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What Disqualifies From Long-term Care Insurance

Common Conditions & Reasons For Insurance Ineligibility

The first step to selling Long Term Care Insurance – April 2022

Top Reasons for Decline:

  • Needing assistance with bathing, eating, dressing, transferring to a bed or chair, toileting, or continence
  • Receiving home care, adult day care, nursing home, or facility care services
  • Use of a walker, wheelchair, quad cane, motorized scooter, nebulizer, ventilator, hospital bed, oxygen, or kidney dialysis
  • Current use of narcotic pain medication
  • Currently in Physical Therapy
  • Receiving disability benefits

Currently in physical therapy? That is one of the top reasons of being declined long term care insurance.

Common Diagnoses Declined:

  • Amyotrophic Lateral Sclerosis
  • Cancer of bone, brain, esophagus, liver, pancreas , stomach
  • Cirrhosis of the liver
  • Frequent/Persistent forgetfulness or memory loss
  • Huntingtons Chorea
  • Metastatic Cancer
  • Multiple Sclerosis
  • Organ Transplant other than kidney or cornea
  • Organic Brain Syndrome
  • Schizophrenia or other forms of Psychosis

Purchasing Insurance To Qualify For Masshealth Exemptions

Whether you should purchase long-term care insurance to qualify for the MassHealth exemptions is a personal decision. Depending on your financial circumstances, you could decide to purchase sufficient long-term care insurance to cover the full cost of any care you might require, thus eliminating the need for public assistance. You might also have other resources you plan on using to supplement whatever coverage you purchase.

As noted above, if you are considering choosing a policy based on whether it is intended to qualify for MassHealth exemptions, you must also consider that using policy benefits to pay for non-nursing home benefits may reduce policy benefits available for nursing home care below the MassHealth required level when you may enter a nursing home. Depending on your situation, you may choose initial benefit levels to reduce the likelihood of going below the MassHealth minimum.

It is important to remember that long term care insurance products are sold with a variety of features and benefit options. The features and benefit options you choose and how you use them may impact whether or not you have a policy that may qualify you for the MassHealth exemptions at the time you enter a nursing home.

For more information regarding the MassHealth program, call MassHealths Customer Service Center at 1-800-841-2900 or visit MassHealths website at

What Are The Responsibilities Of Agents Selling Long

Long-term care insurance can be sold directly by insurance companies by mail or phone solicitation, by agents and brokers who represent one or more insurer, by some estate-planning lawyers or through an employer or other group setting. Most people who buy long-term care insurance do so through an agent. A responsible, well-trained agent can be an important source of information about the policies that you are considering.

Even though insurers are required to train their agents, not all agents who are licensed to sell long-term care insurance are equally well-trained and experienced. Ask about the training and experience of any agent with whom you are thinking of working. Insurers usually pay agents commissions for each policy they sell. The amount of these commissions varies depending on the insurer and the type of policy. An agent might represent only one insurer or might receive a higher commission for selling one policy rather than another. Ask your agent to identify the insurers he or she represents and to explain his or her commission arrangements. This will help you understand whether the agent has an incentive to sell you a particular policy.

Massachusetts requires persons who sell long-term care insurance to:

Massachusetts law prohibits persons who sell long-term care insurance from:

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Activities Of Daily Living

Your eligibility for benefits is triggered if you cant perform 2 of 6 activities of daily living or you are suffering cognitive impairment, such as with dementia or Alzheimers.

You may be eligible to claim benefits from your LTC insurance policy if you need help or supervision to perform at least 2 of these tasks:

  • Personal hygiene

Many LTC insurance plans will also pay if, because of cognitive impairment, youre a danger to yourself or others. Typically, cognitive impairment is due to dementia or Alzheimers, but any mental decline may qualify if the insurer covers it.

Youll need a written statement from your doctor saying you cant perform at least 2 of the 6 functions. Shell also need to affirm that youll be unable to perform these ADLs for at least 90 days or more.

Get To Know The Basics Of Long Term Care Insurance

Western Marketing

Our beginners guide to long term care insurance should help answer a lot of questions regarding long term care insurance. This includes an overview of long term care insurance, what coverage may be available, where to buy long term care insurance, and other common considerations of insurance coverage.

It also reviews other details like at what age you may want to think about getting coverage, critical policy components to consider, common insurance carriers, and even alternative coverage options or plans that may work better for you.

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When Should You Buy Long Term Care Insurance

The American Association for Long Term Care Insurance recommends purchasing a policy in your mid-50s. Even though you may not need the benefits until you are 70 or 80+, you may not qualify if you wait and your health diminishes. Also, premiums correspond to age. So, the longer you wait, the higher the premiums. For someone in their 50s, the annual premium increases 2 – 4% every year and for someone in their 60s, it increases 6 – 8% each year of age. But it is a balancing act. Signing up too early can leave an individual paying for years before you are likely to need the care.

