Does this sound familiar? You visit Mom for Sunday dinner, and she’s still making her signature pie. Later, she asks for help pulling on her sweater. Then she mentions she’s been putting off a shower because she feels unsteady stepping into the tub. Moments like these can open a conversation about what kind of help Mom would welcome at home. It’s also a good time to ask whether she has long-term care insurance and, if she does, offer to review the policy together to see what home care services it may cover.
November is Long-Term Care Insurance Awareness Month, a good time to get familiar with the six activities of daily living, or ADLs, that many insurers consider when evaluating a claim. “Activities of daily living” sound clinical. At home, they’re the ordinary things seniors do every day, like getting dressed, eating a meal, and taking care of themselves in other ways.
What the six activities might look like at home:
- Bathing means washing yourself, including getting into or out of a tub or shower. Someone may need a steadying hand stepping over the tub wall.
- Dressing means putting on and taking off clothes. That might include needing help pulling on pants, managing fasteners or putting on shoes.
- Eating means feeding yourself once food is ready. A senior may need help bringing food from the plate to their mouth.
- Transferring means moving into or out of a bed, chair or wheelchair. Getting up from a favorite armchair may now take another person’s help.
- Toileting means getting to and from the toilet, getting on and off it, and managing personal hygiene afterward.
- Continence means controlling bladder and bowel function or managing related personal hygiene and supplies when that control is limited.
Cooking, shopping and keeping track of medications also matter when you’re deciding what support an aging loved one needs at home. When talking with an insurer, be specific about the task. A senior who needs meals prepared may still be able to feed themselves, so those needs are described differently in a care assessment.
When Do the “6 Things” Matter for a Claim?
Many long-term care insurance policies use a benefit trigger, a condition that must be met before benefits can become payable. For many tax-qualified policies, one route is a licensed practitioner’s certification that a senior needs substantial help with at least two of the six ADLs because of a loss of function expected to last at least 90 days. Needing substantial supervision for safety because of severe cognitive impairment can be a separate route, even if a senior can still bathe and dress independently.
The policy also spells out any elimination period, the waiting period before benefits can be paid. The expected duration of the need for help and the elimination period are separate requirements. Some policies count calendar days toward the waiting period, while others count only days on which the senior receives qualifying care. Ask how your policy counts days and which home care providers and services it covers.
Start With What’s Changed with a Senior’s Daily Activities
In the Sunday dinner example, a natural opening might be, “You mentioned the tub feels unsteady. What would make showering feel easier for you?” If Mom wants help, you can write down what she does on her own, where she needs someone nearby and when she needs hands-on assistance. Details like “needs someone to steady her each time she steps into the tub” give a care professional or claims assessor more to work with than “having trouble at home.”
For discharge planners, case managers and other referral partners, that same level of detail can help a family understand what support to arrange after a transition home. With the older adult’s permission, share which daily tasks require assistance and what kind of help is needed. If the family has a policy, encourage them to pull it out early so they have time to understand the claims process and plan for any waiting period.
How Amada Senior Care Can Help as an Advocate for Seniors and Families
Amada Senior Care provides complimentary long-term care insurance claims advocacy. Our team can review your policy with you, help verify what it covers, assist with claim forms and manage ongoing claims paperwork and billing where applicable. We can also help you plan non-medical in-home care around the parts of the day when you or your loved one would welcome support. The insurer makes the benefit determination under the terms of your policy.
Have a policy you haven’t looked at in years, or wondering if it’s time to file a claim? Contact your local Amada Senior Care office for help reviewing your coverage and deciding what to do next.
