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Long-Term Care Insurance

Engaging Insurance for Eldercare

Alvita Care has a long-standing relationship with most Long-Term Care Insurance Companies. This means that you benefit from our preferred provider relationship! We have opened thousands of claims on behalf of our clients and can be of great assistance to help navigate you or your loved one through this time consuming, laborious process. 

Long-term care is a range of services and supports you may need to meet your personal care needs. Most commonly among long-term care, the care is not medical, but is actually assistance with basic tasks of daily life, these tasks are referred to as activities of daily living (ADLs), such as:

  • Bathing 
  • Dressing 
  • Using the toilet 
  • Transferring (to or from bed or chair) 
  • Caring for incontinence
  • Eating 
  • Housework 
  • Money Management
  • Medication management 
  • Preparing meals and cleaning up 
  • Clothes or grocery shopping 
  • Use of communication devices including the telephone 
  • Pet care 
  • Able to respond correctly to emergency alerts (fire alarms) 

Long term care insurance (“LTC”) is a type of insurance coverage that is available for those who may potentially need long term care. There are different types of long term care insurance (LTC) available but as a standard it covers things that health insurance does not and it can also protect your assets. When an LTC policy is purchased, it helps to eliminate any potential burden that might be placed upon your children or other family member who would be responsible for setting up and providing care. These policies traditionally cover services for adult day care, nursing homes but can also cover services such as assisted living and home care. If you are an LTC policy holder, the benefits will be triggered when you begin to need help with activities of daily living or have a severe cognitive impairment.

Different policies may have different “benefit triggers”—conditions that must exist in order for an insurance company to pay benefits. Only when you are no longer able to perform two or more activities of daily living for an extended amount of time, or have been diagnosed with a cognitive impairment, like Alzheimer’s will a tax-qualified policy begin to pay for care. You must also have a plan of care prescribed by a licensed health-care practitioner. 

The “elimination period,” is the waiting period before a LTC policy begins paying for care. It begins as soon as your benefits have been triggered. You may have to pay for any long-term care services you receive during that time. The most common options are for benefits to start at 20, 30, 60, 90, or 100 days after you begin to receive covered services. 

When buying a long-term care policy, insurance companies will give you a choice of a daily benefit amount for home care, usually the daily benefit amounts range from $50 to $350 per day.  Or sometimes the benefits amount can be a percentage up to a fixed dollar amount.  For example: 75% of the total cost up to $325 per day.  Benefits for home care, nursing homes, etc. are different per policy. 

How Long Will Benefits be Paid? 

It’s most common for benefits to be paid for one, two, three, or five years or for your lifetime. Generally speaking, the longer the benefit period, the higher the premiums. The lifetime maximum amount for the policy is usually calculated based on the daily benefit and the number of years you have chosen for your benefit period. 

Anyone may start a claim on behalf of an Insured. The individual will need the Insured person’s full name, social security number, date of birth, and policy or certificate number available.

By completing an Authorization to Release Information form, the Insured person or Insured’s legal representative may grant another individual access to Protected Health Information (PHI).  Most LTC providers have their own standard form.

Claim Activation > Initial Onsite Assessment > Eligibility Review Process > Determination 

Claims Activation 

  • Call the LTC company and inform the insurance company that a claim would like to be initiated 
  • LTC company will mail a packet of paperwork to the insured that will need to be completed by healthcare professionals

Initial Onsite Assessment 

The initial onsite assessment is a face-to-face interview conducted in the Insured person’s home or assisted living facility by an assessing nurse who will: 

  • Observe the Insured person’s ability to perform ADLs
  • Conduct a functional assessment to evaluate the Insured person’s ability to care for themselves 
  • Perform a standardized cognitive exam to test the Insured person’s memory, word recall, attention and other basic measures of brain health 

The Insured person should have the following documents and information readily available during the face-to-face interview: 

  • Two forms of photo identification (license, ID card, passport); 
  • Names and phone numbers of all primary care and treating physicians; 
  • A list of all current medications, including dosages; 
  • Names and contact numbers for any current caregiver(s); and 
  • Medical history, such as hospital confinement dates, procedures and diagnoses. 

Eligibility Review Process 

A Benefit Analyst will be assigned to evaluate the Insured person’s claim. The Benefit Analyst will work directly with the Insured person, or the Insured person’s personal representative, and care providers, to gather all required claim forms, which may include, among possible others: 

  • Attending Physician Statement 
  • Insured Statement 
  • Authorization to Release Information 

During the eligibility review process, the Benefit Analyst will evaluate the type(s) of Long Term Care Benefits the Insured person wishes to access and the policy or certificate’s coverage limits. The Benefit Analyst will also consider the Insured person’s medical records, assessment interviews, and provider information in order to complete a thorough review of the claim. 

After reaching a benefit eligibility determination, the Benefit Analyst will contact the Insured person, or the Insured’s personal representative, by letter and telephone to discuss the decision made and to answer any related questions. 

Benefits Payments 

Once the claim has been approved and the elimination period met, payments will be distributed from the policy.  The frequency is based on the insurance company (usually every 2 – 4 weeks).  The payments can be made directly to the insured or an ASSIGNMENT OF BENEFITS can be established and the benefits can directly pay the provider. 

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