How Popular Is Long

The number of insurance companies selling long-term care insurance has plummeted since 2000. Slightly more than 100 insurers were selling policies in 2004, according to 2020 data from the National Association of Insurance Commissioners. About a dozen are selling policies today.

The uncertain cost of paying future claims as well as low interest rates since the 2008 recession led to the mass exodus from the market. Low interest rates hurt because insurers invest the premiums their customers pay and rely on the returns to make money.

The market is continuing to change. Genworth, one of the largest remaining carriers, suspended sales of individual long-term care insurance through agents and brokers in March 2019. The company sells policies to groups and directly to individual consumers through its own sales department.

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Can I Qualify For Long

If you have osteoporosis you can probably qualify for long-term care coverage. Every insurance company has different criteria to determine who they can insure. Its important to work with an experienced, independent agent who is familiar with the four main types of long-term care coverage. An independent, long-term care specialist can recommend the perfect policy for you based upon your health history.

What Assets Count For Medicaid

Health Care in America: Insurance Gaps and Medical Deserts

Assets eligible for Medicaid consideration include:

  • Checking and Savings Accounts Any checking or savings account with your name or your spouses name count as an asset. Therefore, having a high amount of funds in those accounts could disqualify you. This includes long-term savings accounts or investments like CDs.
  • Stocks and Bonds Any investment accounts you have, including bonds, stocks, or funds, count toward your eligibility. These are considered assets that you can withdraw and pay for medical expenses and long-term care. Therefore, the state will assume you have enough funds to pay for your care.
  • Real Estate Other Than Your Primary Residence Your primary residence does not count. But if you own secondary property such as a rental home, vacation property, or even a co-owned property like a timeshare, these count.
  • Extra Cars Your primary vehicle will not count, but any additional cars and recreational vehicles do count as assets.
  • Life Insurance The cash value of a life insurance policy also counts. If the amount exceeds $1,500, then any excess is considered an asset to your estate and will be considered in your application.
  • Cash While you can possess some cash, too much may disqualify you. For example, if you have $50,000 in a checking account, it would most likely disqualify you unless you could prove those funds were dedicated to something specific.

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Personal Care Benefits Must Be Specified Carefully With Your Insurance Provider

While your LTC insurance may say it doesnt pay for personal care, light housekeeping, or running errands, it is sometimes possible if you meet the policys ADL requirements.

Your policy may also exclude any care provided by the family. However, there is sometimes a workaround. Specific language may exclude your spouse, in-laws, or siblings, but a grandchild, niece, or nephew may qualify.

Long Term Care Insurance For Assisted Living

Does your parent have long term care insurance? Should they buy a policy? Many retirees know that they may one day need personal assistance with daily activities or long-term care in an assisted living community. With this realization, many older Americans are planning for this type of care and have purchased long term care insurance as part of their retirement planning. If your family is considering the cost of assisted living, ask your parent if they have long term care insurance, and review their policy to understand how it can defray the costs of needed care.

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If I Have Osteoporosis Will I Have To Take A Physical In Order To Qualify For Long

Some long-term care insurers do not require a physical if you have osteoporosis. Most long-term care insurance companies will review your medical records in order to determine if they can insure you. Ask your long-term care insurance specialist what underwriting criteria each company will use before deciding which long-term care insurance policy is best for you.

Ltci In The United States

What Disqualifies You From Long

Some 7 million individuals have some form of long-term care insurance. The vast majority have what is referred to as traditional, or health-based, LTC insurance. The opposite is true for new policy sales. Some 350,000 new policies are sold each year with 84 percent being linked-benefit or life insurance policies that include a LTC benefit.

In the U.S., the nation’s long-term care insurance companies paid out a record $11 billion in claims in 2019 to some 310,000 policyholders.

A new study projects that the lifetime chance of long-term care insurance policy usage. Someone purchasing coverage at age 65 has a 50% likelihood of using their policy benefits, especially when there is no elimination period for home care benefits.

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How The Pandemic Is Changing Long


The Covid-19 pandemic likely had a significant impact on long-term care insurance , though most of the effects wont be known for a while yet.

The pandemic appeared to increase interest in and purchases of LTCI. Its too early for the data to be available, but anecdotal reports from insurers and agents indicates that the pandemic increased inquiries about and purchases of different types of LTCI.

The widespread effects of the pandemic made more people aware of the potential they might need LTC at some point. The pandemic also made more people realize that the need for LTC can arise suddenly and much earlier in life than they realized.

The increased interest in LTCI is consistent with reports that people became more concerned about estate planning during the pandemic.

The pandemic also taught insurers and agents to stress that LTCI is not nursing home insurance. A widespread misunderstanding about LTC in general and LTCI has been the assumption that the care primarily is delivered in a nursing home or an assisted living residence. In fact, the majority of LTCI claims paid by insurers now are for home care.

A negative effect of the pandemic on LTCI is that it is more difficult to qualify for LTCI. Insurers reportedly are declining more applications for several reasons.

More insurers are lowering the age limit at which theyll issue policies. Also, the list of pre-existing conditions that will disqualify an applicant is lengthening at many insurers.

