How Do I Qualify For Benefits?

What Has to Happen for Me to Get Benefits?

Benefits are triggered in most policies available today by a licensed health care practitioner certifying in the last 12 months that your health condition requires  someone to be nearby to assist you, if needed, with two of six “activities of daily living” (ADLs), and that your condition is likely to last 90 days or longer.  Those ADLs are eating, bathing, dressing, toileting, continence, or transferring. 

Alternatively, benefits may be triggered by you being diagnosed with severe cognitive impairment.

In either case, you’ll also need a Plan of Care.

Those are the basic, standardized triggers for a claim established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  HIPAA compliant policies are called qualified LTC policies, and may be traditional or hybrid policies.

Your policy will also have a "deductible" (called the elimination period) which we'll discuss later in these notes.  It, however, should not be equated with the HIPAA requirement that your condition be likely to last 90 days or longer. 

You may have a 30 or 60 day deductible and be eligible for benefits after that period so long as the health condition that causes you to file your claim is certified as being likely to last for at least 90 days.