Just like aging itself is inevitable, so too is the eventual need for long-term care for many people. Experts believe that most Americans over the age of 65 will need long-term care services at some point in their lives, and the total average cost of these services is a whopping $138,000. Given this high cost, it can be a relief to find that an aging loved one has a long-term care insurance policy.

Long-term care (LTC) insurance is a type of insurance policy designed to help seniors pay for long-term care needs like custodial and personal care services. LTC insurance stands out from other insurance products because traditional health insurance plans, including Medicare, rarely cover long-term care services outside of skilled nursing care. LTC insurance enables seniors to access the care they need with the peace of mind of knowing that they won’t be responsible for the full cost of care. After filing their claim and getting it approved, beneficiaries receive a set amount of reimbursement per day to cover a portion of long-term care costs.

However, successfully submitting a long-term care insurance claim can be a complicated, confusing process. There are several different LTC insurance policy types, and various policies independently set their standards for reimbursement. Even the amount of reimbursement and which specific services are covered differ between different policies. 

This guide to filing a long-term care insurance claim will help you navigate this often overwhelming process. We take you through filing an LTC insurance claim step-by-step, including the steps you need to take both before and after filing the claim. Reading the guide below can help you successfully submit LTC claims for yourself or a loved one and get the most out of your long-term care insurance policy. 

Before You File a Long-Term Care Insurance Claim

Before You File a Long-Term Care Insurance Claim

Read The Entire Policy

It’s easy to simply skim over the details of one’s insurance policy, much like scrolling to the bottom of a “terms and conditions” page when you download a new mobile app. But, it’s pertinent that you read the entire policy- footnotes and all- when it comes to LTC insurance. Reading through the policy as the first step to submitting a claim will help you establish from the get-go how much reimbursement you can expect, how long that reimbursement may take, which services are covered, and other crucial details.

Consult an Expert for Assistance 

If the thought of reading through a lengthy, dense insurance policy on your own is unappealing, you’re not alone. Not only are insurance policies typically long, but they also may include confusing terminology or industry jargon that can make it difficult for some seniors and their family members to understand the policy documents fully. 

To remedy this problem and ensure you’re on the right track to getting your claim approved, consider consulting an expert for assistance. LTC insurance consultants specialize in helping seniors and their families file long-term care claims and can be of great help when trying to understand the details of one’s policy terms. An insurance expert can also help facilitate the claim submission process and help your family stay organized so that nothing falls through the cracks. 

Determine When to File a Long-Term Care Insurance Claim

When you file a long-term care insurance claim can have an impact on how fast you’re reimbursed, or even if you receive any reimbursement whatsoever. Three different situations make someone eligible for long-term care insurance reimbursement: 

  • You plan to start using long-term care services within the next two weeks.
  • You’re already receiving long-term care services.
  • You recently received long-term care services and want to claim benefits after-the-fact.

All three of the situations above make someone eligible to receive reimbursement from their LTC insurance provider. If the above conditions do not apply to you, for example, if you plan to use long-term services in the next six months but not within the next few weeks, then it’s likely not the right time to file a claim. 

Understand the Activities of Daily Living and Other Benefit Triggers 

A “benefit trigger” is a standard that one needs to meet before an LTC insurance company will begin to reimburse them for care, or in other words, standards they need to meet that triggers their LTC benefits to kick-in. In general, LTC insurance policies accept two different benefit triggers. 

Cognitive Impairment 

The first accepted benefit trigger is cognitive impairment. To satisfy the benefit trigger, one must demonstrate “severe” cognitive impairment, which indicates dementia. Typically, a physician will need to submit a form certifying cognitive impairment. The policyholder may also have to undergo a cognitive screening to determine if their impairment is considered severe. The specific markers of cognitive impairment, such as short-term memory loss or struggles with language, required to trigger one’s benefits can vary depending on the insurer, so it’s imperative to understand the specifics of your policy.

Assistance with ADLs

The other common benefit trigger is needing assistance with the activities of daily living (ADLs). ADLs are tasks that one must complete daily, including: 

  • Dressing
  • Bathing and showering 
  • Grooming (shaving, combing hair, etc.) and other personal hygiene tasks 
  • Toileting and continence 
  • Eating 
  • Transferring, or the ability to walk and get in and out of a bed/chair independently 

The LTC insurance industry standard is that policyholders must need assistance with a minimum of two of their ADLs to trigger their benefits to begin. However, since specifics vary, it’s a good idea to check your policy to see if the required number of assisted ADLs differs. Additionally, the exact language used to describe ADLs can vary depending on one’s specific policy, so if you aren’t sure about what one of the ADLs listed in your policy means, consult a physician or insurance expert.

Check the Elimination Period

Many LTC insurance policies require beneficiaries to satisfy an “elimination period” before their benefits kick in. An elimination period is a specified amount of time during which policyholders must pay for their long-term care out-of-pocket without assistance from the LTC insurance company. Think of it as a deductible for a health insurance policy that one must pay in full before the insurance company starts paying for their medical care. After the elimination period, which is usually somewhere between 30-90 days, is complete, the insurance company will begin reimbursing policyholders for their care moving forward. However, they will not refund anyone for care received during the elimination period, so be sure to factor the cost of care during that time into your budget. 

