What activities of daily living (ADLs) does the IRS recognize when certifying someone as chronically ill?
Executive summary
The Internal Revenue Service recognizes six standard activities of daily living (ADLs) — eating, toileting, transferring, bathing, dressing, and continence — and treats a person as “chronically ill” when a licensed health-care practitioner certifies that the person cannot perform at least two of those ADLs without substantial assistance for at least 90 days (or meets alternative cognitive-impairment criteria) [1] [2] [3]. That ADL list and the two-out-of-six + 90-day threshold appear across IRS forms, publications, and the statutory text (Forms 1099‑LTC and 8853, Publication 502, and IRC §7702B) and drive tax treatment and qualified long‑term care rules [1] [4] [2] [3].
1. The six ADLs the IRS uses — the canonical list and where it appears
The IRS (and the underlying statute) explicitly defines the six activities of daily living as eating, toileting, transferring, bathing, dressing, and continence, and that enumeration is cited in the Internal Revenue Code §7702B and repeated in IRS guidance and form instructions such as Publication 502, the Form 1099‑LTC instructions, and Form 8853 instructions [3] [2] [1] [4].
2. The operational test — two ADLs for 90 days and the certification requirement
To trigger the “chronically ill” designation under the ADL test, a licensed health‑care practitioner must certify that the individual has been unable to perform without substantial assistance at least two of the six ADLs for a period of at least 90 days due to a loss of functional capacity; this certification generally must be current (often within the prior 12 months) and is a recurring requirement tied to tax and insurance rules [2] [1] [4].
3. The cognitive‑impairment alternative and related protections
The statute and IRS guidance also provide a second pathway: an individual requiring “substantial supervision to be protected from threats to health and safety due to severe cognitive impairment” qualifies as chronically ill, which is treated as an alternative trigger to the ADL test in tax and qualified long‑term‑care contexts [2] [3].
4. How this definition matters in practice — tax forms, LTC contracts, and deductions
That ADL definition controls whether accelerated death benefits are excludable, whether long‑term care services qualify as deductible medical expenses, and whether insurance contracts are “qualified” for favorable tax treatment; the IRS uses the ADL/cognitive triggers in issuing Form 1099‑LTC, in Publication 502’s guidance on deductible medical expenses, and in rules governing qualified LTC insurance under IRC §7702B [1] [2] [4] [3].
5. Nuance and variability — insurance underwriting, safe harbors, and documentation
While the six ADLs and the two‑of‑six, 90‑day rule are statutory, IRS interim rules and industry practice create nuances: insurers may rely on pre‑1997 standards under certain safe harbors, qualified contracts must consider at least five of the six ADLs when defining chronic illness for the policy, and documentation practices differ — custodians do not always require submission of medical proof even when the beneficiary claims chronically ill status for distribution rules [5] [6] [7].
6. Limits of the record and practical implications for claimants
Public IRS sources and statute make the ADL list and the two‑of‑six + 90‑day rule clear, but they leave operational details — how practitioners document “substantial assistance,” how insurers interpret borderline cases, and how plan administrators review certifications — to guidance, contracts, and administrative practice; reporting reviewed here documents the legal baseline but not every real‑world procedural variation [2] [5] [6].