Long Term Care Insurance

Long-Term Care Primer

Patient/Policyholder

• The policyholder (patient) or family member should contact their insurance carrier to discuss eligibility to receive benefits.  

• You may assign a family member or advisor as your primary claim representative (your contact person). In that case, that person assumes full responsibility for the claimant and shall be the health care power of attorney or health care proxy.   

• Before calling your Benefit Intake Specialist (BIS), gather the information about your policy. Have your *Certificate of coverage, date of birth, Social Security #, address for care (your address), and Doctor's statement (if you have one) on hand when you call your insurance company.   

• After your BIS reviews your policy, an Initial Claim Packet (ICP) is sent to you for your review.  Complete the requested information, if any, and sign.  The ICP includes information about your coverage, such as the elimination period, the maximum reimbursement for a day and month, lifetime benefits, and other pertinent information.  

Requirements for receiving claim benefits   

• LTC carriers require the patient/client to meet the minimum ADLs (Activities of Daily Living) for approval to receive benefits.  

• The criteria are;  need help with at least two of the six ADL or cognitive impairments. The six ADLs are Bathing, Toileting, Eating, Dressing, Mobility, and Personal hygiene. 

• Your insurance carrier may send an RN to assess and approve the claim for benefits. Others discuss your condition with your PCP (your Doctor) for their medical opinion.  Once approved for benefits, there is an elimination period before receiving reimbursements; the usual period is 30 to 120 days aftercare starts.   

Elimination Period 

• An elimination period is a term used in the insurance industry that refers to the length of time between when a subscriber is deemed impaired (start of elimination period), and receiving benefit payments from an insurer.   

• The Elimination Period (EP) depends on your insurance policy.  Some insurance policies start counting benefit eligibility only after the insurance company has approved your claim.  Other insurers backdate the claim and start counting from the day a claimant is deemed impaired.   *Ask your insurer for their definition of the start for elimination period.

• LTC insurance Carriers require Care Providers to be Home Health Agencies licensed by the State of Hawaii and require Agencies to have accurate patient care records when submitting claims for reimbursement.   

• LQHHCS creates, maintains, and submits care records for its customers, freeing them from these tasks.  

• Claims are submitted twice a month. Five days after each care period ends, approximately on the 5th and 20th of the month.   

• Reimbursement payments are sent directly to the client or arrangements are to be sent to LQHHCS.  If the latter is the case, and if a balance exists between the reimbursement and invoiced amount,  the client's account is billed semi-monthly for the difference.  

• If you have questions not described in the above text, please call LQHHCS Office at 808-623-7109 and ask to speak with an LTC specialist who will assist in answering your question. 

*If you've missed placed your Certificate of coverage, you may request a copy of the certificate from your insurance carrier.