Filing a Long-Term Care Insurance Claim

Obtain All Necessary Claim Documents

The first step to filing a long-term care insurance claim is to contact the insurer to obtain all necessary claim forms. Sometimes referred to as a “claim initiation kit,” this group of documents may include a claimant statement, physician statements, a HIPAA compliance form, and more. The exact forms included in one’s claim initiation kit will vary depending on the insurance company, and sometimes from person-to-person. Even if you think you know which forms to complete, be sure to read through the entire packet and make sure you have appointments in place for providers to complete the necessary paperwork. In some cases, policyholders can access their claim initiation kit online. 

Pay Attention to Detail

One surefire way to get a claim rejected is to fill out the paperwork incorrectly or submit the claim initiation kit incompletely. Once you receive your claim initiation kit, your first step should be carefully reading through to catch any details you may have missed when doing your initial research. 

If working with a professional, it’s a good idea to have them read over both the policy itself and the claim initiation kit before you submit your claim documents. Another set of eyes is always a good idea to help catch any errors, and an informed professional is especially well-poised to help you correctly fill out every necessary piece of paperwork. 

Contact Your Physician, Care Community, Or Other Provider

You or your loved one’s physician, residential care community, or another type of health provider (such as an in-home nurse) will be required by the insurance company to verify the beneficiary’s need for care. Once you read through your claim initiation kit and understand which providers will need to complete an assessment or evaluation, reach out to schedule any necessary appointments. 

Keep Detailed Records

Submitting a claim for long-term care insurance and getting the claim approved can sometimes be a long process, and may require you to speak with several different people from the insurance company. To remain organized throughout the process and prevent any important information from slipping through the cracks, keep logs of your correspondences with the insurance company’s representatives. 

Keeping notes from your correspondences can also save you time as it prevents you from asking the same questions repeatedly or backtracking because you forgot an important detail from your conversation with the insurer. If communicating by phone, jot down some notes, and if communicating via email, create a separate folder in your inbox where you can store all of your messages with the company.

After You File a Long-Term Care Insurance Claim

After You File a Long-Term Care Insurance Claim

Follow Up with the Insurer

As when completing any important transaction, it’s a good idea to follow up with the insurer after submitting your completed long-term care insurance claim. Make sure that the insurance company received all of the necessary documents and that the responsible parties filled out the paperwork completely. If there was an error or oversight on the claim documents, following up with the insurer yourself rather than waiting for them to reach out will speed up the rectification process. 

Wait for a Decision

Perhaps the most challenging part, mentally, of the claim submission process is the waiting period after all of the claim documents have been submitted. One rarely receives a decision about their claim status on the same day that they submitted it. Expect to wait for an average of 30-45 days to hear back from the insurance company. Keep in mind that you will have to pay for you or your loved one’s care while waiting for a decision from the company. However, assuming you’ve already satisfied the elimination period, it’s likely that you’ll be reimbursed (up to the policy’s stated daily maximum reimbursement limit) for the period between when you submitted your claim and when the company approved it. 

Continue to Submit Invoices to the Insurer

Long-term care insurance claims are not a one-and-done situation. To continue to receive benefits, you’ll most likely need to continue to submit invoices or receipts from your care provider to the insurance company regularly. When working with the company to initially submit your claim, find out how frequently they’ll need you to continue to send invoices (e.g., once a month vs. once every six months).

While you will still need to keep track of your receipts and long-term care records, the hard work is over once your claim has been approved. Paying attention to details, staying organized, and asking for help if you need it is key to getting the most out of your long-term care insurance policy. 

Download our Long-Term Care Insurance Claim Checklist below for a printable, step-by-step guide that you can keep handy while you navigate the claim submission process.

Works Cited

  1. Dey, Judith and Favreault, Melissa. “Long-Term Services and Supports for Older Americans: Risks and Financing Research Brief.” U.S. Department of Health & Human Services, 1 July 2015, https://aspe.hhs.gov/basic-report/long-term-services-and-supports-older-americans-risks-and-financing-research-brief. Accessed 7 October 2020. 
  2. Lankford, Kimberly. “When Long-Term-Care Policies Kick In.” Kiplinger, 12 June 2017, https://www.kiplinger.com/article/insurance/t036-c001-s001-when-long-term-care-policies-kick-in.html. Accessed 7 October 2020. 
  3. “What is Long-term Care Insurance?” U.S. Department of Health & Human Services, 23 July 2020, https://longtermcare.acl.gov/costs-how-to-pay/what-is-long-term-care-insurance/. Accessed 2 October 2020. 
  4. “When to File a Claim.” Genworth Financial, Inc., 2 April 2019, https://www.genworth.com/claims/long-term-care-claims/when-to-file-a-claim.html. Accessed 7 October 2020.