Most long-term care insurance policies will pay for non-medical home care in your parent’s own home, and the way you access it is to file a claim with the carrier, have your parent assessed as benefit eligible, satisfy the policy’s elimination period, and then send the carrier ongoing documentation of the care that was provided. The carrier either reimburses your parent or, in many cases, pays the agency directly once an assignment of benefits is in place.
That is the short version. The longer version is where families get stuck, usually at eleven at night with a policy booklet from 1998 on the kitchen table and a sibling on the phone who wants to know why this is taking so long.
Does the policy pay for care at home, or only in a facility?
Older policies sometimes covered facility care only. Most policies written in the last twenty-five years are comprehensive, meaning they cover care in the home as well as assisted living and nursing facility care, and many pay a home care benefit at the same daily or monthly maximum as facility care.
The page you are looking for in the policy is usually called the schedule of benefits or the policy summary. Three numbers matter: the daily or monthly maximum, the elimination period, and the lifetime benefit or benefit pool. If you cannot find the policy itself, the carrier can send a copy along with an in-force illustration showing what remains.
What makes a parent “benefit eligible”?
Almost every policy uses the same two triggers. The first is needing substantial assistance with a set number of activities of daily living, typically two out of six: bathing, dressing, toileting, transferring, continence and eating. The second is cognitive impairment requiring supervision, which stands on its own and does not require the two-ADL test.
This is the part families underestimate. A parent who is still walking, still talking and still charming on the phone may very well meet the cognitive trigger. The determination is made by the carrier, usually after an assessment by a licensed health care professional the carrier sends or arranges. Your parent’s physician’s notes carry real weight here, so it is worth asking the physician’s office to document what is actually happening at home.
What is an elimination period, and why does it surprise people?
The elimination period is the waiting period before benefits begin, most often 30, 60 or 90 days. It is essentially a deductible measured in time rather than dollars, and the family pays out of pocket during it.
The detail that catches families out is how days are counted. Some policies count calendar days from the date your parent became benefit eligible, so a 90-day elimination period is roughly three months no matter how much care is delivered. Others count service days, meaning only days on which paid care was actually provided. Under a service-day policy, care three days a week takes about 30 weeks to satisfy a 90-day elimination period. Same policy language, very different first bill.
Some policies also waive the elimination period for home care entirely. It is worth a phone call to the claims department to ask which of these three applies before you build a schedule around it.
How do you open the claim, step by step?
- Find the policy number and the carrier’s claims phone number. If the policy is missing, the carrier’s customer service line can locate it by your parent’s name, date of birth and Social Security number.
- Confirm whether you have legal authority to act. Most carriers will not discuss a claim with an adult child without a power of attorney, an authorized representative form or your parent on the line giving verbal consent.
- Call the claims line and ask for a home care claim packet. Ask specifically: how is the elimination period counted, is there a home care waiver, what is the daily or monthly maximum, and does the carrier require a licensed agency.
- Complete the claim forms. There is usually a policyholder statement, an authorization to release information, and a physician’s or attending statement the doctor’s office completes.
- Schedule the benefit eligibility assessment. The carrier typically arranges this, often in the home, sometimes by phone.
- Sign an assignment of benefits if the carrier and the agency both allow it, so payment goes directly to the agency rather than passing through your parent’s checking account.
- Start the ongoing documentation. Carriers generally want invoices, dated visit records showing hours and the assistance provided, and proof the provider is licensed and insured.
Who handles the paperwork once care starts?
We do the part that belongs to us. Paragon Home Care assists families with long-term care claim documentation: itemized invoices, dated records of the care provided, our license and insurance information, and the forms carriers routinely ask a provider to complete. What we cannot do is interpret the policy, decide a claim or advise you on coverage. Those questions belong with the carrier and, if the policy language is genuinely unclear, with an elder law attorney.
Carriers do ask who is delivering the care, and the answer matters. Paragon Home Care is a Home Care Organization licensed by the Virginia Department of Health, Office of Licensure and Certification. Its scope is non-medical: personal care, companion care and homemaker services. Paragon does not provide skilled nursing, therapy or any other skilled or medical service. Our caregivers are Paragon employees, screened, trained, insured, bonded and supervised, which means the documentation trail a carrier asks for already exists. A registry that refers independent contractors is a different arrangement, and some policies treat it differently.
What do you do while the claim is pending?
You do not have to wait. Care can begin while a claim is in process, and under a service-day elimination period it has to, because nothing counts until care is actually being delivered. Most families start with a few hours a week rather than a full schedule. It is not all or nothing, and starting small is often what makes a parent willing to say yes at the door.
Rates range from $38 to $60 per hour depending on the care plan. Ask what’s included in the rate, not just what the rate is. In ours: NCCDP-trained caregivers, employed and supervised, and Sensi.AI 24/7 safety monitoring at no additional cost, which is how a daughter three states away knows how the night actually went instead of taking it on faith.
Activities of daily living are the foundation. Connection is the difference.
Questions families ask next
Will Medicare pay for any of this?
No. Medicare does not pay for home care, which is the hourly, non-medical help with bathing, dressing, meals and companionship that we provide. Medicare may cover home health, which is intermittent skilled care ordered by a physician after a qualifying event, and that episode ends. Home care is what many families arrange for the day after it does.
My parent has a policy but has never filed. Is it too late?
Not by itself. As long as premiums have been paid or the policy is paid up, benefits are generally available when the eligibility triggers are met. Some policies also have a waiver of premium provision that stops premium payments once a claim is approved, which is worth asking about on the same call.
Can the policy pay a family member to provide the care?
Some policies allow it, many do not, and most that do impose conditions such as training requirements or exclusions for a spouse or a person living in the home. Ask the carrier directly rather than assuming, and get the answer in writing before you build a plan around it.
A calm next step
If you are holding a policy and are not sure what it says, bring it to the conversation. We will tell you plainly what we can document and what only the carrier can answer. Call 703-942-8950 – we answer around the clock. You can also book a complimentary in-home assessment at https://paragonhomecare.com/book-an-assessment/ or reach us through the contact form at https://paragonhomecare.com/contact/.
If you are earlier than that, still working out whether there is a problem to solve, our family guide “When Home Stops Working” is at https://paragonhomecare.com/family-guide/.
Paragon Home Care, 1313 Dolley Madison Blvd, Suite 401, McLean, VA 22101. 703-942-8950. mail@paragonhomecare.com. Serving McLean, Vienna, Great Falls, Falls Church, Tysons, Arlington, Fairfax, Annandale, Alexandria and the surrounding Northern Virginia communities. Private pay and long-term care insurance only.
More than tasks. Meaningful care.