TL;DR
  • Federal law protects less than families assume. GINA does not apply to long-term care, life, or disability insurance, so a predictive genetic result can legally be used in those underwriting decisions.
  • Long-term care underwriters do not need a genetic test to find a cognitive concern. They review medical records, prescription histories, shared industry databases, and their own cognitive screening of older applicants.
  • Health, not money, is what closes the door. In 2019 applications, 19.4% of applicants ages 40 to 49 were declined, rising to 53.6% after age 75; for couples age 75 and older, there is a 78.5% chance at least one spouse is declined.
  • Waiting is expensive as well as risky. The same $165,000 policy averages $5,010 a year for a couple at 55 and $7,030 at 65.
  • The workable sequence is evaluate, insure, then test — settle coverage while you are insurable, and take symptoms to a doctor immediately rather than delaying care to protect an application.

Why the Order of These Two Decisions Matters

Last month this series covered the new FDA-cleared blood tests for Alzheimer's disease and what an APOE4 result does and does not mean (read that post). The single question families asked most after it was not medical. It was this: if we find out, what does it do to our insurance?

The answer depends almost entirely on sequence. A long-term care insurance policy that is already in force cannot be repriced or revoked because of a test result you get later. An application that has not been submitted yet is a different situation, because underwriting looks at the record as it exists on the day you apply.

That is the whole planning problem in one sentence: the information is permanent, and the insurability window is not.

What GINA Protects, and What It Leaves Out

The Genetic Information Nondiscrimination Act of 2008 is the law most people have heard of, and it is genuinely strong — inside its boundaries. GINA bars health insurers and most employers from requesting genetic information or using it to set premiums, deny coverage, hire, or fire.

Its boundaries are the problem. The National Human Genome Research Institute states plainly that GINA's health insurance protections do not cover long-term care insurance, life insurance, or disability insurance, though some states add protections in those lines (National Human Genome Research Institute). Those three lines are exactly the ones a family thinking about dementia risk would want.

The lines of insurance most relevant to a dementia diagnosis — long-term care, life, and disability — sit outside the law most families believe protects them.

State law fills part of the gap, unevenly. In the NAIC's compilation of state genetic-testing provisions, Massachusetts and Maine are among the states whose restrictions explicitly reach long-term care coverage, while others such as Arizona, California, Delaware, and Minnesota address life or disability lines only (National Association of Insurance Commissioners). Where you live changes the answer, so this is a question for your own state's insurance department, not a national rule of thumb.

Change is moving, slowly. NCOIL's Life Insurance Genetic Testing Model Act — the first serious model aimed at the carve-out GINA left in 2008 for life, long-term care, and disability coverage — closed public comment on February 4, 2026 and was on track for a substantive vote at the Spring National Meeting. The draft works as a one-way ratchet: a carrier may use a negative predictive result to improve an applicant's class, but may not surcharge or decline based on a positive one. Family history remains usable (actuary.info analysis of the Spring 2026 draft). At the state level, Minnesota's HF3701, introduced February 25, 2026 and still in committee, would bar long-term care, life, and disability insurers from using genetic information for underwriting or pricing (Minnesota HF3701).

None of that helps a family applying this month. Plan around the law as it is written today.

Man in his fifties sitting with his elderly mother across from an insurance advisor, reviewing coverage paperwork

What Long-Term Care Underwriters Actually Look At

It is a mistake to imagine underwriting as a search for a gene. Genetic results are a small part of a much wider file, and the rest of the file is what usually decides the case.

Applications for long-term care coverage typically include a detailed health history and, for older applicants, cognitive screening questions. Insurers may request physician notes or electronic records showing memory complaints, cognitive testing, neurology referrals, blood biomarker results, diagnostic codes, and assessment impressions; they may also review prescription histories and coded information held by the Medical Information Bureau (LTC Shop).

Cognitive screening is now routine and fast. Applicants age 60 and older are typically screened during long-term care underwriting, and Nationwide replaced its 20-minute telephone assessment with an online screening that takes as little as three minutes, built on Neurotrack's technology (Nationwide). An applicant can be declined on the strength of that screening and a chart note, with no genetic test anywhere in the file.

There is also a distinction worth understanding. The NCOIL draft defines a genetic test as presymptomatic analysis of DNA, RNA, chromosomes, proteins, or metabolites tied to an inherited condition, and expressly excludes standard blood chemistry panels and diagnostic results that evaluate a condition an applicant already has symptoms of (actuary.info). Practically, a p-tau217 test ordered as part of a symptomatic workup is diagnostic, not predictive — but the memory complaint that prompted it is already in the record either way.

Health, Not Money, Is What Closes the Door

Families tend to treat long-term care insurance as a budgeting decision they can revisit later. Underwriting data says otherwise.

