This is a question that often arises in conversation with LTCi shoppers. Years ago many policies had what was called a “medical ncessity” trigger that restricted some, like Alzheimer’s patients and those who are cognitively impaired, from being able to go on claim if certain medical conditions did not accompany their impairment.
However, Congress has passed legislation that pretty much standardized benefit triggers for all tax-qualified policies these days. There are two main triggers that are usually found in modern policies and they are:
1. The inability to perform at least two of the following activities of daily living: eating, dressing, bathing, toileting, continence, and transferring (for instance from a bed to a chair).
2. Cognitive impairment diagnosed by a licensed health care practitioner that causes the person to need substantial supervision in order to assure their safety and health.
Many policies also state that the assistance needed may not necessarily be hands-on. Instead, if just stand-by assistance is needed that is enough to trigger benefits under the policy requirements.
The challenge that LTCi carriers have in writing the language for their policies is that they have to be careful (1) not to make the triggers so liberal that almost anyone can start getting paid benefits for frivilous reasons and therefore drive up the cost of these policies to the point that they are prohibitive for most people to buy, and yet (2) still allow those who truly need care to get the coverage that they require under the policy guidelines.
This question, along with many others related to LTCi is discussed in an interesting article I just found that is very good reading: