Most long-term care insurance policies pay for care at home once the person meets the policy's benefit trigger and the waiting period ends. This guide covers what policies usually pay for, how families qualify, what paperwork to gather and where Medicare stops.
Short Answer: Yes, If the Policy and the Person Qualify
Families often wonder whether long-term care insurance will pay for in-home care, and for most policies the answer is yes. Benefits begin once the policyholder meets the policy's benefit trigger and the waiting period has passed. Until then, the family covers the cost of care.
The question reaches a large number of households. About 70% of adults who reach age 65 develop severe long-term care needs, and 29% go on to receive paid home care after 65. A policy bought years earlier can carry much of that cost.
This article gives general information. Every policy is different, and the policy's own language decides what is covered for your family. The insurer can confirm the details for your policy.
The sections below walk through what policies usually pay for, how to qualify, why agencies matter and what to have ready before you call.
What a Long-Term Care Insurance Policy Typically Covers at Home
Most policies pay for personal care, which means hands-on help with bathing, dressing, transferring from bed to chair and toileting. Many also pay for homemaker help such as laundry, light housekeeping and meal preparation, and some pay for companion-type services. Long-term care insurance home care benefits are built around the daily tasks that become hard because of age, illness or injury.
Home is where most families put the benefit to use. In 2012 claims data, 51% of newly opened long-term care insurance claims paid for home care, compared with 30.5% for nursing home care and 18.5% for assisted living.
Policies pay in one of two ways. A reimbursement policy repays the cost of services billed by a provider, up to a daily or monthly limit. A cash or indemnity policy pays a flat daily or monthly amount once the policyholder qualifies. The policy's schedule of benefits shows which kind you have.
Most policies also set a maximum daily or monthly benefit and a total pool of benefits, so the hours of care a family schedules shape how long the money lasts. Whether companion-type services are covered varies by policy, so the wording on homemaker and companion care is worth reading closely.
Many of the services policies are built to pay for are the ones families arrange locally. At Home Care Partners, Companion Care Services include companionship, errand running, accompanying clients to appointments, meal preparation and medication reminders. Personal Care Services include dressing, grooming, transferring from bed to chair, feeding, and toileting and incontinence care. Both are part of the support families can arrange through assisted living at home in Lincoln and across Lancaster County. Because clients choose when and how often they receive care, families can match visits to the hours a policy reimburses.
Families who want to set a benefit amount beside real costs can read how Home Care Partners helps families use long-term care benefits or private pay to bring care home.
How Benefit Triggers and Elimination Periods Work
Two gates stand between a family and the first benefit payment. One is the benefit trigger. The other is the elimination period.
Most policies set the benefit trigger as needing hands-on help with two or more of six activities of daily living: bathing, dressing, transferring, toileting, eating and continence. Transferring means moving from bed to chair, and continence means managing bladder and bowel function. A diagnosed cognitive impairment, such as dementia, can also trigger benefits on its own. A physician's statement usually documents which trigger applies.
The elimination period works as a waiting period. Policyholders choose it when they buy the policy, and an elimination period of 30, 60 or 90 days is common. During those days the family pays for care out of pocket. Among 2012 applicants for new individual policies, 92.3% of buyers chose a 90-day elimination period.
Some policies count a day toward the elimination period only when paid care is received that day. For those policies, the visit schedule during the waiting period affects how soon benefits begin, so it helps to ask the insurer how days are counted before services start. The waiting period is also a good time to line up a provider and gather the paperwork described below.
The exact number of ADLs, the trigger definition and the length of the elimination period all live in the policy's own paperwork. A policyholder should confirm both directly with the insurer.
Families who are unsure how a loved one's needs line up with the six activities can request a free Care Assessment from Home Care Partners. The assessment reviews a person's mental, physical, environmental and financial condition and results in a plan for meeting needs.
Why Coverage Usually Calls for a Licensed Home Care Agency
Insurers pay for care they can verify. For that reason, most policies define qualified care as care delivered by a licensed or certified home care agency, or in some cases by an independently licensed provider. Payments to an unlicensed family member or friend generally fall outside that definition.
