You’ve paid premiums for years—sometimes decades. The policy was meant for “someday.” But now you’re watching your parent struggle with daily tasks, and you’re wondering: Is it time? Should we start using their long-term care insurance?
Understanding when to use LTC insurance is one of the most common questions families face. Many wait too long, paying out of pocket for care they could have covered. Others aren’t sure if their loved one’s situation qualifies. This guide will help you recognize the signs and understand exactly when benefits become available.
Understanding Benefit Triggers: When LTC Insurance Pays
Every tax-qualified long-term care insurance policy uses standardized criteria—called “benefit triggers”—to determine when benefits begin. Understanding these triggers is essential when considering when to use LTC insurance for yourself or a family member.
Your loved one typically qualifies for benefits when one of two conditions is met:
Trigger #1: Needing Help with Activities of Daily Living (ADLs)
Most policies require that your loved one needs substantial assistance with at least two of six basic activities of daily living:
- Bathing — Getting in and out of a tub or shower, washing
- Dressing — Putting on and taking off clothes, selecting appropriate attire
- Toileting — Getting to and using the toilet
- Transferring — Moving from bed to chair, standing up
- Continence — Controlling bladder and bowel function
- Eating — Getting food from plate to mouth (not meal preparation)
“Substantial assistance” typically means either hands-on help or standby assistance for safety. If your parent can’t bathe safely without someone present to prevent falls, or needs help getting dressed each morning, they may meet this trigger.
Trigger #2: Cognitive Impairment
The second trigger is severe cognitive impairment that makes a person unable to live safely without supervision. This includes conditions such as:
- Alzheimer’s disease
- Vascular dementia
- Lewy body dementia
- Parkinson’s disease with cognitive decline
- Other forms of dementia or memory loss
Even if your loved one can physically perform ADLs, they may qualify for benefits if cognitive impairment makes them a danger to themselves, such as forgetting to turn off the stove, wandering away from home, or being unable to manage medications safely.
▶ Key point: A healthcare professional must certify that the need for assistance is expected to last at least 90 consecutive days. This doesn’t mean you wait 90 days to file—it means the condition must be expected to be ongoing.
Warning Signs: When to Use LTC Insurance May Be Right
Families often recognize the need for care gradually. These warning signs suggest it may be time to explore when to use LTC insurance benefits:
Physical Warning Signs
→ Difficulty with bathing or grooming — Unwashed hair, body odor, resistance to showering, or needing help getting in and out of the tub
→ Trouble getting dressed — Wearing the same clothes repeatedly, struggling with buttons or zippers, putting clothes on incorrectly
→ Balance and mobility issues — Frequent falls, difficulty getting out of chairs, unsteady walking, needing furniture for support
→ Unexplained weight loss — May indicate difficulty preparing meals or feeding themselves
→ Incontinence — Accidents, wet or soiled clothing, unusual odors in the home
Cognitive Warning Signs
→ Confusion about familiar routines — Getting lost in familiar places, forgetting how to use household appliances, not recognizing family members
→ Medication mismanagement — Missing doses, taking too much, confusing medications
→ Unsafe behaviors — Leaving the stove on, not recognizing dangerous situations, wandering
→ Poor judgment — Falling for scams, making unusual financial decisions, neglecting bills
→ Personality changes — Increased agitation, withdrawal, depression, or anxiety
Environmental Warning Signs
→ Cluttered or unsanitary home — Piled up mail, expired food in the refrigerator, garbage accumulating
→ Neglected household tasks — Dirty laundry piling up, dishes unwashed, lawn overgrown
→ Bruises or injuries — May indicate unreported falls
Why Families Wait Too Long to Use LTC Insurance
Understanding when to use LTC insurance is one thing. Acting on it is another. Many families delay filing claims for reasons that ultimately cost them money and peace of mind.
Denial about the situation:
It’s hard to accept that a parent needs help. Families often minimize problems or assume they’ll improve. “Mom just had a bad week” becomes months of struggling before anyone takes action.
Not wanting to “use up” benefits:
Some families worry about exhausting benefits too early, so they pay out of pocket while saving the insurance “for later.” But care needs often increase over time. Using benefits now—when they’re appropriate—doesn’t mean they won’t be there for future needs.
Pride and resistance from the care recipient:
Seniors often don’t want to admit they need help. They may downplay their struggles or refuse assistance. During insurance assessments, they might perform better than usual because they don’t want strangers to see them struggling.
Confusion about whether they qualify:
Families aren’t sure if their loved one’s situation is “bad enough” to file a claim. The answer: If your loved one needs regular help with two or more ADLs or has cognitive impairment requiring supervision, understanding when to use LTC insurance becomes critical—it’s worth exploring your options immediately.
