Caring for a loved one who requires ongoing care can be both emotionally and financially stressful. Long-term care insurance can often provide significant financial relief, but understanding how and when to activate the policy can be confusing.
We understand how overwhelming this can be and TheKey’s Long-Term Care Center of Excellence is here to help. Our team of experts can guide you through every step of the way so that you can focus on providing the best care for your loved one while we navigate the claims process effectively, from beginning to end. We can assist you in maximizing your family members’ LTC benefits and ensure that you get the necessary care services in place immediately.
It’s important to note that the person must be receiving care before filing a claim for LTC insurance benefits. We understand this can be counterintuitive, but we’ll help you prove the need to the insurance company first. Let us help you maneuver through this process with compassion and empathy.
How to Start Receiving LTC Benefits
It’s important to gather all the medical information and documentation related to your loved one’s home care, such as the name, address, and phone number of their doctors, along with dates of any hospitalization or rehabilitation stays.
If you’re starting with home care services, you can contact TheKey’s Long-Term Care Center of Excellence for help connecting with your loved one’s Long-Term Care (LTC) insurance carrier to begin the eligibility review process. Please note that the approval process can vary depending on individual insurance carriers and policies and may take a few months to complete. However, in most cases, the benefits are covered retroactively.
We understand that you may be unsure about the benefit eligibility review process therefore it’s important to keep in mind that initiating this review does not automatically mean that your loved one will be eligible for home care services. Long-term care insurance policies have specific criteria for determining eligibility, and we are here to support you every step of the way. We will provide you with all the information you need to navigate this process and find the best possible solution for your loved one’s needs. Here are a few ways they can qualify:
1. They Require Help with Specific Daily Activities
In order for a client to be eligible for benefits under most policies, they must need assistance with a minimum of two Activities of Daily Living (ADLs). Six functional areas define an individual’s daily activities: Alternatively, the care can be deemed medically necessary by the prescribing physician and certified as such.
· Bathing
· Dressing
· Toileting
· Eating
· Transferring
· Continence care
Be aware that ADLs are not as straightforward as they sound. For instance, if your loved one requires help moving from a bed to a wheelchair, that will meet the definition of “transferring.” But helping to get in and out of a car would not. Similarly, needing help with meal preparation does not meet the requirement for “eating.” However, if they have tremors and require someone to feed them, that qualifies.
2. They Are Diagnosed with Severe Cognitive Impairment
The second option is to provide clinical evidence of severe cognitive impairment, which can be established through brain imaging or standardized tests, like the Mini-Mental State Examination (MMSE). However, it’s worth noting that not all long-term care insurance carriers consider physician notes and visits as evidence of cognitive impairment. Most will require a home visit from a registered nurse and records from your loved one’s home care provider.
As a result, complete, and consistent documentation from the home care provider becomes critical at this point. This is because some measures may not give an accurate picture of the need for home care services. For instance, someone with frontotemporal dementia might display behavior changes at home but score within the normal range on a standardized test.
Additionally, older adults may experience “sundowning,” where their functioning worsens at the end of the day. In such cases, a home visit in the morning would not reflect their true need for services. It’s recommended that you present your loved one at their worst, not their best. It’s natural for people to try to “show off” and prove they can be independent, but that doesn’t offer a real reflection of their care needs and can lead to denial of benefits. Instead, focus on the challenges the person faces, why they’re not safe in their own home, and what’s contributing to their need for assistance, including diagnoses and medications that put them at fall risk.
What Happens After Your Loved One Qualifies for LTC Benefits?
Even after the initial assessment, the process is not over. LTC carriers usually review cases on an ongoing basis, typically every 90 days, but this may vary by carrier. This reassessment may involve more home visits, calls to confirm if services are still needed, or a review of records, among other things.
We want to assure you that you can be prepared for the reassessment by documenting any changes in your loved one’s condition, especially if there’s a decrease in health or functioning. You and your home care providers can keep regular reports detailing the services provided, hours spent in the home, and why those services are necessary.
You can expect follow-up calls from the LTC carrier. It’s crucial to confirm that they have your direct number as family. In some cases, elders lose benefits because they mention they are independent with their ADLs, despite requiring assistance.
What to Do If Your Loved One’s Claim Is Denied
Claims denials can occur at any stage of the benefits or review process. It is essential to understand that we are always here to support you throughout this process and provide any guidance you may need. Your well-being and that of your loved ones are our top priority, and we are committed to helping you appeal the denial and resubmit all the necessary paperwork. If you believe that your loved one’s claim has been improperly denied or delayed, we recommend that you contact your state’s Department of Insurance and request a review.
How to Make LTC Claims Denial Less Likely
· Offer a clear picture of your loved one’s level of function, and what conditions or medications make the need for home care critical.
· Provide consistent and complete documentation from the home care provider that reflects all the hours and services they are eligible to receive.
· File all claims and documentation on time.
· Write down notes about changes in functioning or health that could affect benefits and share that information with the home care provider, your loved one’s physicians, or directly with the LTC carrier.
3 Common Myths About Long-Term Care Insurance
Navigating LTC insurance can be tricky—particularly when considering the cost and amount of coverage your loved one might want and need.
Here are a few common myths and facts about LTC insurance and home care.
Myth #1: Medicare Will Cover Home Care Costs
Medicare typically covers skilled home health services, like care from a registered nurse and/or a speech, physical, or occupational therapist. However, it does not cover what’s called home care services, also known as custodial home care or personal care (daily, basic, non-medical care, like eating and bathing). In some cases, Medicare will send a home aide to assist with bathing and dressing, but the hours and duration are typically extremely limited, and you cannot choose the home care agency.
Myth #2: LTC Insurance Will Cover All In-Home Care Costs
How much is covered will depend on the specific policy. Always ask for a copy of the policy and look at the schedule of benefits to see your loved one’s daily benefit amount, the number of days allowed, and the maximum lifetime benefit. Also, ask if they have supplemental coverage. This type of coverage can pay for food delivery services, such as Meals on Wheels, incontinence supplies, durable medical equipment like wheelchairs and hospital beds, and even home modifications (i.e., ramps). Supplemental benefits come with their own rules and restrictions, though, so ask about those, too.
Myth #3: The Only Out-of-Pocket Costs with LTC Insurance Are the Premiums
It’s important to note that home care benefits won’t start until your loved one has already started receiving care. This means that you’ll need to pay for the costs upfront. While insurance coverage is usually retroactive, most policies have an elimination or waiting period for benefits. The length of these waiting periods can vary, with some plans requiring a 90-day waiting period before payments begin, and others requiring the person to receive a set number of days of home care services before paying. It’s crucial to understand how the elimination period in your policy works so that you can plan accordingly. Additionally, there might be some costs associated with the professional caregiver’s mileage if they need to drive your loved one to lunch or other activities outside their home.
The Long-Term Care Center of Excellence
The Long-Term Care Center of Excellence, offered by TheKey, is available to provide assistance with all of your long-term care needs. Allow us to guide you through the process and ensure that you are informed every step of the way. Our team of experts is dedicated to providing you with high-quality service and support, and we are committed to helping you make informed decisions about your long-term care. Please do not hesitate to contact us if you have any questions or would like to learn more about our services.