Activities
of Daily Living
Activities of Daily Living (ADL's)
are activities you perform everyday, there are six to be considered.
Bathing: Your
ability to wash yourself by sponge bath in a tub or shower, including
getting in and out of the tub or shower.
Continence: Your
ability to maintain control of your bowel and bladder function or
when unable to maintain control of bowel or bladder, the ability
to perform associated personal hygiene (including caring for catheter
or colostomy bag.)
Dressing: Your
ability to put on and take off all items of clothing and any braces,
fasteners or artificial limbs.
Eating: Your
ability to feed yourself by getting food into your body from a receptacle
(such as a plate or cup or table) or by a feeding tube or intravenously.
Toileting: Your
ability to get to and from the toilet, to get on and off the toilet
and perform associated hygiene.
Transferring: Your
ability to change positions such as moving from bed to standing,
chair to standing, bed to chair and the reverse of these activities.
Activities of Daily Living (ADL): Eating, walking, transferring
from a bed to a chair, dressing, bathing, using a toilet and remaining
continent. Most policies use the inability to perform ADLs to determine
benefits eligibility (see Benefit Trigger). To follow are ADL standards:
Hands-On Assistance: Measure used by some private policies
where you cannot perform the activities of daily living without actual
assistance. This is a less generous benefit trigger feature than the
standby assistance definition. Standby Assistance: An individual
may be able to perform the activity of daily living but would need
someone standing right next to them, ready to provide them assistance
if needed. This is a more generous benefit trigger feature than the
hands-on assistance definition.
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Chronically
Ill
Individual means an insured who has
been certified by a Licensed Health Care Practitioner that they are
expected to be unable to perform, without substantial human assistance,
at least 2 ADL's for a period of at least 90 days from inception of
the illness or injury. Or having a severe cognitive impairment that
requires substantial supervision to protect the insured or others
from threats to health and safety.
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Waiver
of Premium eliminates premiums while
receiving certain types of care. Not all policies waiver the premium
for home care. This is an important feature and we recommend policies
that waive the premium for any type of long term care claim.
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Severe
Cognitive Impairment means a deficiency
in: your short term or long-term memory; orientation as to person,
place or time; deductive or abstract reasoning or judgment as it relates
to safety awareness.
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Substantial
Human Assistance
means either actual hands-on physical assistance or supervisory
assistance or standby or by another individual, without which
you would not be able to perform your Activity of Daily Living.
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Respite
Care means the care and or supervision
of individuals with deficiencies in ADL's or who are severely cognitively
impaired. It is provided when a family member or care giver who normally
provides long term care services on a regular basis takes a short
term leave or rest from their caregiving responsibilities.
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Alternate
Plan of Care means health care or
personal care services that are not specifically covered by this policy
but which you, your Physician and your care coordinator and the insurance
company agree would be appropriate to meet your long-term care needs.
This provides flexibility in a contract for types of service and care
that may still remain in the future and allows for the unknown.
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Caregiver
Training means training you or a
person designated to assist you in the proper use and care of a therapeutic
device or caregiving procedure. This is usually for a family member
or friend outside of the formally trained person who might be attending
to you when your professional caregiver is not on duty.
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Elimination
Periods
This is like a deductible. It is a number
of days that you pay for your own care before your benefits kick in.
It is the number of days you are responsible for paying before your
policy begins to pay benefits. You can choose 0,20,30,60,90 100, 180,
or 365 depending on the company.. So, if you had a 60-day elimination
period and the cost of care was $100 per day, you would have to pay
$6000 out of pocket before the policy would begin to pay.
You need to select an elimination period
that you are financially comfortable with, keeping in mind that the
cost of care will most likely continue to rise with inflation. Don't
forget if you are 65 or over and on Medicare there is a chance that
Medicare might pay a portion of the 1st 100 days if you satisfy strick
qualifying criteria. Visit the consumer tutorial to learn more.
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Plan
of Care means a written plan of
services developed by a Licensed Health Care Professional.
Remember that the different companies have different definitions of
Health Care Professional. Read the fine print!!!
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Hospice
Care means services that are designed
to provide palliative care and to alleviate physical, emotional, social
and spiritual discomforts of a terminally ill individual, as well
as providing supportive care to the primary caregiver and family of
the terminally ill individual.
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Bed
Reservation allows the insured to
be reimbursed for the reservation of a room and bed in a nursing or
assisted living facility if he or she has to leave the facility for
any reason. Some policies pay this only for a hospitalization. Again-read
the fine print!!
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Benefit
Increase Riders or
Inflation
Protection
One of the most important considerations
should be adding a benefit increase option to your policy, at an additional
premium. This rider will allow your MDB to increase each year, helping
you keep up with future increased costs in care. There are 3 options
available: simple, compound or Guaranteed Purchase Option Rider (GPOR)
which is based on the Consumer Price Index.
The GPOR provides an automatic increase
of the Daily Benefit every three years, based on the Consumer Price
Index. The purchase option will be offered to you every 3 years, if
you decline a total of 4 increases, the rider will terminate and no
additional offers will be made. All increases will be purchased at
your attained age or your age at the time the offer is extended.
The Simple Benefit Increase Rider provides
an automatic increase in your Daily Benefit on each policy anniversary.
The increase will be 5% of the original Daily Benefit. For example
if you had a $100 Daily Benefit on your 1st policy anniversary,
the benefit would increase to $105 per day. On the 2nd
anniversary it would increase to $110 per day etc. With the Simple
Benefit Increase Rider, your Daily Benefit would double in 20 years.
Remember- the benefit increases annually-Not the premium!!
The Compound Benefit Increase Rider provides
for an automatic increase of the Daily Benefit on each policy anniversary
of an amount equal to 5% of the previous year’s Daily Benefit. For
example, if you had a $100 Daily Benefit on your 1st policy
anniversary, your benefit would increase to $105 per day. On
the 2nd anniversary it would increase 5% of $105 to $110.25
per day. The benefit would continue compounding over the life of the
policy. With the Compound Benefit Increase Rider your Daily Benefit
would double in 15 years.
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Care-Coordinator
means a Registered Professional Nurse or
Licensed Social Worker who is trained and experienced in providing
care coordination services. Some policies provide this at your option
and some companies charge this services against your lifetime maximum.
Read the fine print. These things matter at claim time.
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Maximum
Daily Benefit (MDB)
The MDB is the maximum amount your policy
will pay for expenses incurred on any one given day. If you choose
a fully integrated policy, it will be the maximum benefit paid on
any given day for services received in a Nursing Home, Assisted Living
Facility, Hospice Facility or Respite Care.
Home Care Benefits can be paid on a Daily,
Weekly or Monthly Maximum Benefit (MMB). The Daily Benefit or MDB
would be the maximum paid for any one day of services. A Weekly Benefit
would be calculated multiplying your MDB times 7, the number of days
in a week. And Monthly would be the maximum amount paid for home care
services or community service received in any one calendar month or
a 30 day period. This monthly benefit is determined by multiplying
your maximum daily benefit times the number of days in the month.
The average annual
cost of a nursing home nationwide is $65,000 or $150/day.(1)
(1) Sources:
U.S. Census Bureau, National Center for Health Services, Health Insurance
Association of American, New England Journal of Medicine, LA Times
9/27/2000
