Helpful Tips on Filing a Long Term Care Insurance Claim

Know the Ropes

When the time comes to file a long term care insurance claim, it can often happen during a stressful period for you and/or your family. In most cases, you will contact the insurance company directly and they will walk you through the necessary steps, but knowing the ropes before you make that first call can streamline the process and minimize worry.

In most cases, the claims process will involve these steps:
• Telephone intake call
• Face-to-Face Assessment
• Plan of Care
• Completing claims paperwork and Attending Physician’s Statement
• Benefits Payment

As a full-service professional, I truly care about my clients, and want to make sure that they are able to easily obtain the optimum coverage to which they are entitled, and to do so as soon as they, or their families, feel that it is necessary. In the many years I have been assisting clients—including my own father— to navigate the system, I have found the following tips to be particularly helpful.

Know your policy benefit triggers

Most policies today allow you to access your benefits when you need physical assistance with at least 2 of 6 activities of daily living (ADLs) or supervision due to cognitive impairment.

ADL assistance can be in the form of standby care (i.e. balance problems causing falls) or hands-on care. Needing help with bathing and dressing are the most common ADLs that will qualify for benefits.

With cognitive impairment, the most common claims are for dementia, including Alzheimer’s disease. When you become a safety threat to yourself or others, it is time to consider accessing your long term care insurance benefits. It is important that your doctor is familiar with dementia associated with aging, and can administer in-depth memory tests (i.e. MoCA -Montreal Cognitive Assessment), as well as interview family members to understand any surrounding issues.

Enlist the Help of an Advocate

For any number of reasons, it seems to be human nature to minimize our ailments and limitations. This tendency will NOT help you in the claims process. For that reason, I highly recommend having a third party, i.e. someone fully knowledgeable about your current health history and situation, act as your advocate who will make the initial telephone call on your behalf and be present when your face-to-face assessment is completed. This is to insure that ALL relevant health information is given to the insurance company so they have a complete picture as to your needs. In the best case scenario, this should be a spouse or partner, immediate family member, or close friend, but if need be, as a service to you, I can act as your advocate and assist with filing your claim. Other viable options are to hire a Geriatric Care Manager or to contact the Home Care Agency you plan to hire and ask them to assist you in opening your claim for benefits.

Here is a true example of why we should NOT advocate for ourselves:

Mary lived alone and began having balance problems. She had fallen several times in the past year and when she did fall, she could not get up. Otherwise, she was able to perform all of her ADLs (activities of daily living) and said so on the intake telephone call. Therefore, the analyst told her she did not qualify to open a claim at that time. When Mary told me this, I called the insurance company as her Advocate, and requested that the claim process be started. After the intake analyst asked about help with ADLs, I added that Mary had fallen several times, could not get up without assistance and was at risk for further complications if she continued falling. With this additional information the intake analyst agreed that a claim should be initiated.

When in doubt, make the call!

Often, a long term care event begins with an acute condition (i.e. a fall and broken hip) and the expectation of recovery. As we age, these conditions can frequently develop complications and recovery may be slow or not at all. The good news is, you are not penalized for starting the claims process, and if the situation is indeed deemed temporary (less than 90 days for most policies) the claim will then be closed by the insurance company. However, should the condition worsen or become long term, you will now be that much closer to completing the process and getting your benefits.

The Steps to Filing a Claim

Step #1: Telephone Intake Call
When your advocate calls your Insurance carrier, the intake analyst will determine if starting the claim process is warranted. The analyst may specifically ask which activities of daily living the claimant needs help with or to describe the mental impairment symptoms. It is the job of your advocate to make sure any pertinent information not asked for is given.

Step #2: Face-to-Face Assessment
Once you have completed the telephone assessment and it is determined that your claim should be initiated, you will be contacted by a care coordinator/manager to schedule an in-person interview. If you are in a skilled nursing facility and needing hands on assistance, the insurance company may waive the face to face assessment and request a report from the facility. If you are at home, the care manager will make an appointment to come to your home for the interview. Your advocate should be present. Once again, it is the job of your advocate to make sure all pertinent information is given to the care manager. An example:

Bob, a widower, was diagnosed with COPD and as his breathing became more difficult over the years it required more effort, and took longer, to accomplish is ADLs. After Bob initiated a claim, the care manager arranged the face-to-face meeting with Bob at his home. When she asked him about his activities of daily living, Bob kept saying, “no problem, I can do that”, so the care manager reported that “the insured stated no help was needed with any ADLs”. His claim was then denied.. However, when Bob told his son this, the son called the insurance company and requested a 2nd face to face interview and attended it as Bob’s advocate. When the care manager finished her questions, they then discussed how long it took Bob to complete his ADLs and how exhausted he became. Once this information was added to the report, the claim was opened without a problem.

Step #3: Plan of Care
When the Care Manager has completed the face to face assessment, he or she will prepare a plan of care, listing how many hours per day you need assistance from another person and the type of assistance needed, such as companion care for dementia or assistance with meal preparation and bathing.
An important point—-the hours listed should not be affected by the family members available to perform these tasks. Once the claim is approved you can then decide which tasks and hours you want to delegate to a paid formal caregiver.

