How to Access Your Long Term Care Insurance Benefits

Personal Care Inc.Wayne Abraham
Personal Care, Inc.
Greensboro, North Carolina

Member of the national ElderCare Matters Alliance,
North Carolina chapter

If you or a family member reach a point when you believe it is time to use that long term care insurance policy that was purchased, what do you do? All too often people don’t read the fine print on their policies and aren’t sure how to go about accessing them when they need them.

There are some basic things to keep in mind when you have reached this point. First of all, do you qualify? Different policies have different requirements for what constitutes eligibility. The industry standard is that you must need help with at least two activities of daily living or ADLs. These include tasks such as bathing, dressing, toileting, and others.

When you contact your long term care insurance company about activating your policy and receiving benefits they will send an RN out to do an assessment as well as contacting your doctor. Below is a list of items that insurance companies use in order to determine whether or not you are eligible to receive those benefits.

Triggers: these are functional deficits in your ability to perform what are called “Activities of Daily Living” or ADL’s.  These can vary depending upon the policy. Another trigger can be what is called “Cognitive Impairment” that means the person requires supervision.

When starting the assessment process the nurse will evaluate several areas. These include a Mental Status Evaluation, a Current Medication Profile, and observations regarding your Activities of Daily Living and why you require help with them.

During the Mental Status Evaluation the nurse will assess these kinds of items:

  • Orientation: What is the year? Where are we?
  • Registration: Name three objects
  • Attention and Calculation: count backwards from 100
  • Recall: rename the above objects
  • Language: can you follow simple instructions
  • Answering additional questions that the company may have

During the Current Medication Profile the nurse will assess the following:

  • A list of all medications you are currently using
  • A list of all medical equipment you are currently using
  • A list of items regarding your medical history

During the Activities of Daily Living Assessment the nurse will review the following: 

  • Bladder continence
  • Bowel continence
  • Eating
  • Dressing
  • Toileting
  • Ability to move in and out of a chair or bed
  • Bathing
  • Responsibility for own medications
  • Indoor Mobility
  • Outdoor Mobility
  • Ability to use the telephone
  • Shopping
  • Meal Preparation
  • Homemaking
  • Laundry
  • Transportation
  • Equipment usage (such as a walker or portable oxygen)

It’s important to have family members or other caregivers present during the assessment process so that they can answer any questions that the person being assessed cannot. Quite frequently people minimize the amount or kinds of help that they need out of personal pride. We all want to be independent. However, this defeats the assessment process. Caregivers need to be there to explain how things normally proceed, or ways in which they have had to assist the person. We remind people not to tell them what you can do on your “best” day. Tell them what you can and cannot do when you are not feeling well. It is only natural for any of us to want to believe that we can do everything for ourselves, even when it’s not true. I like to remind people that we all need help and use assistive devices. If you wear glasses or contacts, or use a mode of transportation other than walking, then voila you are using an assistive device! 

Some other aspects of long term care policies that folks need to understand is that they quite frequently have a deductible or waiting period before the policy starts to pay benefits. These of course vary with the type of policy but they can be anywhere from 30 days to 100 days. Normally there are also benefit limits. It is important when making a decision about receiving Home Care to understand what dollar limit there is either per day, per week, or per month with your policy. 

You also need to know if your insurance company is going to reimburse you for the expenses, or pay the provider directly. Some companies offer it as an option, others do not, and they can even vary within a company for different policies. Knowing this is critical because you will need to have an understanding with your provider as to whether or not they are going to submit the claims or you are. And whether or not they will accept assignment of benefits, or if you have to pay them upfront and be reimbursed by the insurance company. 

It’s also important to know whether or not your policy covers Home Care, or institutionalization, or both. Quite frequently there are different qualifications for these two types of long term care, and they may have different deductibles or reimbursement rates. Some policies have a different benefit for Home Care than they do for facility care. And policies can have different lifetime benefit limits for Home Care versus facility care. All of these factors need to be weighed when making a decision about what to do.

The key to accessing your long term care policy is to work with someone who can help you to interpret and understand your policy. And to be sure who the provider is so that they work with you to help you make the best use of the policy for which you paid.

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