Long-Term Care Benefit Triggers

When LTC policies were introduced, insurers frequently required at least three days of prior hospitalization or skilled nursing home stays before the LTC policy benefits were “triggered.” Although most LTC policies require a physician’s certification that nursing home care is required because of illness, injury, or medical emergency, most polices no longer require hospitalization. 

Benefit Triggers 

Benefit triggers are the conditions that must occur before the insured can start receiving benefits. Although insurance policies vary, the most common “triggers” in long-term care insurance policies are:  

  • Medical Necessity; 
  • Loss of Functional Capacity; and  
  • Cognitive Impairment.  

Usually only one of these triggers need exist in order to qualify for benefit payments. The way benefit triggers are defined in the policy can have an impact on how easily the insured qualifies for benefits. Benefit triggers vary between policies and the same policy might use a different trigger for home care than it does for nursing home care. Be sure to read the policy.

The following is an example of benefit triggers from an actual long term care insurance policy: 

To be eligible for any type of benefit under this policy, your Physician must show that you meet one of the three following benefit qualifiers:  

  • Medical Necessity: You must require covered care due to sickness or injury. The care prescribed must be consistent with accepted medical standards for treating the diagnosed condition and could not have been omitted without adversely affecting your condition. 
  • Loss of Functional Capacity: You need active personal assistance to perform at least two of the six defined Activities of Daily Living.  
  • Cognitive Impairment: You require supervision and direction because of cognitive impairment. 

Most companies look to your inability to perform certain “activities of daily living” (ADLs) to figure out when you can start to receive benefits. The standard definitions of the six types of Activities of Daily Living are: 

  • Eating: The process of putting food into the body from some receptacle, such as a cup or plate; by means of a feeding tube; or intravenously. 
  • Bathing: The act of washing oneself in a bathtub or shower, or by sponge bath. It also includes the individual’s ability to get into and out of a shower or tub. 
  • Dressing: The individual’s ability to put on and take off all items of clothing and any needed braces, fasteners or artificial limbs. 
  • Toileting: Getting to and from the toilet; on and off the toilet; and performing associated personal hygiene. 
  • Transferring: Defined as moving into or out of a chair, bed, or wheelchair. 
  • Continence: The individual’s ability to control his or her bowel or bladder functions; adequately perform needed personal hygiene, including taking care of a catheter or colostomy bag, when unable to control bowel or bladder functions. 

 Pay close attention to what the policy uses as a trigger for paying benefits if the insured develops a cognitive impairment such as Alzheimer’s disease. A person with Alzheimer’s may be physically able to perform activities but is no longer capable of doing them without help. Mental-function tests are commonly substituted as benefit triggers for cognitive impairments. Ask whether you must require someone to perform the activity for you, rather than just stand by and supervise you, in order to trigger benefits. 

Want to know more about LTC benefit triggers? Check out our LTC Fundamental course in our Insurance Continuing Education Course Catalog. 

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