Benefit triggers are the criteria that an insurance company will use to determine if you are eligible for benefits. Most companies use a specific assessment form that will be filled out by a nurse/social worker team. Benefit triggers:
- Are the criteria insurance policies use to determine if you are eligible for long-term care benefits
- Are determined through a company sponsored nurse/social worker assessment of your condition.
- Usually are defined in terms of Activities of Daily Living (ADLs) or cognitive impairments
- Most policies pay benefits when you need help with two or more of six ADLs or when you have a cognitive impairment
- Once you have been assessed, your care manager from the insurance company will approve a Plan of Care that outlines the benefits for which you are eligible.
The "elimination period" is the amount of time that must pass after a benefit trigger occurs but before you start receiving payment for services. An elimination period:
- Is like the deductible you have on car insurance, except it is measured in time rather than by dollar amount
- Most policies allow you to choose an elimination period of 30, 60, or 90 days at the time you purchased your policy
- During the period, you must cover the cost of any services you receive
- Some policies specify that in order to satisfy an elimination period, you must receive paid care or pay for services during that time
Once your benefits begin:
- Most policies pay your costs up to a pre-set daily limit until the lifetime maximum is reached
- Other policies pay a pre-set cash amount for each day that you meet the benefit trigger, whether you receive paid long-term care services on those days or not
- These "cash disability" policies offer more flexibility but are potentially more expensive