D.I.Y Guide to LTCI Claims
8 Steps to Filing a Claim - Jennipher Ama, Village Plan and David Wolf, Wolf & Associates
Villageplan? would like to help you and your loved one navigate the world of Long-Term Care insurance claims while you go through this difficult time in your lives. We would like to offer the assistance of our AGING CARE EXPERTS (should you need us) as well as provide this D.I.Y (Do-It-Yourself) guide to filing a Long-Term Care insurance claim.
Our goal for this guide is to empower families of those needing care to successfully file a Long-Term Care insurance claim, while minimizing any anxieties that may arise as a result of this unfamiliar process.
Paths to Filing a Claim
There are three different ways to go about filing a claim. You can either: 1) completely Do-It-Yourself; 2) consult with an Villageplan? AGING CARE EXPERT along the way if you encounter questions or hurdles; or 3) completely Hire-It-Away with Villageplan?. The choice is yours. If you need help along the way (or would like to outsource the entire process) we are available in whatever capacity you need us.
Also, please be aware that each insurance company assigns a Care Coordinator to your case at the time of claim initiation. These individuals can be very helpful, but it is also important to know that you can hire an external expert (one who is not affiliated with the insurance company) to advocate for you (an AGING CARE EXPERT).
Whichever way you chose to go about this process, we want to help you not only succeed but also do so with the least amount of stress possible.
8 Steps to D.I.Y. (Do-It-Yourself)
Here are eight steps to take to help you file your Long-Term Care (LTC) insurance claim. Please always know that Villageplan? AGING CARE EXPERTS are a phone call away should you need additional help:
1. Assign Someone as the Point Person
The very first thing to do is to assign someone as a point person. Typically, this person is a family member or friend that is involved in organizing the claim communication (keeping a log of who they spoke to, when, and what the outcome was of the communication). Your assigned point person will have the following attributes:
2. Hire a “Qualified LTC Care Provider”*
Qualified care services (provided by a “qualified LTC care provider”*) must begin before submitting a claim. It is important to review the definitions of “Home Care Providers” and “Long-Term Care Facilities” (or “Assisted Living Facilities” or “Residential Care Facilities”) to confirm your chosen care provider meets the criteria. The older the policy is, the more care you will want to take confirming these definitions.
Policies issued decades ago may have definitions of home health care providers or care facilities that are more limited. They also may even include terms no longer used (as they may have preceded types of care providers we have today). A few of these terms are “Alternate Care Facilities”, “Intermediate Care Facilities”, or “Custodial Care Facilities”. All these terms preceded the “Assisted Living Facilities” we know today. Take care to understand the definitions of these older terms. Also, older policies may require certain types of Home Care providers. Definitions of providers have largely simplified over the years to the more timeless terms we have today. The wise consumer understands this evolution and carefully confirms that a provider meets the terms in these older care provider definitions.
If you are uncertain or believe the care provider may not qualify, it is critical to consult with your insurance professional or an AGING CARE EXPERT to confirm. In most cases, this “qualified care” is performed by a formal, licensed home care agency or home health care agency (although in some policies it might also be an independently licensed home care provider) or by an assisted living facility (or skilled nursing facility). Again, newer policies are very flexible with regard to qualified care providers, but older policies may have some criteria you will want to confirm before hiring a care provider or care facility. Most policies will exclude “non-licensed” care such as receiving help from your neighbor or family member.
* As defined by your policy
3. Review the “Plan of Care” and Caregiving Notes
Your policy has “triggers” (or key definitions) listed within the contract. These “triggering” definitions outline the conditions that must be met (with regard to the care needs of the policyholder) for the policy to pay a benefit. Newer policies define this in terms of inabilities due to cognitive impairment or physical limitations (refer to the definition of “Chronically Ill” in your policy). Older policies may have other triggering mechanisms that existed prior to these triggers being standardized in the late 1990s.
Unfortunately, many times home care agencies or care facilities won’t clearly or fully document all your care needs with the Long-Term Care policies “triggering” definitions in mind (how the policy pays out benefits based on physical or cognitive limitations and safety concerns). Ask the care provider not to submit the “Plan of Care” to the insurance company without first allowing you the opportunity to review it's thoroughness and accuracy. As you review it, you will want to do so with a careful eye, checking especially for consistency with your policy’s “triggers”. AGING CARE EXPERT can provide this skilled perspective based on years of experience doing this. The “Plan of Care” should depict your true functioning level and/or cognitive impairment. If it does not, ask to have it represent you. When you are ready to file the claim, it is best for you to submit the “Plan of Care” yourself.
4. When Visiting Your PCP, Be as Complete as Possible
Your insurance company will review your medical records as part of the approval process. If it’s been a while since you have seen your primary care provider/doctor (PCP), it’s likely you’ll need to see him/her. That doctor may ask you personal questions about private self-care areas like bathing, dressing, toileting and continency. If our PCP does not ask these critical questions, you will need to take the initiative to report these things to him/her and ask that they be included in your medical chart. Despite feeling as though you want to remain independent, it is vital to be as accurate as you can, as this is in your best interest. It is also important to remember that successful Long-Term Care insurance claims necessitate statements of “safety” concern due to PHYSICAL or COGNITIVE limitations. You will want to review your policy for a list of the physical limitations or “Activities of Daily Living” (referred to as ADLs) which trigger your policy.
