Clients typically purchase long-term care insurance (LTCI) many years before they may need to use the policy—19 years before, on average. Since so much time has passed between the purchase and time of claim, this can lead to confusion regarding what benefits were purchased and how the claims process works. When you sell an LTCI policy, you want to be sure the insurance carrier will meet expectations when the client needs to use the policy. The long-term care industry has an average of 93% claims approval rate with many of the initial claim denials happening due to incomplete paperwork on behalf of a policyholder’s case. Therefore, understanding the claims process is vital to ensure your client is prepared.
Who Is Eligible for Long-Term Care Insurance?
But first, both you can the client should be aware of the eligibility requirements that are usually followed by each LTCI carrier. These include:
- Insured Eligibility: Has the policyholder met the benefit trigger of their policy? Has this been verified by face-to-face assessments, medical records, or other documentation from a licensed medical practitioner?
- Provider Eligibility: Has the provider met the requirements stipulated in the insurance policy? For instance, is there a requirement for state licensure or a specific number of beds in a facility?
- Covered Service: Is the claim for a service outlined in the policy?
Read More: Who Is a Good Candidate for Long-Term Care Insurance?
Starting the LTCI Claims Process
When your client starts the claims process, they (or their family member) should have the following on hand for the intake process:
- Policy number
- HIPAA form (will be requested by claims department)
- Power of Attorney (may need to be provided to claims department in order to discuss benefits or health conditions)
- Names of doctors, hospitals, facilities, or providers
During the intake process, the LTCI benefits, including the elimination period or deductible, are reviewed with your client. Your client will also be asked to provide the names, addresses, and phone numbers of any doctors, hospitals, facilities, or providers that can verify their long-term care illness. If your client has chosen a provider, they should provide this information to the insurance company so they can verify eligibility of the provider (as mentioned above).
Many carriers also have care managers available on staff to assist your client in finding care, coordinating care, and navigating the claim process.
After LTCI Claim Approval and Beyond
Your client should continue to pay their LTCI premiums during the claims intake process until they are granted approval on their claim. The insurance carrier will refund any unearned premium that was collected once the claim is approved and the client is now on waiver of premium.
Your client may have to be recertified periodically (each year or otherwise) to show that their level of care has not changed. Your client should also communicate any change in care with the insurance company.
The long-term care insurance claims process can be confusing for your client, but with these tips, you can rest assured that the insurance company will meet expectations at the time of claim for your clients. If we can assist with a claim, please do not hesitate to contact us.
