Eligibility for benefits is triggered in most traditional LTC as well as hybrid 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, or that you require substantial supervision to protect yourself from threats to health and safety due to severe cognitive impairment. The ADLs are eating, bathing, toileting, continence, transferring, and dressing.
In either case, you will also need a Plan of Care prescribed by your health care professional.
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 policies, and may be traditional or hybrid contracts.
You should also know that there are other products on the market that are not long-term care policies, but that offer short-term limited benefits for home health care or facility care. These may be alternatives to consider where traditional or hybrid products are out of reach because of cost or issue age considerations.
Your policy will have a “deductible” (called the elimination period), which we’ll discuss later on this website. It, however, should not be equated with the HIPAA requirement that a condition be likely to last 90 days or longer. Traditional policies, though not hybrid products, may offer a 30 or 60 day elimination period, after which the insured could be eligible for benefits so long as the health condition that caused the claim to be filed was certified as being likely to last for at least 90 days.