If they already have long-term care insurance — how to actually use the policy

This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.

You've found the policy in your parent's filing cabinet, or maybe you knew it existed but never actually looked at it until something changed. Now your parent is in assisted living, or they need home care, or they're considering a nursing home, and you're realizing that having a long-term care insurance policy is completely different from understanding what it actually does. You open the document and there's page after page of dense language about "covered services" and "elimination periods" and "benefit triggers" and suddenly you understand why people say "I have insurance but I don't know what it covers."

This is where most families get stuck. The insurance exists. It's been paid for faithfully for years. But when the time comes to actually use it, the path forward isn't obvious. You don't know if the facility your parent chose accepts the insurance. You don't know when the money starts flowing. You don't know what your parent will end up paying out of pocket even with coverage. You definitely don't know what you're supposed to do right now, this week, to make the insurance actually work instead of just sitting there in a folder.

The good news is that the process is much more straightforward than the language makes it sound. It's not intuitive, and there are definitely ways to mess it up, but there are also clear steps. You don't need to be an insurance expert. You just need to know what to look for, what questions to ask, and what timeline to expect. Let me walk you through it from the moment you realize your parent might need care.

Finding the Policy and Confirming It Still Exists

Locate the policy document first. This sounds obvious, but it's a genuine first step in many families. Your parent might not remember which company issued it. You need the actual document.

Start by asking your parent directly. They might keep it with their will or in an "insurance" folder. They might have told a financial advisor or lawyer about it. If your parent is competent and communicative, a direct question is fastest.

If not, check safe deposit boxes, ask whether a financial advisor knows about the policies, or look through recent tax documents. Many people have kept policies for decades and forgotten about them.

Once you know the company, call customer service. Explain you're locating a policy and give names and dates. The insurance company might require that you're an authorized representative before discussing the policy. Some require written authorization or power of attorney before confirming the policy exists.

Don't wait. If your parent is declining cognitively or facing health crisis, you want the insurance company to know you're coming. Some policies have waiting lists to file claims, and some insurers have specific procedures about notification timelines.

Understanding What the Policy Actually Covers

Once you have the policy document, you need to read it. It's lengthy and bureaucratic, but you don't need to read all of it. You need specific information.

Start with the summary or rider pages. They should summarize main benefits. Look for these key numbers: the daily benefit amount (how much the insurance pays per day), the benefit period (how long it will pay), and the elimination period (the waiting time before benefits start).

The daily benefit is what the insurance company pays toward care daily. If your parent is in a facility costing $200 daily and the policy covers $150, the company pays $150 and you pay $50. If the facility costs $120, the company pays $120. The daily benefit is your maximum.

The benefit period is how long the insurance will pay. Some policies cover three years, some five, some unlimited. This matters for planning. If the policy covers three years but your parent needs care for seven years, you're responsible for the last four years out of pocket.

The elimination period is the waiting time before the insurance starts paying. This is often 30, 60, or 90 days. During this time, you pay all costs. A family sometimes doesn't realize there's going to be this waiting period and is shocked when they expect insurance to start covering costs immediately and it doesn't. Plan for this. Know the elimination period before your parent enters a care facility.

You also need to know what kind of care is covered. Most policies cover nursing home care and home care. Some also cover assisted living or adult day programs. Some are limited. If your parent is planning to move to an assisted living facility but the policy only covers nursing home care, that's a real problem to solve before moving. Call the insurance company and ask explicitly: "Does this policy cover assisted living?" Get the answer in writing if you can.

Look for any mention of networks or approved facilities. Some policies require you to use facilities from the insurance company's network. Others allow you to choose any facility. If there's a network requirement, you need to know whether the facility your parent wants to use is on it. Call the insurance company and ask for a list of approved facilities in your area.

The Elimination Period: Your Hidden Out-of-Pocket Risk

This deserves its own section because most families underestimate it. The elimination period is the number of days you pay for care before the insurance company starts reimbursing. It's not usually 30 or 60 or 90 days of total care. It's 30 or 60 or 90 consecutive days. Some policies have an elimination period of "0 days," meaning coverage starts immediately. Some have 30 days. Some have 90 days. One hundred days isn't uncommon.

Here's what that means in dollars. If your parent moves to a nursing home that costs $250 daily, and the policy has a 90-day elimination period, you're paying $22,500 out of pocket before the insurance company pays a single dollar. That's a real chunk of money. Many families don't know about this until they're moving their parent into care and the administrator asks how they're paying for the first three months.

The elimination period usually only applies the first time your parent uses the insurance. So if your parent needs thirty days of care, recovers, and then two years later needs care again, there's not a new elimination period—the policy starts paying immediately. But if they need continuous care, the 90-day waiting period applies to all of that continuous stay.

Some policies let you "waive" the elimination period for a higher daily benefit or shorter duration. Some don't. You need to know which you have.

Filing the Claim: The Timeline and What to Expect

When your parent needs to start receiving covered care, you need to notify the insurance company. You can usually do this by calling and speaking to a representative, though some companies prefer a formal letter. Don't assume the insurance company will figure out that your parent needs care—you have to tell them.

Here's what happens next: the insurance company will ask you to have your parent's doctor submit a form certifying that your parent needs long-term care. This is usually a straightforward medical assessment. The doctor indicates that your parent cannot perform daily living activities without help, or is cognitively impaired, or is confined to home or facility. The insurance company needs this medical certification before they'll pay anything.

