Long Term Care Insurance and Home Care
Long Term Care Insurance Process
• Policy purchase – cost depends on person’s age, overall health, amount of coverage, length of coverage and optional benefits chosen
• Benefit triggers – recommended to focus on using ADL side of policies to get approved because cognitive impairment required is quite high
• Elimination period – set number of days policy holder must pay for their own care before insurance starts covering costs (either calendar days or care days that count ttowards this clock)
• Coverage – insurance pays up to daily or monthly maximum (most plans have a fixed “total value” amount
• Types of care covered – most cover a range of services with the exception of IADLs (instrumental activities of daily living) and coverage can depend on the setting of care (home, independent living, assisted living, etc.)
• Claims process – best practice is to complete a 3-way call with family and insurance company before a claim is filed
• Inflation protection – most commonly it is a 5% compounded annual increase
• Assignment of Benefit (AOB) Process
o Insurance company pays Qualicare directly and is much more efficient
o Insurance company sends EOB (Explanation of Benefits) directly to Qualicare and the family – this allows you to see what services are being paid for and if any services have been denied (which you can then resubmit with the insurance company as applicable)
• Recommended to get involved from the beginning through hands-on communication with the family and insurance company
o Call #1 – 3-way call with family and insurance company to find out details of the policy and review overall claims process
o Call #2 – 3-way call with family and insurance company to actually file the claim (ensure you prepare the ADLs for either you or the family to explain to the insurance company)
Client Name:
LTC Name:
DOB:
Policy #:
Last 4 of SSN:
Phone:
Fax/Upload:
Elimination Period:
*Determine how days of credit works (e.g. Does 1 care day = 1 week)
Waiver of Premium:
Inflation Rider (%):
Daily/Weekly/Monthly Benefit:
ADL’s (2 or 3):
ADL’s – Differentiation between “Hands on or Full Assist” vs. “Standby”
What are the “worst” day needs? Build care plan to this.
Max hours per shift (Based on ADL’s, MCI) – e.g. no more than 4hours/shift
**Are the ADL’s broken up by “On Demand” vs. “Non On Demand ADL’s”?
**”On Demand”: Bathing, Dressing, Eating – May lower “hour” requirement
**”Non On Demand”: Continence, Toileting, Ambulation/Transfer
Max $’s per caregiver
Total Value:
Home and/or Nursing Home (inc. Respite?):
AOB:
Provider needs:
Mileage:
Case Mgmt:
Riders: