Does Long-Term Care Insurance Pay for In-Home Care in Texas

Yes, many long-term care insurance policies cover in-home care in Texas. However, benefits do not begin automatically. Coverage depends on the policyholder’s care needs, the policy’s benefit triggers, elimination period, benefit limits, and requirements for eligible caregivers or home-care agencies.

Families often purchase long-term care insurance so an older adult can remain safely and comfortably at home. In many cases, that is exactly what the policy can help accomplish. The Texas Department of Insurance explains that long-term care insurance may cover nursing care and other health services provided at home. Some policies also cover personal care, respite care, household assistance, caregiver training, or other support services.

The important word is “may.” Long-term care insurance policies are contracts, and two policies issued by the same insurance company can have very different requirements. Families should review the actual policy—not simply rely on the carrier’s name or a general description of its coverage.

What types of in-home care may be covered?

Depending on the policy, covered services may include:

• Bathing, dressing, grooming and toileting
• Assistance with transferring, walking and mobility
• Meal preparation and help with eating
• Medication reminders
• Supervision for dementia or other cognitive impairments
• Respite care for a family caregiver
• Light housekeeping, errands and companionship when included in the care plan
• Certain skilled nursing or therapy services

A policy may use terms such as “home health care,” “personal care,” “custodial care,” “homemaker services” or “informal care.” These terms are not necessarily interchangeable. The definitions in the individual policy determine which services qualify for reimbursement.

What are long-term care insurance benefit triggers?

A long-term care insurance policy does not normally pay benefits simply because someone is older, lives alone or could use companionship. The insured person must first meet the policy’s benefit trigger.

Many tax-qualified policies require the insured person to meet one of these standards:

• The person is expected to need substantial assistance with at least two of the six activities of daily living for at least 90 days; or
• The person has a severe cognitive impairment that requires substantial supervision.

The six activities of daily living, commonly called ADLs, are:

• Bathing
• Continence
• Dressing
• Eating
• Toileting
• Transferring

A licensed healthcare practitioner will typically need to certify the person’s condition and establish a plan of care.

Dementia may qualify as a benefit trigger even when the person can still perform several physical activities independently. In that situation, the claim may depend on the policy’s definition of cognitive impairment and the need for supervision to protect the person from threats to their health or safety.

Older or non-tax-qualified policies may use different standards, such as medical necessity or disability. The actual policy language controls eligibility.

What is an elimination period?

Even after the insured person meets the benefit trigger, the policy may require an elimination period before it begins paying benefits. An elimination period works somewhat like a deductible, except it is measured in days rather than dollars.

The Texas Department of Insurance states that elimination periods commonly range from 30 to 180 days. However, how those days are counted can make an enormous difference.

Calendar-day elimination period: Every calendar day may count after eligibility begins, whether or not the person receives paid care that day.

Service-day elimination period: Only days on which qualifying care is received may count. For example, if someone receives care three days per week, satisfying a 90-service-day elimination period could take approximately seven months.

Before care starts, ask the insurance carrier:

• What event starts the elimination period?
• Does the policy count calendar days or service days?
• Must the insured receive paid care for a day to count?
• Do services have to be provided by an approved agency?
• What records must be submitted for each day?
• Is the elimination period satisfied once, or can it apply again after a break in care?

Whenever possible, obtain the carrier’s answers in writing.

Will the policy pay for any caregiver?

Not necessarily. Some policies require care to be provided by a licensed home-care agency, an employee of an approved agency or a caregiver who is not related to the insured person.

Most traditional policies do not pay a spouse or adult child to provide care, although some policies offer cash benefits or contain more flexible caregiver provisions. Families should never assume that privately hiring a caregiver—or paying a relative—will qualify for reimbursement.

Before selecting a provider, confirm:

• Whether non-medical personal care is covered
• Whether the provider must be licensed or agency-employed
• Whether relatives are excluded from payment
• Whether the insurer must approve the provider
• Which invoices, care notes and plans of care must be submitted
• Whether the policy reimburses actual expenses or pays a fixed cash benefit

How much will the policy pay?

Claim approval does not necessarily mean the policy will pay the entire home-care bill.

An expense-reimbursement policy generally pays eligible expenses up to a daily or monthly benefit limit. An indemnity or cash-benefit policy may pay a predetermined amount once the eligibility requirements are satisfied, regardless of the exact amount spent on care.

An older policy’s original benefit may also have increased through inflation protection. Families should request a current benefit statement showing:

• The current daily or monthly benefit
• The remaining lifetime benefit pool
• Any inflation increases
• The maximum benefit period
• Whether unused daily benefits remain in the benefit pool
• Whether premiums are waived while benefits are being paid

What should families do before starting in-home care?

Use this checklist before the first caregiver shift whenever possible:

1. Find the complete policy, amendments and current schedule of benefits.
2. Contact the claims department and request a claim packet.
3. Ask for a written explanation of the policy’s home-care requirements.
4. Have the appropriate healthcare professional document the person’s functional or cognitive limitations.
5. Confirm whether the elimination period counts calendar days or service days.
6. Verify that the selected home-care agency meets the policy’s requirements.
7. Keep all care plans, daily notes, invoices, proof of payment and carrier correspondence.
8. Review every explanation of benefits and compare it with the submitted invoices.

Beginning the claim process before care starts can help prevent lost elimination-period days, incomplete documentation and the accidental use of an ineligible provider.

Does Medicare pay for ongoing non-medical home care?

Generally, no. Medicare does not pay for ongoing custodial care when personal assistance is the only care needed. Medicare home health coverage is a separate and limited benefit with specific eligibility requirements.

This is why families should investigate long-term care insurance, veterans benefits and other potential payment sources instead of assuming Medicare will cover ongoing caregiver services.

Can Amada Senior Care Dallas help with an LTC insurance policy?

Amada Senior Care Dallas helps families understand how an existing long-term care insurance policy may apply to in-home care. We can review the policy, explain important provisions in plain language, help organize claim documentation, communicate with the carrier and provide the records needed to support eligible home-care claims.

The insurance company—not Amada—makes the final eligibility and reimbursement decisions. However, experienced guidance can help families understand the process, avoid preventable mistakes and make better use of benefits they may have been paying for over many years.

To schedule a complimentary long-term care insurance policy review, call Amada Senior Care Dallas at 972-440-1941 or visit AmadaDallas.com.

This article provides general educational information and is not legal, insurance, tax or medical advice. The insurance policy and carrier’s claim decision determine coverage.