Long-Term Care Insurance Claim Q&A

Navigating long-term care (LTC) insurance claims can be a daunting and complex task. From understanding policy coverage to managing the claims process itself, the journey can be overwhelming. At Cassaday & Company, Inc., our Advanced Strategies Department is solely dedicated to assisting our clients with life, disability, income, and asset protection – including long-term care.

To help clients better understand long-term care insurance claims, our Advanced Strategies team has created a Q&A to answer some of the most common questions we receive surrounding the long-term care insurance claim process.

What Is a Long-Term Care Insurance Claim?

A long-term care (LTC) insurance claim is a request for payment, often in the form of reimbursement up to a certain daily or monthly limit, from an insurance company, for custodial long-term care assistance services typically not covered by regular health insurance.

Custodial care is non-medical care that helps individuals with their activities of daily living (ADL), such as bathing, eating, dressing, toileting, transferring, continence, and other personal needs.

How Does Cassaday Assist Clients with Long-Term Care Claims?

Our Advanced Strategies team is available to assist our clients through the entire long-term care claims process. Our team will:

1. Make calls with the client or Power of Attorney (POA) to initiate the claim with the insurance carrier. (Please note: A health POA is needed for claim and access to the policy, not a financial POA.)
2. Assist with the completion of any related forms
3. Coach clients through the usage of their long-term care policy
4. Connect clients with referrals for care coordination
5. Submit invoices on a client’s behalf as needed until initial funds are received
6. Be readily available to assist should any issues arise once claims are being paid

If the policy was purchased through Cassaday & Co., our team will have knowledge of a client’s latest policy benefits. If the policy was not purchased through Cassaday & Co., we’ll be reliant on details we receive from the client directly or data gathered during a complimentary insurance audit, performed by our Advanced Strategies team, to answer any questions related to policy benefits and coverage.

Is there a Limit to the Assistance Cassaday & Co. Can Provide on a Long-Term Care Claim?

Our team can provide up to three hours of assistance on a claim. Should a claim surpass this time limit, our team will have a conversation with the client to determine next steps.

Who Is Involved in The Long-Term Care Claims Process?

Parties involved in claims are typically: the insured, a loved one who acts as an advocate or power of attorney for the client, the insurance company, and optionally, a member of Cassaday’s Advanced Strategies team.

How is a Long-Term Care Claim Started?

Most insurance carriers will initiate claims over the phone by gathering details related to qualifications.

The two triggers to qualify for a long-term care claim are:

1. Inability to perform at least two of the six Activities of Daily Living (ADLs). ADLs are described as the following:

• • Bathing
  • Eating
  • Dressing
  • Toileting
  • Transferring
  • Continence

2. A cognitive disorder requiring significant assistance.

What Documentation is Required to File a Long-Term Care Claim?

All claims require proof of care and associated costs. Claim forms will need to be completed by the insured and often, the insured’s doctor.

Proof of care may require:

• A nurse from the insurance company to confirm the condition of the patient
• Doctor notes
• Additional documentation specific to the necessary care

Evidence of associated costs may include:

• Invoices
• Receipts
• Facility contracts
• Other financial records

Our team recommends collecting invoices and receipts as soon as care is received so that these can be filed with the claim.

What is the Timeline for Benefits to be Received?

All claims require an approval period and, in most cases, an elimination or waiting period will need to be satisfied before benefits will begin to be paid out.

It is important to note:

• Approval times can vary widely depending on contract details and a client’s specific care needs. Typically, claim approval is granted after approximately 45 days.
• Elimination periods are a time deductible on the contract.
  • A time deductible, also known as a waiting period deductible, establishes a time that must pass before benefits are payable. While the elimination period can be anywhere from zero days to a year, the norm is typically 90-100 days.

During the period when benefits are not being paid, care must be proven using invoices paid directly. If claim approval is granted during the elimination, benefits will still not be paid until the period has passed.

Elimination periods are defined as either calendar days or service days.

• Calendar day elimination period begins the first day the insured receives care. For example, if a policy has a 30-day elimination period, and the client starts receiving care on April 1^st, the elimination period will be satisfied on May 1^st, even if the insured has not received care for each day in April.

• Service day elimination periods require the insured to receive care for the full number of days listed in the policy. For example, if a policy has a 30-day elimination period, and the client receives care three days a week, it will take 70 calendar days to meet the elimination period.
  • To ensure the elimination period is met with limited out of pocket costs, we encourage clients to consider hiring help for even a few hours a day through the elimination period to start receiving policy benefits sooner before the cost of care goes up substantially.

If the claim is approved after the elimination period is met, the insurance company will pay eligible benefits for any days of care between the elimination period and the claim approval. It is important to note that most contracts waive the premiums once benefits are being paid. 

What if I Have Additional Benefits Available?

Some contracts have additional benefits such as care coordination, respite care, home modifications, shared benefits, and more. Our team will assist clients in identifying benefits available in their contract and when they can be used. In some cases, certain benefits are available before the elimination period is met. In this case, our team will assist with making the call to initiate such benefits.

To better understand your policy and its benefits, please reference Deciphering Long-Term Care Insurance: What Should I Know About My Policy?

If you have any questions about long-term insurance claims, or any of the services our Advanced Strategies team provides, please contact your advisor. If you are not a Cassaday client, we welcome you to call us at (703) 506-8200 or email info@cassaday.com.