Help With Long Term Care Claims

long term care insurance helpWho is an eligible long term care provider?  The confusion and problems on this issue (who is an eligible care provider) in long term care insurance claims is just legion! But it is not completely insolvable…

There are only a few things to know – and corresponding solutions:

Read the Long Term Care Insurance Contract

Does the contract (a) pay for your type of care (i.e. if it is a facility only policy no home health care provider will ever be “eligible”) and (b) require a provider licensed by the state. In the case of nursing homes and assisted living facilities, the licensure is nearly always done by the state. But home health care providers are not licensed in every state. Further, where there are licensures, it can sometimes be Medicare/caid licensure rather than home care or private duty. So if the policy requires state licensure – and you live in a state that does not license private duty home care providers – then send in a copy of your business license and a copy of the license of the RN you have on staff. Usually in combination this will solve the problem

Call the Long Term Care Insurance Carrier

In our experience, each long term care insurance carrier is slightly different in what they will allow for an eligible carrier. Some contracts will allow “informal” care givers (i.e. folks with no formal training or licensure such as a CNA, LPN or RN license) and family as care givers. Most contracts will not pay informal or family care givers however. Further, some carriers will insist on a Medicare/caid licensed home health care provider while others won’t. It is hard to know without calling the carrier and asking what the criteria are. Sometimes it will be spelled out in the contract (especially if it pays informal or family care givers), so reading the contract can answer these for you. There is only one “workaround” for paying family as caregivers if the policy specifically will not pay family. Whoever is going to be the caregiver must get the minimal licensure required to fulfill the contract AND operate a s company to bill for services and track daily visitation duties. Families who already have an RN or LPN in the family can often make this transition easier than those who have no one with prior medical certifications.

Finally, don’t waste energy on fighting it if you are in a no-win situation. We have seen family after family get angry, talk to lawyers, spend hard-earned cash trying to force a carrier to pay for a type of care giver that is either not approved in the contract (e.g. pay for home health care when it is facility only) or is not properly licensed (e.g. they just LIKE the caregiver they have from HHC provider “A” but the carrier won’t pay that HHC provider for licensure reasons). You are in no-win situation there and since you only have finite energy to care for your family member and cope with the finances, it is just easier to comply with the rules in the contract than to battle it endlessly.

To be fair, there have been egregious cases of insurance fraud on both sides of the fence – individuals defrauding carriers and carriers not being fair to policy owners. But before you spend tons of your finite energy chasing these things, give us a call for a second opinion. We have done this enough to give you help with your claim by providing an unbiased opinion as to whether you have a legit “beef” on the “eligible care provider” problem.


Some Additional Links to help you with your long term care claim journey

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