Yes, it covers home care. The details decide how much.
If your parent owns a long-term care insurance policy, it almost certainly covers non-medical home care: personal care, companion care, homemaker services and respite. Policies sold since the mid-1990s were designed around the idea that most people want to receive care at home. The questions that matter are when the policy starts paying, how much it pays, and what proof the carrier wants. Getting those three right is the difference between a claim that pays in six weeks and one that drags on for six months.
When benefits begin: the triggers
Federally tax-qualified policies (nearly all sold since 1997) use standardized triggers. Benefits begin when a licensed health care practitioner certifies that the insured either:
- Cannot perform at least two of six activities of daily living (bathing, dressing, toileting, transferring, continence, eating) without substantial assistance for a period expected to last at least 90 days, or
- Has a severe cognitive impairment (such as Alzheimer’s disease or another dementia) that requires substantial supervision for safety.
“Substantial assistance” includes both hands-on help and stand-by help, meaning someone must be within arm’s reach in case of a fall. Many families do not realize a parent qualifies because they think of “help” only as physically doing the task.
Some carriers send their own nurse to perform an in-home assessment before approving benefits. Having your agency’s care plan and the physician’s certification ready shortens that step.
The elimination period
Most policies have an elimination period, a deductible measured in days rather than dollars, commonly 30, 60 or 90 days. Two details matter:
- Calendar days versus service days. Some policies count every calendar day from the date you qualify; others count only days on which you received and paid for covered care. A 90-service-day elimination period with care three days a week takes about seven months to satisfy. Ask the carrier which applies.
- One-time versus per-episode. Many policies require you to satisfy the elimination period only once in a lifetime; some restart it after a gap in care.
During the elimination period you pay privately. Keep every invoice; carriers require proof that care was received on those days.
Reimbursement versus indemnity
- Indemnity or cash policies pay a flat amount once you qualify, regardless of what you spend, and usually allow more flexibility in who provides care.
Check the schedule of benefits page for the daily or monthly maximum, the benefit period or pool of money, and whether an inflation rider has increased those figures since the policy was issued. A policy bought in 2005 with 5 percent compound inflation protection may pay far more today than the original numbers suggest.
Why carriers require a licensed agency
Reimbursement policies almost always require that home care be provided by a licensed home care agency (in Pennsylvania, one licensed by the Department of Health under 28 Pa. Code Chapter 611). Claims for cash paid to an unlicensed individual, or to a family member, are routinely denied. The federal employees’ program, for example, requires formal agencies to supply their state license and tax identification and states that services paid in cash cannot be validated.
The reason is documentation. A licensed agency produces the records a claims examiner needs to confirm that covered care happened on specific days and addressed the ADLs that triggered the claim.
The paperwork that gets claims approved
From working with carriers, this is what they consistently ask for and what we provide:
| Document | Who provides it | Why the carrier wants it |
|---|---|---|
| Physician or practitioner certification of the ADL or cognitive trigger | The insured’s doctor (we can supply our assessment to support it) | Establishes eligibility and the start of the elimination period |
| Written plan of care listing the ADLs assisted, the schedule and the caregiver’s tasks | The agency | Shows the care matches the trigger; carriers compare notes to the plan |
| Daily caregiver notes recording what was done each visit, including which ADLs | The agency | Proof of service on each date; the single most common reason for denial when missing or vague |
| The agency | Reimbursement basis | |
| Agency license information and tax ID | The agency | Confirms a qualified provider |
| Proof of payment (if the policy reimburses you rather than paying the agency) | You | Documents the care provided |
A frequent problem: the care plan lists two ADLs, but the caregiver’s note for a given day mentions only one. Examiners can deny that day. Our caregivers document every ADL assisted at every visit for exactly this reason.
How to start a claim in Pennsylvania
- Find the policy and the schedule of benefits. If you cannot find it, the carrier will send a copy; the insured or their power of attorney must request it.
- Call the carrier’s claims line and ask for the claim packet, the exact eligibility definitions, whether the elimination period counts calendar or service days, and whether the carrier will pay the agency directly.
- Get the physician certification started at the next appointment. Bring the carrier’s form.
- Start care. Waiting to start care until the claim is approved usually just delays the elimination period.
- Send the plan of care, notes and invoices on the schedule the carrier specifies, typically monthly. Keep copies.
- Follow up in writing. If a claim stalls, Pennsylvania’s Insurance Department accepts consumer complaints, and your county Area Agency on Aging’s APPRISE counselors can explain policy language at no charge.
Using the policy alongside other resources
If you would like us to review a policy’s benefit page with you and explain what documentation we provide, call (717) 695-2704 or request a consultation.
Frequently asked questions
Does It's Your Home Care bill my long-term care insurer directly?
What if my parent bought the policy 20 years ago?
Can family members be paid under the policy?
Is the benefit taxable?
Who regulates long-term care insurance in Pennsylvania?
Sources
- Long-term care insurance: qualifying for benefits (2 of 6 ADLs; cognitive impairment) — American Bar Association, Bifocal
- Using long-term care insurance for home health care — A Place for Mom
- Using your benefits — claims information (documentation, licensed agency requirements) — Federal Long Term Care Insurance Program
- Pennsylvania Insurance Department — consumer help — Pennsylvania Insurance Department
- 28 Pa. Code § 611.57 — Information to be provided to the consumer — Pennsylvania Code
This article is general information for Pennsylvania families and is not medical, legal, financial, or insurance advice. It's Your Home Care is a non-medical home care agency licensed by the Pennsylvania Department of Health; we do not provide skilled nursing or medical services. Program rules and eligibility change; confirm details with the agency or program named, your physician, or a qualified advisor before making decisions.