An agency gives the insurer what it needs to approve a claim and keep paying it. The provider meets state licensing standards, and each visit is documented with the date, the hours and the tasks completed. The insurer can match those records against the plan of care and the policy's benefit schedule.
This is why families who want to use a policy's home care benefit typically set up service with an agency before or as they open a claim. Family members who have been providing care stay involved while agency Caregivers handle the hands-on tasks and give the family a break.
Home Care Partners helps families use long-term care benefits to bring care home. That includes confirming what a policy requires and setting up service to match, so the first visit lines up with the claim.
Policies differ on this point, and the policy's definition of a qualified provider is the one that counts. The definition usually appears in the section on covered providers or home care benefits, and the insurer can explain it.
Documentation to Gather Before You Call the Insurer
The claim process usually follows a simple shape. The family notifies the insurer, completes the insurer's forms and any required assessment, and submits visit records once service begins. Having the right papers in hand shortens the time between "we think Mom qualifies" and a claim that is open and paying.
A long-term home care insurance claim moves faster when these items are ready:
- The policy number and a copy of the full policy, including the schedule of benefits.
- A physician's written statement confirming that the person needs help with the required number of ADLs or has a cognitive impairment.
- The name and license information of the home care provider who will deliver service.
- A plan of care that comes out of an assessment, which many insurers require.
- A way to submit ongoing visit records, since many insurers ask for them every two weeks.
Once a claim is open, most insurers ask for visit records on a regular schedule. An agency that keeps dated visit notes makes that routine easier for the family to follow.
Where Medicare Fits Into Home Care Costs
Families often assume Medicare will cover ongoing help at home. Medicare Part A and Part B cover medically necessary, intermittent skilled nursing and therapy at home when a doctor orders it and the person is homebound. That includes part-time skilled nursing, physical therapy, occupational therapy and speech-language pathology.
Medicare does not pay for 24-hour care at home, delivered meals, homemaker services such as shopping and cleaning, or custodial personal care such as help with bathing, dressing and using the bathroom.
Long-term care insurance is designed to fill that gap. Medicare pays for skilled, time-limited care after an illness, injury or hospital stay. A long-term care policy pays for ongoing personal care at home, which is why the two programs work side by side and neither stands in for the other.
When a loved one receives both kinds of help, Home Care Partners' Care Management coordinates communication between families, doctors and other care teams so skilled visits and daily personal care fit together.
Families weighing these options and ready to talk through what their policy covers can start a conversation with Karla Frese and the Home Care Partners team.
Frequently Asked Questions
Can long-term care insurance pay a family member to provide care at home?
Most policies define qualified care as care from a licensed or certified home care agency, so payments to an unlicensed family member or friend are generally not covered. A few policies allow other arrangements, and the policy's definition of a qualified provider has the final say.
Does long-term care insurance cover in-home care for dementia?
Most policies treat a diagnosed cognitive impairment, such as dementia, as a benefit trigger on its own. Once the trigger is met and the elimination period has passed, personal care and homemaker help at home are typically covered under the policy's home care benefit.
Do we pay anything before benefits start?
Yes. Most policies include an elimination period, commonly 30, 60 or 90 days, chosen when the policy was purchased. The family pays for care out of pocket during those days, and some policies count only days on which paid care is received.
Does long-term care insurance cover companion care?
Many policies cover homemaker and companion-type services such as meal preparation, errands and companionship, and the wording varies from policy to policy. The policy's home care section and the insurer can confirm which services qualify.
Does Medicare pay for personal care at home?
Medicare covers skilled, intermittent home health care ordered by a doctor for a homebound person. It does not cover custodial personal care such as bathing, dressing and toileting, which is the kind of ongoing help long-term care insurance is designed to pay for.
Our Caregiving team provides personal one-on-one attention for your loved one. When you are ready to begin your care journey, we are the experts that will answer your questions and help you implement a plan.
Home Care Partners is locally owned and committed to providing Thoughtful, Quality, and Dedicated Care.
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