The Financial Cost of Waiting to Use LTC Insurance
Delaying when to use LTC insurance has real financial consequences. According to the Federal Long Term Care Insurance Program’s 2024 Cost of Care Survey:
- Home care: $51,000 per year ($33/hour, 6 hours/day, 5 days/week)
- Assisted living: $66,000 per year ($5,511/month)
- Nursing home (semi-private): $112,000 per year ($308/day)
Every month you delay deciding when to use LTC insurance and start using available benefits, you’re potentially paying thousands of dollars out of pocket for care your insurance could cover.
In 2024, long-term care insurers paid more than $16.8 billion in claims. The average monthly benefit for stand-alone policies is substantial. That’s money available to help—but only if you use it.
Understanding the Elimination Period
Most long-term care insurance policies have an “elimination period”—a waiting period before benefits begin. Common elimination periods are 30, 60, or 90 days.
There are two types:
• Calendar day elimination: You count every day after meeting benefit triggers. A 90-day period means about three months before benefits start.
• Service day elimination: You count only the days you actually receive care. If you receive care three days a week, a 90-day elimination period could take over seven months to satisfy.
▶ Important: When determining when to use LTC insurance, remember that during the elimination period, you pay for care out of pocket. This is another reason not to delay—the clock doesn’t start until you file a claim and begin receiving qualifying care.
Some policies waive the elimination period for home care or allow it to be satisfied with unpaid family caregiving. Check your specific policy terms.
Where Most Claims Begin: Home Care First
If you’re wondering when to use LTC insurance for a family member, here’s an encouraging statistic: According to industry data, 73% of new long-term care insurance claims begin with care received at home. Only 18% start in assisted living and 9% in nursing homes.
This means most families deciding when to use LTC insurance start using their benefits for exactly the kind of help you might be considering right now—a home care aide who helps with bathing and dressing, or a caregiver who provides supervision for someone with memory loss.
You don’t need to wait until a crisis forces a nursing home admission. In fact, knowing when to use LTC insurance and starting care earlier often helps people stay at home longer.
Steps to Take When You Decide It’s Time to Use LTC Insurance
If you’re seeing warning signs and thinking about when to use LTC insurance, here’s a practical path forward:
✓ Review the policy. — Find the policy documents and review benefit triggers, daily benefit amounts, elimination period, and covered services. Understanding what’s covered helps you plan.
✓ Document the need for care. — Keep notes about specific struggles with ADLs or unsafe behaviors. This documentation supports the claim.
✓ Get a physician’s assessment. — Your loved one’s doctor will need to certify that care is medically necessary and expected to last at least 90 days.
✓ Contact the insurance company. — Call the claims department to understand their specific process and required paperwork.
✓ Choose a qualified care provider. — Your policy may have requirements about who can provide care. Some require licensed agencies; others allow family caregivers under certain conditions.
✓ Prepare for the assessment. — The insurance company will likely send an assessor. Be honest about struggles—this isn’t the time for your loved one to “perform.” The assessment should reflect daily reality.
When to Use LTC Insurance: Starting the Conversation
If you’re noticing warning signs and wondering when to use LTC insurance, but your loved one resists the idea of needing help, consider these approaches:
• Frame it as using an investment. — “You’ve been paying for this insurance for 20 years. Let’s get some benefit from it.”
• Start small. — A few hours of help per week feels less threatening than full-time care.
• Focus on safety and independence. — “Having some help at home will let you stay here instead of moving to a facility.”
• Involve their doctor. — Recommendations from trusted medical professionals often carry weight.
References
- Administration for Community Living. (2024). Receiving Long-Term Care Insurance Benefits. https://acl.gov
- AHIP. (2025). Long-Term Care Insurance Coverage: State-to-State 2025 Report. https://www.ahip.org
- Federal Long Term Care Insurance Program. (2025). Costs of Long Term Care. https://www.ltcfeds.gov
- American Association for Long-Term Care Insurance. (2024). Long-Term Care Insurance Claims Data. https://www.aaltci.org
- HealthInAging.org. (2024). Caregiver Guide: Problems of Daily Living. https://www.healthinaging.org
Let Us Help You Navigate Your LTC Insurance Benefits
Deciding when to use LTC insurance is an important step, and you don’t have to figure it out alone. At All Heart Home Care, we specialize in helping San Diego families understand and maximize their long-term care insurance benefits. Our experience helps you determine the right time to start using your coverage.
As San Diego’s LTC insurance claim experts, we’ve guided hundreds of families through the claims process. We understand what insurers need to see, how to document care properly, and how to avoid common mistakes that lead to delays or denials.
Our nurse-led team provides the professional, compassionate home care that helps your loved one maintain independence while giving you peace of mind. Whether you need a few hours of help each week or around-the-clock care, we’ll work with your insurance to maximize your benefits.
Ready to explore your options? Call us at (619) 736-4677 for a free consultation. We’ll help you understand your policy, assess your loved one’s needs, and create a care plan that works.
Disclaimer: This article is for informational purposes only and does not constitute medical or insurance advice. Always consult with your insurance provider and healthcare professionals regarding specific coverage and care decisions.
