - that is why the policy was purchased in the first place. Plus, many companies offer professional case management, which is available right away.
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