Mar 10 2025 61 mins 1
The wave of long-term care insurance claims is rapidly approaching, and home care agencies need to be prepared. With nearly 4 million policies written between 1995-2005, we're entering a period where these policyholders—now in their peak claim years of 80-85—are seeking home care services in record numbers.
Bill Comfort, with over three decades of experience in long-term care insurance, walks us through the critical steps agencies must take to successfully work with these valuable clients. First and foremost is understanding whether your agency qualifies as an eligible provider under various policy definitions. While many policies use the term "home health care" generically, the actual definitions vary widely. Most policies specify providers must be "licensed by the state if licensure is required"—a crucial distinction for agencies in non-licensure states.
Documentation emerges as perhaps the most critical factor in successful claims management. Agencies must carefully document whether assistance with Activities of Daily Living (ADLs) is hands-on or standby—a distinction that can determine claim approval or denial. The caregiving notes must consistently reflect assistance with at least two of the six ADLs (bathing, dressing, transferring, toileting, eating, and continence) for clients to maintain benefit eligibility.
Payment structures present another consideration, with Bill strongly recommending against accepting assignment of benefits until claims are fully established. This protects agencies from financial exposure when claims are delayed or denied. Instead, establish procedures to help clients submit claims while maintaining your direct billing relationship.
Building referral partnerships with financial advisors and insurance agents offers tremendous growth potential. Organizations like NAIFA and FPA provide perfect networking opportunities where agencies can position themselves as knowledgeable resources. By demonstrating expertise in navigating long-term care insurance claims, your agency can attract both insurance-funded and private-pay clients.
Ready to position your agency as an expert in long-term care insurance claims? Learn more about obtaining the Long-Term Care Claims Professional certification to demonstrate your expertise and grow this valuable revenue stream.
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