Regions:
Having long-term care insurance can provide valuable financial support when you or a loved one
needs help at home. However, having a policy does not necessarily mean benefits begin as soon
as care is needed.
Before benefits are activated, your insurance company may require certain eligibility,
documentation, or claims requirements to be completed. Understanding these requirements
before care becomes urgent can help your family prepare, avoid delays, and know what questions
to ask.
Every policy is different, but here are some of the most common things to consider.
Understanding Your Policy's Benefit Triggers
Long-term care insurance policies generally establish specific criteria, often called benefit
triggers, that determine when someone qualifies for benefits.
Many policies consider whether an individual needs assistance with a certain number of
Activities of Daily Living (ADLs), which commonly include:
Some policies may also provide benefits for individuals with a qualifying cognitive impairment
that affects memory, judgment, reasoning, or the ability to remain safe without supervision.
Your insurer may require medical documentation and an assessment to determine whether you
meet these requirements.
Documentation, Assessment and Your Plan of Care
Before approving benefits, your insurer may request documentation from a physician or another
qualified healthcare professional describing your condition, functional limitations, or need for
assistance.
An assessment may also be required to evaluate your physical abilities, cognitive functioning,
safety needs, and ability to perform everyday activities.
Depending on your policy, you may also need a written plan of care identifying the type of
assistance you need, how frequently care should be provided, and where services will take place.
Ask your insurer exactly what documentation is required and who is responsible for completing
it. Gathering this information early may help prevent unnecessary delays.
Is Your Benefit Based on Hours or Dollars?
Not every long-term care insurance policy pays benefits in the same way.
Some policies may authorize or reimburse a certain number of hours of care, while others
provide benefits based on a daily, weekly, or monthly dollar amount.
It is important to understand not only whether you qualify for benefits, but also how much care
your policy will actually cover.
Ask your insurance company:
Knowing these answers can help your family build a realistic care plan.
Does Your Policy Have an Elimination Period?
An elimination period is a waiting period that may need to be satisfied before eligible benefits
begin.
Depending on the policy, this could be 30, 60, 90 days or another specified period. Some policies
may not have one.
It is also important to understand how those days are counted. Some policies count calendar
days, while others may count only days when qualifying care is actually received.
A 90-day elimination period, for example, does not necessarily mean the insurance company
begins paying exactly 90 calendar days after you first need assistance.
Before care begins, ask:
Understanding whether your policy covers custodial/personal care, skilled care, or both is
another important step.
Custodial or personal care may include assistance with bathing, dressing, mobility, meal
preparation, supervision, companionship, and other everyday activities.
Skilled care generally involves services provided by licensed healthcare professionals, such as
certain nursing services.
Ask your insurer what type of care has been approved, which specific services are covered, and
whether there are any exclusions or limitations.
Make Sure Your Home Care Provider Is Eligible
Your policy may also establish requirements for who can provide your care.
For example, some policies may require services to be provided by a licensed home care agency
or another qualified provider. Policies may also differ in whether services provided by family
members are eligible.
Before choosing an agency, ask your insurer what qualifications the provider must meet.
You should also find out what the insurance company will need from the home care agency. This
could include licensing information, a plan of care, service records, invoices, caregiver
information, or other documentation.
Establish a Billing Contact Before Care Begins
One of the most helpful things you can do is speak with your insurance company before services
begin and identify the person or department responsible for your claim.
Find out:
Keep this contact information available and consider sharing it with your home care agency so
billing or documentation questions can be addressed efficiently.
What If Insurance Doesn't Cover All the Care You Need?
Long-term care insurance can be an important resource, but your policy may not cover all the
care you need or would like to receive.
For example, your policy might provide benefits for a certain number of hours or up to a
particular dollar amount, while you or your family feel additional assistance, supervision,
companionship, or personal care would be beneficial.
Depending on service availability in your area, Venture Forthe may be able to help supplement
insurance-covered services with private-pay home care.
This can allow you to develop a care schedule based on your actual needs rather than limiting
your entire care plan to what your insurance policy reimburses.
Questions to Ask Before You Need Care
If you have a long-term care insurance policy, consider contacting your insurer before care
becomes urgent and asking:
1. What are my benefit triggers?
2. Does my policy have an elimination period, and how does it work?
3. Is my benefit based on hours, a dollar amount, or another structure?
4. What are my daily, monthly, and total benefit limits?
5. Does my policy cover skilled care, custodial/personal care, or both?
6. What qualifications must my home care provider meet?
7. What documentation will you need from me and the home care agency?
8. Who will be my point of contact for claims and billing?
9. How should invoices be submitted and processed?
Having these answers before you need care can make the transition much easier.
Venture Forthe Can Help You Prepare for Care at Home
Navigating a long-term care insurance policy while trying to arrange care for yourself or
someone you love can feel complicated.
Venture Forthe can help you understand the home care services available in your area and
provide information that may be requested by your long-term care insurance carrier.
If your policy does not cover all the care you need or want, ask us about private-pay home care
options that may be available to supplement your insurance-covered services.
Have a long-term care insurance policy and wondering what comes next? Contact Venture Forthe
to learn more about available home care services and how we can help you prepare for care at
home. Call today 1- 800 – 701-1233.
