Your loved one needs a caregiver at home and has a Long Term Care insurance policy…now what?

Long-Term Care (LTC) insurance is one option many people choose to provide financial protection when they begin to need help with the activities of daily living. LTC insurance coverage in Pennsylvania provides services in your home, a medical facility or a combination of the two.

Make contact with the insurance company and get the following information:

  • Policy Number:  You will need this along with a claim number to reference all correspondence with the insurance company.  
  • Find out whether or not home care is covered: Some of the older policies only covered care in a facility.
  • Elimination Period:  This is like a deductible.  It is the number of days the individual must pay out of pocket for covered services before the insurance company will begin to make payments, usually 30, 60 or 90 days.   Some policies use calendar days and others use days of care.  This is a very important distinction.  For example, 90 calendar days could mean that you pay for care 2 days a week for 3 months (90 days), essentially paying out of pocket for 24 days of care to satisfy the 90 day elimination period.  90 days of care, on the other hand, would mean paying for 90 actual days of care, 90 days in a row or 90 days of care spread out, say 2 days a week for 45 weeks.  As illustrated there is a big difference between the two.     
  • Benefit Amount:  The amount of insurance benefits that a policy will pay per day for covered Long-Term Care expenses.  This can have stipulations as a maximum per day or a maximum pool of money.   
  • Benefit Period:  The length of time a policy will pay a benefit.  Common time frames are 1 year, 5 year, Lifetime.  Sometimes the period can be until a maximum pool of money is exhausted.  
  • Inflation Rider:  Some policies have a rider that will increase the benefit amount over time using simple or compound interest.  Simple vs. compound can make a very big difference.  
  • Benefit Triggers: Activities of daily living and cognitive impairment levels that trigger the need for Long-Term Care.  Activities of Daily Living (ADLS) are activities that measure a person’s level of dependence.  Activities could include bathing, continence, dressing, eating, toileting and transferring (mobility). The policy will pay benefits if you are unable to perform a specified number of ADLs, usually 2 or 3, and/or having cognitive impairment issues.

All of the above information should be included in the policy itself.  If you do not have the physical policy please ask the insurance company for a copy. Always a good practice.

After you have this information notify the insurance company what home care agency you will be working with or if you will be working with a consumer directed private caregiver.  The insurance company will request a copy of the agency license or a copy of the individual caregiver’s credentials.  The insurance company will also want a copy of the plan of care.  Please be advised you are not locked into any one provider, you can change as your needs and wants change, keep the insurance company informed.    

After the claim is approved the insurance company will require copies of care notes, paid invoices and any care plan changes on an ongoing basis, usually by fax.  

All of this can be a little overwhelming,  some people hire an independent Geriatric Care Manager to help and advocate and process the claim.  Some home care agencies will provide the same help and advocacy and process as well.  

Here is a link to the Aging Life Care Association where you can find a Geriatric Care Manager.

Additional Resources:

Pennsylvania Insurance Department, Long Term Care

Administration on Aging  

Please keep in mind that all policies are a little different and this information is a general framework.

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