Navigating the complexities of long-term care insurance can feel overwhelming, especially when you’re already dealing with the stress of a loved one’s declining health. But asking the right long-term care insurance questions before you need to file a claim can mean the difference between a smooth process and months of frustration.
Here’s the reality: traditional long-term care insurers paid over $14 billion in claims in 2023, with the largest providers now paying more than $18 million in benefits every business day. The money is there. But according to the American Association for Long-Term Care Insurance, many claims are initially denied—often because families didn’t fully understand their policy requirements or failed to provide proper documentation. Working with long-term care insurance experts can help you avoid these common pitfalls.
Understanding your policy now—before a crisis hits—puts you in control. Here are eight essential long-term care insurance questions to discuss with your insurance provider:
1. What Is the Elimination Period of My Policy?
The elimination period—often called a “waiting period” or “deductible period”—is one of the most misunderstood aspects of long-term care insurance and should be at the top of your long-term care insurance questions list.
This is the duration you must wait after qualifying for care before your insurance benefits commence. Think of it like a deductible, but measured in time rather than dollars. Elimination periods typically range from 0 to 100 days, depending on your policy.
What you need to know:
- During the elimination period, you are responsible for covering all care costs out-of-pocket
- A longer elimination period generally means lower premium costs—but a longer wait for benefits
- Some policies require you to receive and pay for formal long-term care services during the elimination period to satisfy its conditions
- Other policies count calendar days regardless of whether services are received
▶ Critical distinction — Ask whether your policy counts “service days” (days when you actually receive care) or “calendar days.” This difference can add weeks or months to your waiting period.
2. What Are the Policy’s Benefit Limits?
Long-term care insurance policies set maximum benefit limits in terms of time (one to ten years), a total dollar amount, or both. Understanding these limits is crucial given today’s care costs.
Consider current expenses: according to Genworth’s 2024 Cost of Care Survey, the national median cost for a semi-private nursing home room is now $111,325 per year, while a private room averages $127,750. In-home health aides cost approximately $77,000 annually at the median.
Questions to ask about benefit limits:
- What is my daily or monthly benefit amount?
- Is there a lifetime benefit cap?
- Does my policy include inflation protection, and if so, what type?
- How long would benefits last at current care costs in my area?
✓ Pro tip — If your policy includes compound inflation protection at 3%, a $165,000 initial benefit pool grows to approximately $298,500 by age 85 (if purchased at 65). This matters significantly as care costs continue to rise.
3. What Are the Eligibility Criteria for Activating Benefits?
Most policies require specific conditions to be met before benefits become payable. These “benefit triggers” are among the most important long-term care insurance questions you can ask.
Standard benefit triggers:
ADL Trigger: Inability to perform two or more of the six Activities of Daily Living without substantial assistance:
- Bathing
- Dressing
- Eating
- Transferring (moving from bed to chair)
- Toileting
- Continence
Cognitive Impairment Trigger: Severe cognitive decline requiring substantial supervision to protect health and safety—even if the person can physically perform ADLs.
Industry data shows that cognitive impairment and dementia now represent 52% of all long-term care insurance claims, making this one of the most important long-term care insurance questions to understand.
▶ Important — A licensed healthcare practitioner must certify that the condition is expected to last at least 90 days. Some policies require periodic reassessments to continue receiving benefits.
4. Is a Professional Assessment Required to Initiate Benefits?
Many insurance companies require a professional assessment to determine your need for long-term care services before approving benefit payments. This assessment is typically conducted by a registered nurse or another qualified healthcare professional.
The assessment typically evaluates:
- Which ADLs can the person not perform independently
- The level of assistance required (hands-on help vs. standby supervision)
- Cognitive function and need for supervision
- The type and frequency of care needed
Understanding who conducts this assessment and what the process involves can help streamline your claims process and set appropriate expectations. Some assessments are conducted in person, while others can now be completed via telehealth.
5. Is a Physician’s Statement Necessary for Claim Approval?
In addition to a professional assessment, some policies require an Attending Physician’s Statement (APS) as part of the claims process.
An APS is a detailed report from a physician who has treated or is currently treating the policyholder. It provides medical information, test results, and documentation supporting the necessity for long-term care.
The APS typically includes:
- Diagnosis and medical history
- Current medications and treatments
- Functional limitations and prognosis
- Professional opinion on care needs
✓ Pro tip — Establish communication with your loved one’s healthcare provider early. Some physicians take weeks to complete these forms, which can delay your claim.
6. What Documentation Is Required to File a Claim?
Filing a long-term care insurance claim involves submitting various documents to substantiate your need for benefits. One of the most common reasons for claim denial is insufficient or incomplete documentation.
