A frequent area of confusion when purchasing a long term care policy and at the time that a person is filing a claim is the required 90 day certification. First, some history. This certification requirement is not found in policies issued before 1997.  This language came out of the Balanced Budget Act of 1997 which more clearly defined and standardized the language in long term care policies.

The 90 day certification of chronic illness is part of any tax qualified long term care policy.  Simply speaking, a health condition has to be expected to last at least 90 days before it is considered chronic (or long term) and thus eligible for reimbursement from a long term care insurance policy.

The phrase “expected to last” is important to understand.  This is a statement on paper by a licensed health care practitioner that the individual requires care due to limitations in their ability to take care of their activities of daily living.  Those “ADL’s” include maintaining continence, transferring in and out of a bed or chair, toileting, bathing, dressing, or eating.  Policies state that an individual must need substantial assistance with two of these ADL’s for a period expected to last 90 days or more. (Alternatively, a person can qualify for benefits due to a cognitive impairment.)

Again, the certification is a statement on paper.  If that statement is not obtained, the long term care policy does not come into play nor do any days where care is received count as part of an elimination period (also known as a waiting period or deductible period which must be met before the insurance is responsible to pay).  For example, if an otherwise healthy person breaks their leg, they may be on crutches for 6-8 weeks but, barring any complications, would not be expected to need help for more than 90 days.  Their long term care policy does not come into play.

However, let’s say the individual was hit by the proverbial bus and had a crushed pelvis and a back injury and six months of rehabilitation was expected.  Now they would be able to get the 90 day certification as being “chronically ill” and now the policy becomes relevant.  If they met the requirement of the policy and had a 30 day elimination period, they would be eligible for benefits starting on day 31. However, if the individual had a 180 day elimination period (not usually recommended!), then there would be a 180 day period before being eligible for benefits once that 90 day certification was in place.

The elimination period is an actual number of days that the person must require care before being eligible for benefits.  (Note, in some policies the individual must receive paid care during those days.)

When a person needs care, it is often a crisis situation and the family is trying to piece things together.  Hopefully having a better understanding of both the required 90 day certification and the elimination period will make things easier.