How to File a Long-Term Care Insurance Claim, Step by Step

If your parent has a long-term care insurance policy and they're entering assisted living, the policy is no longer theoretical — it's a monthly benefit waiting to be activated. Here's how to activate it cleanly.

Step 1 — Locate and read the policy

Find the actual policy document, not just the marketing summary. You're looking for:

• Daily or monthly benefit amount (with any inflation rider applied to today's date)
• Elimination period
• Benefit period or total pool
• Covered settings (confirm "assisted living facility" is listed)
• Benefit triggers
• Insurer's claim phone number and address

Can't find the policy? Call the insurer with your parent's name, date of birth, and (if available) policy number. They can re-issue a copy.

Step 2 — Call the insurer and request the claim package

Tell them you'd like to open a claim. They'll send (or email) a claim package that typically includes:

• Claim form for the insured/family
• Attending physician statement
• HIPAA authorization
• Plan of care template
• Authorization to release records from prior providers

Ask the insurer in this call: who is the assigned care coordinator, what's the elimination period for this policy, and can benefits be paid directly to the assisted living home.

Step 3 — Document the benefit trigger

This is where most claims succeed or stall. Your parent's primary care doctor (or a geriatric specialist) needs to document — in writing, on the insurer's form:

• Which ADLs require hands-on help (need at least 2 of 6)
• Or — if cognitive — formal assessment of cognitive impairment (often a Mini-Mental State Exam or MoCA score)
• Expected duration (most insurers want "90 days or longer")

Vague language ("she needs some help") often gets a claim sent back. Specific language ("requires standby assist with bathing and hands-on assist with dressing and transferring") gets approved.

Step 4 — Plan of care from a licensed provider

The assisted living home (or a home health agency or geriatric care manager) writes a plan of care detailing:

• The resident's needs
• What services the home will provide
• Frequency and duration
• Anticipated cost

At Sweetwater Groves, we provide this — and we know what insurers want to see.

Step 5 — Submit and wait

Send everything in one package via the insurer's preferred method (often a secure portal or fax). Keep copies. Note the date.

Expect 30–60 days. The insurer's care coordinator may schedule a phone or in-person assessment with your parent. Cooperate fully — it's a normal step.

Step 6 — Monthly billing and re-certification

Once approved, the home submits monthly invoices showing care delivered. The insurer pays — to the home directly, or to your parent for reimbursement.

Most insurers re-certify benefits every 6–12 months. Stay organized; keep the plan of care current as needs change.

Common pitfalls and how to avoid them

• Doctor's note too vague. Ask for specific ADL language.
• No formal cognitive assessment for dementia. Request a MoCA or MMSE.
• Plan of care from an unlicensed source. Use the home, a home health agency, or a geriatric care manager.
• Missing elimination period tracking. Count days carefully — some insurers require consecutive days of care.
• No follow-up. Call the insurer weekly until approved. Polite persistence pays.

Why this matters at Sweetwater Groves

We accept long-term care insurance and we know the paperwork. We can provide plans of care, monthly invoices, and documentation in the format your specific insurer expects. If you'd like our help walking through your parent's policy and starting the claim, reach out.