Step #4: Attending Physician’s Statement
Once the telephone intake call has been successfully accomplished, the insurance company will usually mail out the claims packet to be completed. This information is important and you should complete it carefully, as this is where I see the processing of many claims run into problems. The packet will include a request for Power of Attorney if someone other than yourself is, or will be, making decisions for you. You should also consider with whom you want the insurance company to be able to discuss your care, and include them on the contact form.

The most important form will be the Attending Physician’s statement that your doctor(s) will need to complete and sign. Fill out as much as possible before sending this to the doctor for completion. An appointment may be necessary to bring the doctor up to date on your current issues, and a written letter stating the detailed reasons for your visit can be very helpful. As we know, most doctors are extremely busy, so the easier you make it for them, the quicker it will get done. I found this technique very useful when advocating for my own father:

After traveling with my parents for week, it became quite apparent to me that my father was in the early stages of Alzheimer’s (he had been diagnosed with mild cognitive impairment 3 yrs prior) and my mother needed help. I called my father’s insurance carrier to open a claim and received the paperwork packet. I then scheduled an appointment with my father’s doctor and I completed the Attending Physician’s statement to the best of my ability. I prepared a letter for the doctor to read prior to our appointment stating what I had witnessed on vacation, and that I needed him to complete the attending physician’s statement so that we could open a long term care claim. After the exam which included memory testing, the physician took my partially completed form, quickly wrote “beginning Alzheimer/dementia” as his diagnosis, signed the form and we were able to proceed with my father’s claim, quickly and efficiently.

Step #5: Benefit Payments
The majority of policy benefits are paid as reimbursement after you incur and pay for the services according to your plan of care. Practically speaking, the reimbursement model usually requires you to carry a 30 – 45 day receivable. If you are incurring expenses for a facility or home care prior to your claim approval, don’t panic. Approved expenses (listed on the plan of care) should be retroactively reimbursed from the date of diagnosis/event on the attending physician’s report.

Disclaimer: This advice is meant to be general in nature, does not apply to all situations. In no way does it promise or override the terms and conditions listed in your long term care insurance policy.

If you need assistance opening a claim on your Long Term Care Insurance Policy, please email or call my office.    jody@jodyhubbard.com       (760) 944 – 3777

Tax Information – Individual LTCi Premium Deduction 2013

LTCi is treated as accident and health insurance for individual taxpayers who itemize deductions. The 2013 Deduction is limited to the lesser of the actual premium paid or eligible LTCi premium amount.

Eligible LTCi premium in 2013:

Attained Age in tax year
Limitation on Premiums
Age 40 or Less $  360
Age 41-50 $  680
Age 50-60 $1,360
Age 61-70 $3,640
Age 71 and older $4,550

Recap of California Assembly Bill 241 Regarding Wages for Home Health Care Workers

home health careAs of January 1, 2014, California home care workers must be paid minimum wage and qualify for overtime pay. As of January 1, 2015 this is expected to be a Federal law.

Most home care workers are currently paid at or above minimum wage. Therefore if you are using a home care worker less than 8 hours per day you should see no change in the cost of your care. If you are hiring caregivers for more than 8 hours per day the cost of your care could increase. Those receiving 24 hour care per day will feel the greatest impact.

Currently most home care agencies give a discounted rate when a caregiver stays 24 hours and sleeps at your home. My current experience in San Diego is that an 8 hour shift costs $170 – $180 and a 24 hour shift with time to sleep costs approximately $250.00. A 24 hour shift could become much more expensive under the new wage laws. Possible offsets will include adding additional caregivers to insure that no one home care worker exceeds an 8-9 hour shift and being able to deduct 8 hours for sleep time (5 hours undisturbed sleep is mandatory).

Bottom line – The cost of extensive home care is increasing in the near future. The details of monitoring a home care worker’s hours and wages will be handled by the Home Care Agency you hire.

The only impact to your long term care insurance will be how far your benefit dollars will go towards paying for home care at time of claim.

If you missed the LivHome webinar broadcasted in November on Assembly Bill 241 please go to LivHomeBlog.com

and follow up Q & A webinar LivHomeBlog.com

Image courtesy of FreeDigitalPhotos.net

Hiring A Home Caregiver

In August I opened a claim on my father’s long term care insurance to pay for a home caregiver 2-3 times a week so that my mother could leave the house without worry and enjoy some much needed personal time. Being in the business I decided I would hire someone directly, save some money, and pay a better wage directly for a better caregiver.

Knowing the real risks of hiring an employee, I researched setting up payment of payroll taxes, workmen’s compensation, and background checks through Hire Family (www.HireFamily.com). To my surprise, when I added up all the costs and headaches associated with managing a caregiver directly (who steps in when the caregiver cannot make it last minute?) I realized that using a Home Care Agency was a better choice and I could leave the headaches to them. In my opinion, saving a few dollars per hour wasn’t worth the aggravation of identifying, hiring, and managing caregivers.