Commonly required documents:
✓ Policyholder Statement — Also known as a claimant’s statement, this form includes basic information, medical history, and reasons for filing the claim
✓ Attending Physician Statement (APS) — Completed by the treating doctor, providing medical records and documentation demonstrating the necessity for care
✓ Nursing Assessment and Plan of Care — A nurse or care provider outlines the current condition and recommends a detailed care plan
✓ Durable Power of Attorney — Required if family members are helping manage the claims process on behalf of the policyholder
Having all necessary documentation prepared before you begin can significantly expedite the claims process. According to claims specialists, many denials happen simply because paperwork didn’t provide the specific information the insurer needed—which is why documentation requirements should be among your first long-term care insurance questions.
7. How Does the Claim Process Work?
Understanding the steps involved in the claims process helps set realistic expectations and timelines. These long-term care insurance questions about process are especially important because, unlike health insurance claims—where providers handle billing directly—long-term care insurance requires the policyholder or family to assemble all paperwork from various sources.
Typical claim process steps:
- Initiate the claim — Contact your insurance company’s claims department to inform them of your need for benefits (can often be done online or by phone)
- Submit required documentation — Provide all necessary forms and medical records as specified by your insurer
- Complete assessments — Undergo any required professional assessments or physician evaluations
- Review and approval — The insurance company reviews your claim and notifies you of approval or denial
- Benefit disbursement — Upon approval, benefits are paid according to your policy’s terms (reimbursement for expenses or direct payment to providers)
✓ Document everything — Record the date, time, and name of every person you speak with at the insurance company. Take detailed notes about what they tell you. This information may be critical if you need to appeal a denial.
8. Are There Policy Exclusions or Limitations I Should Know About?
Being aware of exclusions or limitations within your policy can help you plan for potential out-of-pocket expenses and avoid claim denials. These long-term care insurance questions about exclusions often reveal surprises that families wish they had known earlier.
Common exclusions may include:
- Care provided by unlicensed caregivers or family members
- Services outside of licensed facilities or approved providers
- Pre-existing conditions (typically with a waiting period)
- Care resulting from self-inflicted injuries or substance abuse
- Certain types of care are not specified in older policies (some older policies don’t cover in-home care)
▶ Watch out — According to claims experts, one of the most common denial reasons is using unlicensed caregivers when the policy requires licensed providers. Always verify your caregiver or facility meets your policy’s qualifications before services begin.
What to Do If Your Claim Is Denied
Many claims are initially denied, but that doesn’t mean the end of the road. If your long-term care insurance claim is denied:
✓ Review the denial letter carefully — The insurer must explain the specific reason. This is your roadmap for next steps.
✓ Continue paying premiums — Keep the policy in force while you appeal.
✓ File an appeal promptly — Most insurers have internal appeal procedures with strict deadlines.
✓ Provide additional documentation — Often, denials result from insufficient paperwork rather than ineligibility.
✓ Seek assistance — The AALTCI offers free claims assistance, and your state’s Department of Insurance can help mediate disputes. You can also work with experienced LTCI specialists who know how to navigate appeals successfully.
References
- American Association for Long-Term Care Insurance. (2024). Long-Term Care Insurance Facts – Data – Statistics. https://www.aaltci.org/long-term-care-insurance/learning-center/ltcfacts-2024.php
- Genworth Financial. (2024). Cost of Care Survey. https://www.genworth.com/aging-and-you/finances/cost-of-care.html
- Compare Long Term Care. (2025). Long Term Care Insurance Statistics: 2025 Update. https://www.comparelongtermcare.org/insurance-stats/
- AARP. (2025). How to Use Your Loved One’s Long-Term Care Insurance. https://www.aarp.org/caregiving/financial-legal/info-2024/long-term-care-claims.html
- Federal Long Term Care Insurance Program. (2025). Costs of Long Term Care. https://www.ltcfeds.gov/long-term-care/costs
- ElderLawAnswers. (2024). How to Prevent Long-Term Care Insurance Claim Denials. https://www.elderlawanswers.com/how-to-prevent-long-term-care-insurance-claim-denials-21300
We’ll Help You Navigate Your Long-Term Care Insurance
At All Heart Home Care, we understand that long-term care insurance questions can feel overwhelming—especially when you’re focused on your loved one’s well-being. Our dedicated team helps San Diego families understand and maximize their long-term care insurance benefits every day.
We’ll help you verify policy details, gather required documentation, and navigate the claims process from start to finish. If your claim is denied, we know how to help you appeal. Our experience with LTC insurance across all major providers—Genworth, MassMutual, Mutual of Omaha, Northwestern Mutual, and many others—means you benefit from our expertise without additional cost.
Ready to unlock your benefits? Call us at (619) 736-4677 for a free consultation. We’ll review your policy, answer your long-term care insurance questions, and create a care plan that works with your coverage.
Related resources: Long-Term Care Insurance Experts | Home Care | 24-Hour Home Care
Disclaimer: This article is for informational purposes only and does not constitute legal or insurance advice. Long-term care insurance policies vary significantly. Always review your specific policy documents and consult with your insurance provider or a qualified professional for guidance on your individual situation.