It is important to know that many of the physical limitations with your “activities of daily living” are often associated with balance and fall risks. Thus, it is critical to report these fall concerns. If the claim is supported by cognitive limitations, it is critical the physician document statements that supervision is needed to ensure “safety” (SAFETY being the key word). Cognitive impairment must also be supported by standardized cognitive testing performed by a licensed health care practitioner.
领英推荐
If the policyholder or family is not reporting these “safety” concerns, your physician will likely not document them. After your visit, obtain these records yourself, have them reviewed carefully and (if permitted by your insurance company) ask your point person to send them directly to the insurance company. Supportive medical records are important. If you need assistance in reviewing your records for supportive statements or communicating with physicians, your AGING CARE EXPERT can offer this assistance. He/She can also offer baseline cognitive assessments to determine if a claim is likely to be successful.
5. Contact the Carrier to Start the Claims Process
The first step in initiating your claim is to contact your insurance carrier through their 1-800 CLAIMS HOTLINE provided by your carrier. Your Long-Term Care insurance carrier will assign you to a “Care Coordinator” to assist you with gathering information, ordering an assessment by their nurse (if they choose), and gathering medical records. Again, Care Coordinators are generally very helpful in navigating the process. But it is also helpful to clearly understand that their role is to facilitate a claim, but not to demonstrate that the claim is supported. The claim instead is supported by: 1) the “Plan of Care”,; 2) the medical records; and 3) the insurance assessment. Consequentially, it is of particular importance to have already had an assessment by your care provider or care facility and a written “Plan of Care” before you start the claims process. This ensures you that the assessment was completed with your interests in mind and you have had the opportunity to review and agree with the assessment. You really want this assessment and the corresponding Plan of Care to be completed by an individual representing you. This will avoid challenges with claims eligibility.
These are the 6 items you will need before placing this call:
Record and save the name and phone number (with extension) of the claims manager who will be handling your claim. This will help expedite all calls going forward. If the insurance carrier is going to order an assessment (by their representative), it will be important to learn what providing company will complete the assessment, so that you will already be familiar with them when they call to schedule it with you.
NOTE: Both claims filing and follow-up services are available at a fee-for-service charge through your AGING CARE EXPERT team if you would rather turn it all over.
6. Be Objective During Your Claim’s Assessment
Most insurance companies hire a nurse from an independent company to visit you personally and assess your ability level and your needs. Make sure to tell the nurse or social worker what it’s like on your worst day (even if you are having a better day on the day of your assessment). Remember, complete honesty about your daily living concerns and needs is essential for an accurate representation and assessment. An accurate assessment that represents your full needs is critical to your claim being approved. If you would like, you can hire an AGING CARE EXPERT to participate in this assessment to ensure your needs are communicated accurately.
7. Upon Claim Approval, Get All the Details
When your claim is approved, you will be notified by your insurance carriers' claim department or Care Coordinator. They may do this by phone, mail, or both.
Upon approval:
8. Take Charge of Your Benefits
Most (not all) LTC policies pay you by reimbursing your bills for care services. There are some that indemnify (pay the whole benefit regardless of expenses) but these are less common and largely older policies. Some may indemnify for facility care while reimbursing for home care services. Either way, invoices will need to be submitted in order to receive payment.
While on claim (with a reimbursement-based policy), you will need to submit each of the home care/care facility invoices to the insurance company (along with their reimbursement form). After submitting, you will want to wait two business days, then call to confirm it was received by the insurance company’s claims department. You will be paid directly by the insurance company so don’t forget to do this each time you receive an invoice for care services. Also, review your explanation of benefits when you receive your reimbursement for care services and confirm it is accurate.
Almost all policies allow for an “assignment of benefits”. This means you can assign your benefits to the care provider and they bill the insurance carrier directly. Most home care agencies do not accept “assignment”, but some care facilities will accept this for longer claims. If your care provider does accept “assignment”, it will reduce your involvement in the billing process. However, it is important to recognize that many care providers only accept payment directly from the care recipient’s family. If your policy pays “indemnity” benefits (full benefits regardless of charges incurred), you will not want to “assign” your benefits as the benefits could potentially exceed your caregiving bills.
A Final Word
We hope this guide assists you in filing your claim. We recognize that it is a lot to remember and a lot to do. However, if you follow these steps, it can dramatically increase your chances of a smooth and successful claim. You have plenty to focus on during this challenging time in your life. We hope to make this process easier by helping you understand what to expect and what things you will need to prepare. So whether you would like to 1) Do-It-Yourself; 2) ask for help along the way; or 3) Hire-It-Away, we are available to provide answers and consultation. (Please see the attached “Fee Schedule”.)
If you are inclined to D.I.Y. but feel less than confident in managing the whole process, these are some of the most critical areas for which you may wish to hire an Advocate (AGING CARE EXPERT):
Salutations and Success… Your Villageplan? AGING CARE EXPERTS Team
About David
David Wolf is the president and owner of Wolf & Associates, a Long-Term Care planning firm in Spokane, WA.?Wolf & Associates has specialized solely in Long-Term Care Planning since 1988.?David’s expertise in Long-Term Care Insurance planning with business owners and executives has gained him national recognition in his field.??He has been quoted by the Wall Street Journal, Forbes, Money Magazine, and others.?His depth of knowledge in the Long-Term Care Insurance industry has made him a recognized leader and speaker.??David’s practice niche is working with financial advisors to assist their clients in planning for aging, potential frailty, and protecting the ones that they love.