LONG TERM CARE 8
California Department of Insurance
Protecting California Consumers
Toll Free 800-927-HELP
Respite Care
is short-term care provided in a nursing facility,
in your home or in a community- based program, which is designed
to relieve the primary care giver in your home.
When Will Long-Term Care Insurance Begin Paying Benefits?
All long-term care policies require that your physical or
mental abilities be limited under one of three standards before
benefits will be paid. These standards are often called Benefit
Triggers. Many policies also require that additional conditions
be met before you will receive payment. These “conditions”
are events that must occur (or documents you must submit)
after you meet the “benefit triggers” and before benefits
will be paid.
The 3 Benefit Triggers permitted in long-term care insurance
policies in California are:
1) Impairment
in Activities of Daily Living (ADLs) - “Activities
of Daily Living” (ADLs) are used to measure your physical
abilities to determine if you qualify for benefits. The
law requires tax-qualified policies to pay benefits if you
are impaired in 2 out of the following 6 ADLs: bathing,
dressing, transferring, eating, toileting and continence.
For non-tax qualified policies, the requirement is for 2
out of the following 7 ADLs: ambulating, bathing, dressing,
transferring, eating, toileting and continence. Note that
the additional ADL for non-tax qualified policies is ambulating,
which means walking or moving around inside or outside the
home regardless of the use of a cane, crutches, or braces.Only
two ADLs can be required before benefits will be paid for
nursing home care, RCFE care, or home care in policies sold
after October 1, 2001. “Impairment” means that you need
human assistance or continual supervision to perform an
Activity of Daily Living. Policies that trigger benefits
when you only have to meet one of the ADLs may begin paying
benefits earlier in your disability than if you have to
meet two. However, your premiums will be higher and the
policy will not be tax qualified.
2) Impairment
in Cognitive Ability (or Cognitive Impairment)
- "Impairment in Cognitive Ability” means that you need
supervision or assistance to protect yourself or others
because of mental deterioration caused by Alzheimer’s disease
or any other mental disease. A doctor diagnoses cognitive
impairment based on clinical evidence and by the use of
standardized tests.
3) Medical
Necessity - “Medical Necessity” usually
means your doctor has certified that your medical condition
will deteriorate if you do not receive the care recommended.
However, under California law, an insurer is not allowed
to require that your benefits also be “medically necessary”
before the company will
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