How to Use Long-Term Care Insurance

“We help them understand what’s outlined in the policy and the criteria that determine when they are eligible to file a claim,” says Vice President Steve Sperka at Thrivent, a financial services company that offers long-term care insurance.

You may learn that the insurance company no longer serves this market or even exists.

“Hundreds of companies used to sell these policies. Now there are only six,” Slome says. In this case, you would be referred to a third-party administrator, who would still pay the benefits according to the contract terms.

What an elimination period can mean to you

The policy likely will have an initial elimination period.

This is a number of days that must pass after your loved one starts needing care before the insurance will start paying. It’s like a deductible, the upfront cost you must remit before insurance kicks in.

Ninety days is standard, but elimination periods can range from zero to 180 days.

How to file a long-term care claim

After the elimination period, most policies require covering the costs out of pocket before submitting a claim to get reimbursed. If the insurance company approves your claim, it will pay you back based on the coverage limits.

Your insurer’s claims department will tell you what forms to fill out and the required documents for reimbursement. Sperka from Thrivent says a typical claim requires the following documents:

• Claimant or policyholder statement with the insured’s basic information and reasons for filing the claim.
• Physician statement or plan of care from the physician handling the insured’s care.
• Provider service report from the health care facility or agency where the insured receives care.
• Durable power of attorney for finances if the insured’s family members or friends are helping manage the claims process.

When speaking to the insurance company, take detailed notes about the discussion, including the name of the person you’re speaking to, the date and the time. You might need this information in case of a denial.

Most common reasons that claims are denied

If an insurance company denies your claim and doesn’t reimburse you for the expenses, it will give you a clear explanation for the denial, either over the phone or by mail. Most claim denials happen because a policyholder tried filing for something that wasn’t covered, says Slome of the long-term care insurance association.

“Perhaps the policy required using licensed caregivers, but someone hired their friend from down the street,” he says.

Here are three reasons claims may be denied:

1. Type of care. While in-home care options are popular today, these services were not commonly included in older long-term care insurance policies. “These older policies will deny claims for at-home care but … pay for some services, like home improvements for accessibility,” Slome says.

2. Elimination period requirements. People may try to file long-term care claims without meeting the elimination period first because of the often-confusing way policies count days toward the elimination period. Some policies look at service days when your loved one needs care, not calendar days. 

If the policy has a 90-service-day elimination period and your loved one needs care only three days a week, the coverage will take 30 weeks or 210 days to begin: 3 days of care a week x 30 weeks = 90 service days.

3. Paperwork. Insufficient or improper documentation is another reason Slome sees. For example, someone files a claim without an invoice from the caregiving service.

“The best way to avoid a denial is by closely reviewing all aspects of your policy and connecting with your insurance agent and/or carrier if you have questions about specific eligibility criteria,” Thrivent’s Sperka says. After a claim denial, the insurer should tell you what needs to change for future expenses to be covered.

Whom to contact for assistance

If you believe your claim was unfairly denied and aren’t happy with the insurer’s response, you could contact the AALTCI for its free claims assistance service. It will work with you and the insurer to find a solution.

If that doesn’t work, private companies can take over claims processing for you, relieving you of paperwork or dealing with the insurer.

“Many were long-term care insurance specialists who had large numbers of clients. As these went on claim, they started to help and subsequently expanded,” Slome says. “They typically charge one month of contract benefits.” Contact the AALTCI for referrals to agencies in your state providing this service.

The long-term care insurance industry is not actively trying to deny claims, he says. Insurers paid out a record $13.25 billion in 2022. Understanding your contract’s language and properly following the claims process can help ensure that you get a fair payment, even after an initial denial.