Getting the doctor to complete and submit this form can take anywhere from one week to several weeks. Some doctors are quick about it. Some take forever. Call the insurance company and ask what they need, then call the doctor's office and explain the timeline. Most healthcare providers understand insurance certification and will prioritize it reasonably quickly.

Once the insurance company receives certification, they review the claim. They verify that the care needed matches the policy, that your parent meets "needing care" definition, and that the facility is covered. This review usually takes two to four weeks.

Then they approve or deny the claim, and provide payment information. Some companies pay the facility directly. Some reimburse you for bills. Some do both. You need to know which, as it affects cash flow.

The entire process from notification to first payment usually takes 4 to 8 weeks. Don't assume immediate money. Plan for at least a month, maybe longer.

You're still paying for care out of pocket during this waiting period. This is why the elimination period matters,you might have this certification happening simultaneously, meaning months of payment before reimbursement.

What Counts as Covered Care

The policy defines what counts as "long-term care",usually "help with daily living activities or cognitive impairment requiring supervision." "Daily living activities" in insurance terms means bathing, dressing, eating, toileting, transferring, and continence management. Some policies include grooming and medication management.

The facility or care provider must be qualified to provide the needed level of care. A facility must be licensed as a nursing home or assisted living facility. A home care provider must be a licensed agency. You can't hire someone privately and bill the insurance company.

Some policies are more flexible than others. Some allow individual caregivers hired through an agency. Some require specific agency types. You need to know your policy.

Also important: some policies limit the level of care. They might cover nursing home care only at the "skilled" level. If your parent needs only assistance with daily living activities (help dressing and eating), that's "custodial" care, and some policies don't cover it.

Before your parent moves into a facility, call the insurance company and ask: "My parent needs this kind of care at this facility. Does the policy cover this?" Get the answer before moving, not after.

When Claims Get Denied and What to Do About It

Sometimes the insurance company says no. Sometimes they say no because your parent doesn't meet the medical criteria they defined. Sometimes they say no because the facility isn't approved. Sometimes they say no for reasons that seem arbitrary or unfair to you.

You have the right to appeal a denial. This is usually a formal process where you submit additional documentation and make your case again to the insurance company. You can hire someone to help with this,an insurance advocate or an elder law attorney. You can also do it yourself if you're comfortable writing detailed letters explaining why you believe the claim should be approved.

The appeal process takes time, but it's worth doing if the denial seems incorrect. Many denials are overturned on appeal because the initial review was incomplete or made an error. It's not fun,it involves documentation and back-and-forth communication that's tedious. But if your parent's care costs $300 daily, every month you can convince the insurance company to cover it is $9,000 in your parent's favor.

Keep meticulous records of everything: doctor's notes, certification forms you submitted, communications with the insurance company, receipts from the facility, copies of the policy. This documentation is what makes appeals work.

Managing Ongoing Coverage: Recertification and Continued Communication

Once the insurance company starts paying, they're usually not done with your parent. Most policies require periodic recertification that your parent still needs care. This might be annual or more frequent. The insurance company will notify you when it's time and will ask for an updated medical statement from your parent's doctor.

This is an administrative task that falls to you, usually. You need to follow up with the doctor, get the form filled out, submit it to the insurance company, and make sure everything stays current. If you miss a recertification deadline, the insurance company might stop paying and it can take weeks to get them started again.

Stay in touch with the insurance company during the period when they're covering your parent's care. Let them know if your parent's care situation changes,if they move to a different facility, if their care needs increase or decrease, if they transfer from nursing home to home care. Some changes might affect the benefits.

Also keep copies of all bills and documentation. The insurance company needs to know what's being billed and when. Most facilities send bills monthly. You should be reviewing those bills to make sure they're accurate and then submitting them to the insurance company (or making sure the facility is doing it).

When the Policy Reaches Its Limits

The benefit period determines when the insurance stops paying. If your parent has a five-year benefit period and they've been in care for five years, the insurance company will stop reimbursing. If they have unlimited coverage, it keeps going as long as they're in covered care. But unlimited doesn't mean the facility is free,it means the insurance keeps paying the daily benefit it promised. If the facility costs more than the daily benefit, you're still paying the difference.

Plan ahead for when the insurance might run out. If it's going to end, you need alternative strategies in place. That might be Medicaid (if your parent is low-income or will be by then), family contributions, or out-of-pocket payment. Don't wait until the insurance ends to think about what comes next.

Some people try to switch facilities when insurance runs out, moving to a Medicaid-accepting facility. That can be a reasonable plan, but it requires having Medicaid approved and lined up ahead of time.

The Real Impact

Having a policy is better than not having one, but it's not magic. Most cover some costs, not all. Many families are surprised by how much they still pay. The insurance pays the daily benefit,$250 or $300 or whatever the policy specifies. The actual cost might be more. The family pays the difference.

Also, having coverage doesn't mean you choose your facility. You must choose one the insurance company covers, which limits options.

What insurance does provide is protection from absolute financial devastation. Your parent isn't admitted to the worst Medicaid facility. Not every penny of lifetime savings is consumed in the first years of care. There's structure and coverage, even if imperfect.

Understanding your policy,what it covers, out-of-pocket costs, how to file claims, when it ends,takes time and attention. But that effort prevents serious problems later. You're protecting your parent's financial security and your family's stability by doing this work now.

How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you are concerned about a loved one's cognitive health or safety, consult with their healthcare provider or contact your local Area Agency on Aging for guidance and support.