Benefit Triggers
What Does 'Benefit Triggers' Mean?
A benefit trigger is a requirement that must be met before accessing Long-Term Care Insurance benefits. Once someone meets the benefit trigger requirements, they can file a claim and receive their benefits.
More Information
Benefit triggers allow policyholders to access their Long-Term Care Insurance benefits. Every tax-qualified Long-Term Care Insurance policy has federally regulated benefit triggers requirements. These requirements are the same regardless of policy or company.
Most policies have two benefit triggers. You can access benefits when you meet at least one of these requirements:
- Your health care professional determines you need hands-on or stand-by help with two or more activities of daily living.
- Your health care professional confirms the need for supervision due to cognitive decline or impairment.
- Bathing: The ability to wash yourself in a tub, shower, or sponge bath, including getting in and out.
- Dressing: The ability to put on, take off, and secure all necessary clothing and braces.
- Eating: The ability to feed yourself by getting food and drink into your body.
- Transferring: The ability to move in and out of a bed, chair, or wheelchair.
- Toileting: The ability to get to and from the toilet, use it properly, and manage personal hygiene.
- Continence: The ability to control bladder and bowel functions or manage them with personal hygiene
Your medical professional must expect that your care will need to last at least 90 consecutive days.
Once you have met these requirements, you can file a claim. After you file a claim and the claim is approved, you may need to start an elimination period. Your policy will provide benefits for your long-term care needs once the elimination period ends.
What Is Standby Assistance Under a Long-Term Care Insurance Benefit Trigger?
Standby assistance means another person must be physically present and ready to intervene to prevent injury while the insured performs an Activity of Daily Living (ADL), even if hands-on assistance is not required.
Under a tax-qualified Long-Term Care Insurance policy governed by Internal Revenue Code Section 7702B, standby assistance can qualify as a form of substantial assistance when determining eligibility for benefits.
How Standby Assistance Works
There are two primary forms of substantial assistance:
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Hands-on assistance: Another person must physically help the insured perform an ADL. For example, a caregiver physically lifts someone out of a chair or helps them get dressed.
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Standby assistance: Another person must remain within arm's reach, ready to physically intervene to prevent injury. The caregiver may never actually need to touch the insured.
Example: Bathing
Consider an 80-year-old woman who can shower independently but has poor balance and a significant risk of falling.
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She can wash herself without assistance.
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She can step into the shower.
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However, she needs another person within arm's reach because she could lose her balance and fall.
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The caregiver does not have to physically assist her unless necessary.
Under the federal definition, this can constitute standby assistance with bathing.
Simply having someone elsewhere in the house or available by telephone generally would not meet the standby assistance standard.
How It Affects LTC Insurance Claims
Most tax-qualified Long-Term Care Insurance policies use the following benefit triggers:
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ADL trigger: The insured is unable to perform at least two of six ADLs without substantial assistance from another person, with the inability expected to last at least 90 days.
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Cognitive impairment trigger: The insured requires substantial supervision to protect against threats to health and safety due to severe cognitive impairment.
The six ADLs are bathing, dressing, eating, toileting, transferring and continence.
Importantly, standby assistance can count toward the two-ADL requirement. The insured does not have to be completely incapable of performing the activity.
Policies Not Meeting Federal Guidelines
Some Long-Term Care Insurance policies do not meet federal regulations. Unregulated policies may have different rules for benefit triggers. These policies may make it difficult to access benefits. Some of these policies require individuals to have a terminal condition before accessing their benefits. Most people who need long-term health care are not terminally ill.
Every qualified policy will list its benefit triggers in the policy booklet. You can either talk to a professional or read your policy booklet to determine your policy's benefit triggers.
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