Jody’s Notes – May 2012

April 17th, tax filing day came and went, and I finished my last tax return. Okay, I only do 2 these days (mine and my folks) but seems like every year it gets more complicated. I can’t imagine how I ever survived without Turbo tax.


What do you suppose Generation Y and Seniors in have common?

Interestingly they both prefer city living. I read several articles this past month addressing changes in living preferences of Boomers and Generation Y. Renting vs. Buying, Small vs. Large, Yard vs Patio, and Walkability vs. Automobile. Why Generation Y is Causing the Great Migration of the 21st Century . . .

To read more …


Avoiding Cognitive Decline As You Age

Stay out of the hospital! Hospitalization of older people might place them at higher risk for accelerated cognitive decline a study suggested . . .

To read more …


Don’t Grow Old Without It

The long term care insurance industry has seen a lot changes in the past couple of years and this recent article in the Wall Street Journal stresses the importance of long term care insurance but also some of the growing pains facing the industry . . .

To read more …


Saving a marriage

Several years ago my father’s hearing began to decline. He loves the TV, but my mother doesn’t. Fortunately he was willing to wear TV headphones, which allowed my mother to stay in the living room enjoying other activities.  If you are noticing that you need the TV volume louder than everyone else, you may want to try a pair. In addition, this website has lots of other interesting goodies. . .

www.Aldea.com


Attitude is everything …

attitude is everything-long-term-care-plans

Jody’s Notes – March 2012

jody-hubbard-long-term-care-planning

Jody Hubbard, Long Term Care Planning

It was great to see those of you who stopped by my booth at the San Diego Successful Aging Expo, February 11th and 12th. I had several vibrant senior citizens (80 years +) ask about signing up for long term care insurance, recognizing long term care as a real issue. As you know, most insurance carriers do not accept anyone over 80 years old and frankly the premium cost would be prohibitive. Conversations with these octogenarians reminded me how much our life views and priorities change as we age. I’m committed to helping boomers (45 – 65yr olds) plan for long-term care today.


Did you know that doctors specializing in Gerontology have the highest job satisfaction among all physicians?

Did you also know they’re the lowest paid, in the biggest demand, and the shortage is growing? To read more …Finding a cure or slowing the progression of Alzheimer’s disease would have a significant impact reducing Medicare and Medicaid expenditures in the future. To read more …


Finding a cure or slowing the progression of Alzheimer’s disease would have a significant impact reducing Medicare and Medicaid expenditures in the future.

The Obama Administration is increasing spending on Alzheimer’s research – planning to surpass half a billion dollars next year. To read more …Some older Americans are choosing to be working and happily retired! To read more …


Some older Americans are choosing to be working and happily retired!

Retiring our brains at age 65 may not be in our best interest. To read more …


Attitude is Everything …

There are few things in life we control, however our attitude is one of them. I stumbled across this video which is actually an ad for a Taiwanese Bank. The featured gentlemen have taken positive attitude to a whole new level … I hope you enjoy watching it as much as I did.

This Video is sure to make you smile!

Early Dementia is Difficult to Detect

long-term-care-plan.I recently read this article and it really struck home with me. Whether a family member is experiencing MCI (mild cognitive impairment) or early dementia, it is difficult to pinpoint when behavior changes are more than just  “senior moments”.  When in doubt, a trip to the doctor’s office can be very beneficial, preferably a doctor who specializes in elder care.   Last year I had a first hand experience with the SOCARE Clinic, an outpatient geriatric assessment clinic run by Dr. John Daly.   I accompanied my Uncle Jack to his regular doctor who told me, “He was fine”.  We then visited the SOCARE Clinic, where Jack was put through a series of tests over several weeks.  BTW – most of this was covered by his health insurance.  My Uncle Jack was diagnosed with MCI.  Now, his wife is more understanding when he forgets things. Jack is writing notes to help him remember and there’s less tension in their home. Click here to read Early Dementia Difficult to Detect in UT San Diego

Life Insurance with a LTC rider or straight Long Term Care insurance?

long-term-care-insuranceThere recently was an article in the Wall Street Journal “Combined Insurance Policies Grow” addressing the cost differential between purchasing straight Long Term Care Insurance (LTCi) and Long Term Care Insurance as a rider to a Life Insurance policy. Everyone including myself loves the idea of having a Long Term Care Policy available if you need it and a full refund if you don’t. Only catch is nothing is free, especially a full refund!

When actuaries price life insurance they use mortality statistics. Long Term Care actuaries use morbidity statistics. When you put these 2 actuaries in the same room pricing a product for mortality and morbidity (plus a cushion of course) the cost increases.

So bottom line,  as much as I love the concept of Long Term Care Insurance as a rider to life insurance I find it rarely pencils out in favor of the insured, my client. Exception – If you already have an existing life insurance policy with cash value that can be transferred tax free to another life insurance policy with the LTC rider this may be the right solution.