Long Term Care Insurance Policy Benefit Triggers
LTCI policies may have different benefit triggers for home health care coverage than for nursing home care. Review your long term care policy for specifics.
Activities of Daily Living (ADL)
The inability to do daily living activities is one way long term care insurance companies decide when you are eligible for benefits. Activities of daily living most companies use are bathing, continence, dressing, eating, toileting, and transferring. More specifics on these triggers can be found in your long term care policy. Typically the policy pays benefits when you can not do a certain number of ADLs, such as two of the six or three of the six for a certain period of time.
Be sure you understand the specific rules of ADLs. Policies may define ADLs and may require you to have hands-on assistance with the ADL. Specifying hands-on assistance may make it harder to qualify for benefits than if only standby assistance is required.
Using a test of your mental ability is also one of the benefit triggers. This trigger usually requires that you cannot pass certain mental function tests. Not all policies use this as a benefit trigger.
Doctor Certification of Medical Necessity
Some long term care insurance policies will start paying benefits if your doctor orders the care as medically necessary. Tax-qualified policies do not use this benefit trigger.
Policies sold today do not require prior hospitalization to start benefits. However, Medicare still requires a three-day hospital stay to be eligible for Medicare payment for skilled nursing facility benefits.