Pros And Cons Of Long

Pros Cons
  • Should you need long-term care, a policy can offset a considerable amount of the costs associated with that care, providing some protection for your financial assets as you age.
  • Some plans allow you to choose where you receive your care, empowering older adults who want to remain at home to continue aging in place with hired assistance.
  • Depending on your coverage, if you choose to receive care at home, you can choose to hire and pay family members for their assistance instead of hiring someone from a home health agency.
  • The premium costs of a long-term care insurance policy may exceed the monthly budget of some older adults.
  • Some plans only pay for long-term care provided in a facility rather than including at-home options.
  • Some providers deny coverage to those with preexisting conditions or illnesses.
  • Some plans have an elimination period during which the policyholder is still responsible for the total cost of their care.

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Which Type Of Long

There are four main types of long-term care coverage: traditional long-term care insurance, long-term care partnership programs, life insurance with long-term care riders, and annuities with long-term care riders. The best type of policy for people with osteoporosis is usually a traditional long-term care policy or a long-term care partnership program. However, everyones situation is unique. Click here to try our proprietary Policy Finder tool . It will give you an instant ranking of the four types of policies based upon your answers to a few short questions.

Failure To Pass The Insurance Test

FLTC Insurance Program Announcement

The most apparent issue on this list but one that cannot be overlooked is failing the insurance test. This typically precludes you from filing an insurance license application. It is suggested that you prepare for 2-8 weeks before sitting the coverage test. This will ensure that you are familiar with all of the content that may get evaluated. After that, you may start the application procedure.

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What Services Do Insurance Companies Cover

Insurance policies describe what they will cover, what kind of care they will cover, who can provide the care and conditions that need to be met before a company will pay/reimburse the cost of benefits. Described below are the services required in a long-term care insurance policy approved under current California law. Be aware however, that California law has changed many times over the years and that insurance policies sold in previous years may have different requirements than are shown here.

What Are Disqualifying Conditions For Federal Long Term Insurance Coverage

The new health care bill promoted by President Obama lastMarch 2010 created a voluntary program called the CLASS Act, or the CommunityLiving Assistance Services and Supports Act. This program enables allAmericans to have access to affordable long term insurance. The program isavailable for anyone, regardless of their health condition.

The CLASS Act provides coverage regardless of whether theperson has had a pre-existing condition or not. The important thing is that theperson has paid into the program for 5 years. Mind you, the insurance is veryaffordable. After 5 years of payment, they can already be qualified to claimfor benefits for long-term care. The program will pay a daily benefit for thepurpose of offsetting the cost of long-term care.

However, there are some disqualifying conditions for thiskind of coverage. You will be disqualified if you:

There are still some things that have to be finalized, butyou can be assured that the CLASS act will have a strong impact on long termcare.

Not a bit

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How Are Benefits Paid

Long-term care insurers usually pay benefits on an expense-incurred basis. This means that the insurer must decide if you are eligible for benefits and if your claim is for eligible services. If so, the insurer pays benefits either to you or your provider up to the limits in your policy. Your policy will pay benefits only when you actually receive eligible services. Less common is the indemnity method, where the benefit is a set dollar amount. Under this approach, the insurer decides only whether you are eligible for benefits. If you are, the insurer pays benefits directly to you up to the limit of your policy, regardless of the type of services you receive or whether you receive services at all.

Long Term Care Rejection Statistics


Below we present the percent of applicants that are denied coverage when seeking out long term care insurance plans. As you can see, an applicant that applies for long term care will find that plan denials broadly increase as the individuals age increases.

  • Applicants between the age of 50 and 59 are declined 13.9% of the time.
  • Applicants between the age of 60 and 99 are declined 22.9% of the time.
  • Applicants between the age of 70 and 79 are declined 44.8% of the time.
  • Applicants aged 80 and older are declined 69.8% of the time.

Individuals that are under the age of 50 are denied only 7.3 percent of the time. To reduce your rate of denial, consider applying at a younger age. This is one way to prevent coverage being declined, but also the single most important factor that leads to denials above all others. However, as you will soon see, there are many factors that can contribute to long term care coverage being denied to an applicant.

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Risk Of Rejection And Insurer Differences

When evaluating long term care insurance, it is important to consider that many people may ultimately be rejected from even getting initial coverage at all. Also, for those that an insurer views as higher risk or with certain conditions , individuals may be granted coverage but face higher financial premiums that must be paid over time to receive coverage.

Regardless of ones individual situation, keep one thing in mind as you review this list of common reasons for denials. Underwriters reviewing your medical history are not all the same across organizations. For example, one insurance company may look at your personal situation and deem you to be uninsurable. However, another company could consider your risk factors or history to be perfectly acceptable for them to issue a policy. Therefore, dont be discouraged if you fear getting denied for insurance coverage after reviewing the information below. Even if you get a denial or receive an expensive premium quote, dont give up just yet, even if your rejections happen with several different insurers.


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