LTCI Claim Playbook
A step-by-step walkthrough of activating a long-term care insurance policy for home care in Houston, based on the 15+ carriers we bill directly and the mistakes we see families make most often.
18 min · Printable · By the care team at Homewatch CareGivers of Houston Galleria
1. Find the policy
Locate the actual policy document, not just the annual statement. LTCI policies are typically held with the primary insurance file (a filing cabinet, a safety deposit box, or the estate attorney’s office). If a parent bought it in the 1990s or 2000s, the original carrier may have been acquired since — Genworth, John Hancock, MetLife, TransAmerica and Northwestern Mutual are the most common in Houston. If in doubt, call the carrier’s policyholder service line with the policy number.
2. Confirm the policy is in force
The single most common problem: premium payments stopped years ago and the policy lapsed. If the last premium payment is more than 12 months ago, call the carrier immediately to check status. Some policies have a reinstatement window if lapse was recent.
3. Read the key numbers
- Daily or monthly benefit amount — e.g. “$200/day” or “$6,000/month”
- Elimination period — the “deductible” in days (30, 60, 90, 100). During this window you pay out of pocket; the carrier pays after.
- Benefit period or lifetime cap — 2, 3, 5, or lifetime years of benefit
- Inflation rider — if the daily benefit compounds annually, note the rate
- Cash vs reimbursement — critical distinction; cash policies pay a flat amount when the trigger is met; reimbursement policies pay against actual bills
4. Understand the trigger
Almost every LTCI policy activates on one of two triggers:
- ADL trigger — needs help with 2 or more of 6 Activities of Daily Living (bathing, dressing, toileting, transferring, continence, feeding), certified by a physician
- Cognitive trigger — diagnosed cognitive impairment (dementia, Alzheimer’s, other), certified by a physician
Cognitive triggers are usually the easier path when dementia is involved. ADL triggers require a physician to observe or reliably attest to the ADL deficits on the carrier’s specific form.
5. Get the physician certification
The carrier will send (or the family requests) a specific certification form. The primary-care physician or the specialist (neurologist for dementia) completes it. Common Houston pain point: the primary care doctor has not physically seen the patient in 6+ months and cannot attest to current status. Schedule a visit specifically for the certification.
6. File the initial claim
The claim packet typically includes: the physician certification, an assessment by an approved provider, the intake form from the carrier, and a copy of the policy. Some carriers do a phone assessment; others send a nurse. We can be the approved provider or coordinate with one.
7. Serve the elimination period
Most policies require 30–100 days of eligible care before benefits start paying. During this window you pay privately; after, the carrier pays according to the policy. Some policies count calendar days (any 30-day span works); others require paid-care days (only days when care is provided count). Confirm which model your policy uses.
8. Set up direct billing
Once the claim is approved, most carriers can bill us directly (an Assignment of Benefits arrangement) so the family never fronts the cost. Ask us to send the AOB form to your carrier — we handle 15+ carriers directly. Reimbursement-only carriers require the family to pay first and file for reimbursement monthly, which is more work but doable.
9. Maintain ongoing recertification
Most LTCI benefits require quarterly recertification — a nurse assessment confirming the ADL or cognitive trigger is still met. Miss a recertification and benefits pause. Our Care Manager tracks the recertification calendar so nothing lapses.
10. Common mistakes we see
- Waiting until the policyholder is deep into dementia to activate — the process is easier when the person can still participate in the intake.
- Not knowing the elimination period was calendar-day counted, so care started at day 1 and benefits started at day 31 — perfect.
- Not knowing the carrier requires a specific provider licence — some carriers will not pay a companion-care visit; require personal care or higher.
- Assuming a lapsed policy is dead — some are reinstatable within 5 months of lapse.
Get a free policy review
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