ACTIVITIES OF DAILIY LIVING (ADLs) in Detail
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LTC insurance including "Combo" policies and riders that are explicitly "long-term care" riders now follow the federal "tax-qualified" guidelines as established by HIPAA starting in 1997. This means they require the loss of (or assistance with) at least two (2) out of six (6) of the physical Activities of Daily Living.
(NOTE that "chronic illness" riders which have become widely-available on many life insurance policies are NOT legally "long-term care" benefits and should generally NOT be used when planning for long-term care. They may appear to be very similar, but there are NO uniform federal or state regulations that control how these work or how the ADLs are defined.) How each of the activities are specifically defined may vary from policy to policy.* The following definitions and descriptions are based on the the most commonly used definitions seen in TQ LTC insurance contracts: |
BATHING: The ability to wash yourself, either in the tub or shower - including getting into and out of the tub or shower; or with a sponge.
Generally BATHING does NOT include other personal hygiene tasks, such as brushing teeth, shaving or combing hair.
Generally BATHING does NOT include other personal hygiene tasks, such as brushing teeth, shaving or combing hair.
DRESSING: The ability to put on and take off clothing and other items like adaptive devices.
TRANSFERRING: The ability to get into or out of bed or a chair.
TOILETING. The activity of using a toilet to relieve bowels or bladder, including getting to and from as well as on and off the toilet, with a reasonable degree of hygiene.
NOTE that as it may impact the ability to safely get TO the toilet when the need arises, TOILETING does include "ambulating" as a part of the definition!
NOTE that as it may impact the ability to safely get TO the toilet when the need arises, TOILETING does include "ambulating" as a part of the definition!
CONTINENCE: The ability to control urinary and/or bowel function. If incontinent, the ADL includes the ability to manage it with a reasonable degree of hygiene.
EXAMPLE: If you are incontinent - are unable to control bladder and/or bowel function - but you can manage the condition independently by emptying a colostomy bag or changing adult diapers along with the necessary cleaning and hygiene, then you have NOT lost the CONTINENCE ADL.
EXAMPLE: If you are incontinent - are unable to control bladder and/or bowel function - but you can manage the condition independently by emptying a colostomy bag or changing adult diapers along with the necessary cleaning and hygiene, then you have NOT lost the CONTINENCE ADL.
EATING: The ability to get already-prepared food from the plate or other serving device into your body.
The EATING ADL does NOT include food preparation.
Tube feeding does NOT necessarily mean you have lost the EATING ADL. If you can manage your own tube feeding - along with necessary clean up, hygiene, and care of the feeding tube - then you are independent in the EATING ADL.
The EATING ADL does NOT include food preparation.
Tube feeding does NOT necessarily mean you have lost the EATING ADL. If you can manage your own tube feeding - along with necessary clean up, hygiene, and care of the feeding tube - then you are independent in the EATING ADL.
(NOTE that the list of ADLs does not separately include "ambulating" or "walking". This is not an ADL used by LTC insurance for measuring benefit eligibility. "Ambulating" is often referred to and measured as an ADL by professional care providers, but should not be considered separately when evaluating a policy's BENEFIT ELIGIBILITY. As noted above "ambulating" MAY be a triggering issue as part of the TOILETING ADL.)
Policies issued since 1997 (HIPAA "TAX-QUALIFIED" LTC insurance) require that the ADL help be certified by a doctor, nurse or licensed social worker as being expected to last at least 90 days. This is not a waiting period; it is simply a professional certification that the ADL assistance will be "long-term" (90+ days) vs. "short-term".
Policies issued since 1997 (HIPAA "TAX-QUALIFIED" LTC insurance) require that the ADL help be certified by a doctor, nurse or licensed social worker as being expected to last at least 90 days. This is not a waiting period; it is simply a professional certification that the ADL assistance will be "long-term" (90+ days) vs. "short-term".
The BENEFIT ELIGIBILITY criteria noted above applies generally to most policies sold as "long-term care", but there are exceptions and differences, particularly in older policies (pre-1997) including these more-restrictive provisions:
- The loss of three (3) ADLs.
- Using only five (5) ADLs for consideration.
- Defining the need for ADL help to be only direct, HANDS-ON assistance.
* This information is for educational, informational purposes only and is not meant to provide specific guidance for any particular policy, policyholder, or claim situation. LTCI claims eligibility is determined by the insurance carrier based on the specific criteria in the issued policy contract and the carrier's own guidelines.
- The loss of three (3) ADLs.
- Using only five (5) ADLs for consideration.
- Defining the need for ADL help to be only direct, HANDS-ON assistance.
* This information is for educational, informational purposes only and is not meant to provide specific guidance for any particular policy, policyholder, or claim situation. LTCI claims eligibility is determined by the insurance carrier based on the specific criteria in the issued policy contract and the carrier's own guidelines.
