Long Term Care Insurance (LTCI) is an insurance product that is designed to help individuals pay for the care they receive when they are sick/infirm/frail. Long Term Care Insurance is NOT health insurance. It really is Care Insurance. To qualify for coverage you must need help with your care.
As a Geriatric Care Manager I can help you understand your policy, help you file a claim, and help with ongoing claims processed to maximize your insurance policy.
Generally, the LTCI will begin to reimburse for care once you need help with at least two of the six Activities of Daily Living (ADLs) more than half the time, (walking/ambulating, dressing, bathing, toileting, eating, and transferring from chair to bed, or bed to chair).
To expand on this, when you need help with bathing every time, either every day or once a week, and you need help with eating, bringing the food from the plate to your mouth are activities that can meet the criteria. If you need help putting on socks every day, but put on everything else independently that may not meet that criteria.
Another way of qualifying for payment (reimbursement for care) under LTCI is a diagnosis of confusion/dementia that impairs an individual’s ability to function without directions from others. If your mother has dementia, you could qualify to collect your LTCI benefit even if the need for help is inconsistent. Sometimes individuals with dementia can use the toilet independently, but can’t find the toilet, so they need help/supervision almost constantly. They may be able to feed themselves, but need prompting to stay focused on eating. They may dress themselves, but wear boots in the house and slippers outside, so they need monitoring or supervision to stay safe.
This change of condition can be an event or catastrophic change, a stroke, a fall where they break a hip, or hit their head or more gradual. As in a slow decline over time making it hard to put a date on when they began needing that much help.
Using this criteria you may find that your mother might qualify for using the LTCI policy to help pay for care. GREAT, that is why she paid those premiums all those months/years. The process starts when you file a claim with the LTCI Company. You will need information like your mother’s name, date of birth, policy #, address, etc and will likely need her with you in the beginning. You’re going to be asked questions about diagnosis, physician, and what type of assistance is needed at this time. The LTCI uses pre-screening questions as a tool to ask “why do you think your mother qualifies?” What does your mother need help with, has the help already started? How often do you need the help? Who is it that helps? Have you been hospitalized recently? When did this begin?
Be prepared before you call. When thinking about the Q & A session, it is important to run through your answers before you make that call. We like to paint a very optimistic or positive portrait of ourselves and family. Therefore, you need to be very honest about the needs that exist. How much help is necessary? Communicate the worst days in the week, not the best days to answer these questions.
Pull out the actual LTCI policy, review the procedure and call the phone number listed on the policy and begin to file the claim. The representative will ask the necessary questions and send a packet of information that needs to be completed promptly and returned to them.
This first step is important and the follow-up paperwork should be done as quickly as possible. Your mother may have an elimination period where she must pay for care before the policy begins to reimburse her for those expenses. Most policies allow you to go back to up to six months for services provided. Using this LTCI to help pay for care was the goal when she decided to buy the policy.