Paying for care
Using long-term care insurance for care at home
If there’s a long-term care insurance policy, it may pay for most or all of the aide and nursing hours. Getting the claim started takes paperwork most families have never seen. We do most of it.
We call back within 30 minutes, 8am to 8pm, 7 days a week.
When a policy starts paying
The help someone needs may already qualify
Most policies sold since the late 1990s start paying when a licensed health care practitioner certifies one of two things:
- The person can’t do at least two of six activities of daily living without substantial help, and that’s expected to last at least 90 days. The six are bathing, dressing, eating, using the toilet, continence, and moving in and out of a bed or chair.
- Or the person has a severe cognitive impairment, such as dementia, and needs substantial supervision to stay safe.
Older policies may use different terms, so we always read the actual policy.
Many families spend months helping with bathing, dressing or getting to the bathroom without realizing this is the kind of help the policy was bought to pay for. If someone in the family is already giving this help every day, it’s worth checking the policy now.
Not sure whether the person qualifies? Our nurse can do an assessment at home and tell you how the needs line up with the policy’s terms. The insurance company makes the final decision.
What we handle
We take on the claim paperwork
- A nurse assessment that documents the help needed with daily activities (bathing, dressing, eating, toileting, moving around) or with memory and thinking, in the terms insurers look for.
- A physical exam by one of our physicians when the insurance company requires one. We arrange it and do it at home.
- The written plan of care the insurer asks for, prepared by our nurse.
- Claim forms and monthly invoices in the format the insurer wants.
- Calls to the insurance company to open the claim and follow up on it.
- The recertifications that keep the policy paying.
We bill the insurer directly when the policy allows it. When it doesn’t, we bill the family and provide everything needed for reimbursement.
Insurers also require care from a licensed or registered agency. Nexstep is a New Jersey Health Care Service Firm (registration HP0390200), accredited by ACHC for skilled nursing and home health aides.
We’ve helped families with claims through John Hancock, Prudential and Genworth, and with claims managed by Davies. Nexstep isn’t affiliated with any insurance company, and every policy is different.
The waiting period
We count the days for you
Most policies have an elimination period: a set number of days, often 30 to 90, before benefits start. Some policies count every calendar day; others count only days when paid care was given.
We keep track of the days so you know when benefits should begin and aren’t guessing.
How it works
From the policy to the first paid claim
- Call us or request a consultation. Have the policy, or the insurer’s name and policy number, handy if you can.
- We review the policy and tell you what it covers, the daily or monthly benefit, and the waiting period.
- Our nurse does the assessment at home, and a physician exam is scheduled if the insurer needs one.
- Care starts. We send the paperwork and invoices and keep after the insurer until the claim is approved.
Questions families ask
Questions about long-term care insurance
What is the elimination period?
It’s the waiting period before the policy starts paying, a bit like a deductible counted in days instead of dollars. It’s often 30, 60 or 90 days. During those days, care is private pay. A few policies have no waiting period for care at home, so check yours.
Do the waiting days have to be days of paid care?
It depends on the policy. Some count every calendar day once the person qualifies. Others count only days when paid care was given, so three visits a week means the wait takes longer. Some policies make you meet the waiting period once in a lifetime; others restart it after a long break in claims. We read the policy and keep the count for you.
Does the person have to qualify before the waiting period starts?
Yes. The days usually start counting from the date the person meets the benefit trigger (help with two daily activities, or a severe cognitive impairment), as certified by a licensed health care practitioner. That’s one reason to get an assessment early.
Can care start before the claim is approved?
Yes. Many families start care right away so the waiting period begins counting. Until benefits start, care is private pay.
What if the claim is denied?
We’ll go over the denial letter with you, find what was missing, and help you appeal.
Does the policy cover nursing as well as aides?
Often, yes. It depends on the policy. We’ll check.
Do you accept Medicare or Medicaid?
No. Our services are private pay or paid through long-term care insurance. Medicare does not pay for ongoing private duty aides.
Next step
Have a policy and not sure what it covers?
Send it to us or call. We’ll read it and tell you what it means for care at home.
- NJ Health Care Service FirmHP0390200
- ACHC AccreditedHome Health & Skilled Nursing
- Physician-ledEvery care plan reviewed by our Medical Director
- All aides are CHHACertified, Nexstep employees
- Insured & bondedBackground and driving-record checked