Short answer: For a tax-qualified policy, a licensed health care practitioner must certify within the past 12 months that the person cannot perform at least 2 of 6 activities of daily living for at least 90 days, or needs substantial supervision because of severe cognitive impairment, and the care must follow a plan of care. The policy’s elimination period then has to be met.
The six activities of daily living are eating, toileting, transferring, bathing, dressing and continence. A tax-qualified contract must consider at least 5 of them when deciding whether someone is chronically ill. The 90 days is an expectation about how long the loss of function will last, not a waiting period the person must sit through first.
Covered services are diagnostic, preventive, therapeutic, rehabilitative, and maintenance or personal care services needed by a chronically ill person under a plan of care prescribed by a licensed health care practitioner. That includes custodial help with daily activities, the kind of care Medicare generally does not pay for over the long term.
Separately, most policies have an elimination period, a number of days of care the insured pays for before benefits begin. Where care is covered (home, assisted living, nursing facility) and how much is paid per day or month are policy terms.