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Long Term Care Insurance Claims

Long Term Care Insurance Claims
Medicaid Planning
April 30, 2019

As a Florida elder care attorney who assists with Medicaid planning, I often tell the adult children of my clients that while Medicaid planning is a great service, it will never beat cold hard cash. If you're not independently wealthy, the next best hedge against the threat of long-term care costs is the ability to make a Florida long-term care insurance claim.

Sadly, most Floridians don't look into purchasing long-term care insurance until its too late and therefore too expensive. But for those who do have long-term care insurance policies, the benefits are huge (assuming that there isn't a problem with a long-term care insurance claims denial, which we can also help with). The primary benefit to being able to make a long-term care insurance claim is that everyone accepts long-term care insurance. Its the equivalent of having extra cash. Not every assisted living facility accepts Medicaid, but they will all take long-term care insurance. Similarly, not all private home health care agencies will bill Medicaid - but they'll all be happy to assist with a long-term care insurance claim.

Before I get into long-term care insurance claim denials, I should explain:

What is a Long Term Care Insurance Claim?

Long term care insurance claims are made when a long-term care insurance policyholder requires help with at least two out of five activities of daily living (ADLs). The five primary activities of daily living are:

  • toileting / maintaining continence
  • eating
  • dressing
  • bathing / showering
  • transferring (e.g. being able to get out of bed and into the bathroom)

Why do I need long-term care insurance?

First, let me mention: I don't sell long-term care insurance - although I'm happy to recommend insurance agents that I trust if you would like a recommendation. But, I still believe everyone who can afford to purchase a long-term care insurance policy should do just that. While the primary beneficiary of any long-term care insurance policy is the policy holder. A no-less-important secondary beneficiary is the policyholder's family and perhaps even close friends.

A huge misconception is that Medicare will pay long-term care expenses? The reality is that Medicare has a very limited long-term care benefit. Medicare will not pay for more than 100 days of long-term care in a skilled nursing or rehab facility (and only the first 20 days are paid in full). Medicare will also not pay for home health care. Medicare should not be thought of as a long-term care policy. This is why private long-term care is preferable (and if that is not possible, why people turn to Medicaid planning).

When one requires assistance with these activities of daily living, the most common caregivers are family and then close friends. Being a caregiver is incredibly important, but can be absolutely draining and debilitating without any respite or breaks. According to a 1999 study by the American Medical Association, up to 63% of caregivers will predecease the person they are caring for.

I have personally spoken on expert panels at caregiver conferences (such as the Fearless Caregiver Conference held nationwide) and when I speak to these caregivers, the stress on their faces is just so readily apparent. Medicaid planning or buying long-term care insurance makes it possible for the caregiver to take a break knowing that their loved one is being helped by a professional caregiver at least for a few hours a day without having to come out of pocket.

Bottom line: long-term care insurance helps the health of both the one who needs the care and the caregiver and can make a huge difference in terms of quality of life.

What Type of Long-Term Care Insurance Policy Should I Buy?

As a medicaid planning lawyer, I am partial to Florida partnership policies because it helps protect more assets should Medicaid be needed to supplement whatever your long-term care policy fails to cover.

Florida’s Long-term  Care Partnership Program is a partnership program between Medicaid and private long-term care insurers designed to encourage individuals to purchase private  long-term care insurance. Long-term Care  Partnership policies are tax qualified (a portion of premiums paid may be  claimed as a tax deduction) under federal law; provide policyholders with  inflation protection; and most importantly, provide dollar-for-dollar asset  protection in the event the policyholder needs to apply for long-term care Medicaid  assistance. For every dollar that a  partnership policy pays out in benefits, a dollar of assets can be protected  from Medicaid spend-down requirements.

But, more generally speaking, most long-term care insurance policies are indemnity plans - meaning they pay a set daily rate, sometimes depending on they type of care needed (home health, ALF or skilled nursing). All but the most expensive long-term care policies will have an elimination period (initial time frame where care will not be provided, think of it as a deductible) and will only pay long-term care insurance claims for a set period of time (e.g. five years).

Obviously the more favorable the terms to the policyholder, the more expensive the long-term care premiums will be.

Long Term Care Insurance Claim Exclusions & Fine Print

This is where friction can come into play. What will and what wont the long-term care insurance policy pay for when a claim is submitted. Its important to worth with a long-term care insurance educator, not just a salesman. You need to understand, with eyes wide open, what you are purchasing and then know when and how to hold the carrier's feet to the fire when they improperly fail or refuse to pay a LTC insurance claim.

Its important to know: 

  • are preexisting conditions covered? 
  • what level of care is covered? Does the policy pay claims on dementia patients?
  • how much is the daily benefit in all long-term care contexts?
  • will the payments increase with inflation?
  • can family caregivers make long-term care insurance claims and get paid?

Hiring a Long Term Care Insurance Claim Attorney

The next article will link to what to do if your long-term care insurance carrier denies a claim and how we can help.

The following is a list of long-term care insurance companies with which you may have a policy. If you are not receiving the benefits you deserve, we are likely able to help at no cost to you.

  • Aetna
  • Allianz
  • American Republic
  • Bankers Life and Casualty
  • Berkshire Life
  • Conseco
  • Continental Casualty Company (CNA)
  • Genworth (GE)
  • John Hancock
  • Knights of Columbus
  • Mass Mutual
  • Med America
  • Met-Life
  • Mutual of Omaha
  • Northwestern
  • New York Life
  • Penn Treaty American
  • Prudential Financial
  • State Farm
  • Unum

To read more about how we can help fight a long-term care insurance claim denial, or improper long-term care insurance discontinuation, click on the link.

Long-Term Care Insurance Resources

Jason Neufeld is the Founder and Managing Partner of Elder Needs Law, a Florida estate planning and elder law firm he created in 2017. With more than 15 years of experience practicing law, he represents clients in a wide range of legal matters, including Medicaid planning, estate planning, elder law, probate, Medicare, and life insurance.

Jason received his Juris Doctor from the University of Miami — School of Law and is a member of the Florida Bar and the Broward County Bar Association. He has received numerous accolades for his work, including being named a Rising Star and Super Lawyer by Super Lawyers and among the Florida Legal Elite by Florida Trend in 2024.

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