A Texas long-term care insurer is drafting the provision that determines when an insured becomes eligible for policy benefits. Under the Texas long-term care insurance minimum standards, which of the following may be used as the benefit trigger?

Why D is correct

Under 28 TAC 3.3818 (Standards for Eligibility for Benefits), eligibility for benefits must be keyed to the insured's condition, meaning the inability to perform activities of daily living or severe cognitive impairment, and the definitions must be set out in the policy so the insured can see exactly when benefits start. A trigger that turns only on hospitalization, on a relative's request, or on some other unrelated event is not permitted, because it would let the insurer pay or refuse to pay without reference to the insured's functional or cognitive loss.

Why the other options are wrong

• A) Exhaustion of Medicare supplement benefits is unrelated to the insured's condition and cannot be used as the trigger for long-term care benefits.
• B) A relative's request is not an objective measure of eligibility; benefit eligibility must be measured against the policy's disclosed functional or cognitive criteria.
• C) Hospital admission alone is not an acceptable trigger under 28 TAC 3.3818; the trigger must rest on the insured's functional or cognitive impairment.

Memory hook

Trigger on the person, not the place: ADLs or cognition.