Long-term care insurance decline rates by applicant age, 2019 applicationsIndividual applicants ages 40 to 49 were declined 19.4 percent of the time and applicants after age 75 were declined 53.6 percent of the time. For couples, the chance at least one spouse is declined runs 35 percent at ages 40 to 49 and 78.5 percent at age 75 or older.0%20%40%60%80%Share of applications declined for health reasonsIndividual, ages 40–49one applicant19.4%Individual, after age 75one applicant53.6%Couple, ages 40–49at least one spouse declined35.0%Couple, age 75 or olderat least one spouse declined78.5%
Decline rates for traditional long-term care insurance applications, from an analysis of 2019 applications compiled for the 2020 Milliman Long-Term Care Insurance Survey. Data: American Association for Long-Term Care Insurance.

Two things stand out. First, decline rates rise steeply with age: 19.4% of individual applicants ages 40 to 49 were declined, against 53.6% after age 75. Second, couples face compounded risk, because one shared application often means one shared decision — the chance that at least one spouse is declined runs from 35.0% in the youngest bracket to 78.5% at 75 and older (AALTCI).

The association's own guidance is to begin investigating coverage in the early-to-mid 50s, before Medicare eligibility, and to talk to a specialist early if there are existing conditions or medications beyond the routine (AALTCI).

What Waiting Costs, in Dollars

Age changes price as well as eligibility, and the gap is not small.

Average annual premium for a $165,000 long-term care insurance policy, 2026A single man buying at age 55 with 3 percent compound growth averages 2,200 dollars a year. A couple both age 55 averages 5,010 dollars combined. A couple both age 65 averages 7,030 dollars combined.$0$2K$4K$6K$8KAverage annual premium, 2026Single man, age 553% compound growth$2,200Couple, both age 55combined annual premium$5,010Couple, both age 65combined, 3% compound growth$7,030
Average annual premiums for $165,000 in initial benefits, July 2026 pricing. Data: 2026 AALTCI Long-Term Care Insurance Price Index. Premiums vary by state, carrier, and health at application.

A couple buying at 55 averages $5,010 a year for $165,000 in initial benefits; the same couple at 65 averages $7,030. A single woman at 60 averages $4,450. Carrier spread matters as much as age: for an Illinois couple both 60, the most expensive of five leading insurers cost 56.24% more per year than the least expensive for virtually identical coverage, and at 65 the spread between low and high carrier rates reached 80% (AALTCI 2026 Price Index).

Two practical consequences. Shopping more than one carrier is not optional. And a policy purchased at 55 is cheaper per year than the same coverage at 65 while also being far more likely to be issued at all.

What Families Are Actually Buying Now

The market has shifted under this conversation. Hybrid or combination products — life insurance or an annuity with long-term care benefits attached — have become the leading private long-term care solution, with momentum moving away from stand-alone policies, according to a LIMRA and EY study drawing on 35 insurance companies and nine executive interviews (LIMRA).

Hybrids are still medically underwritten, so the sequencing logic does not change. What changes is the shape of the tradeoff: different benefit triggers, different guarantees, and a death benefit if care is never needed.

That last point addresses the objection this coverage always draws. Actuaries surveyed by AALTCI estimated that someone buying at age 60 with a zero-day elimination period has roughly a 50% lifetime chance of using the policy, falling to about 35% with a 90-day elimination period, since some people recover or die within the waiting period (AALTCI).

Adult daughter and her mother sitting on a couch reviewing long-term care coverage options on a laptop at home

The Sequence That Protects Families

Specialists who work in cognitive underwriting describe a consistent order: review your health history with a long-term care insurance professional before ordering new tests, complete underwriting and get coverage in force, and pursue Alzheimer's or genetic testing afterward, when the result can no longer affect eligibility. The plain-language version is apply first, test later (LTC Shop).

One boundary matters more than the insurance: this is not a reason to delay medical care. If someone is having memory trouble now, that is a symptom, and symptoms belong in front of a clinician this month. The sequencing advice applies to predictive testing in people without symptoms — the curiosity case, the family-history case, the direct-to-consumer case — not to the person who needs a diagnosis.

If testing has already happened, the situation is narrower but not hopeless: gather every result and physician note, work with a broker experienced in cognitive underwriting who knows which carriers view the file most reasonably, and answer every application question truthfully (LTC Shop). Misrepresentation on an application is a far worse outcome than a decline, because it can void a claim years later, when the family is relying on it.

What Families Should Actually Do This Month

  • Separate the two decisions on paper. Write down which family members are considering testing and which have no coverage in place. Those lists drive the order of operations.
  • Check your state before you assume you are unprotected. A few states restrict genetic underwriting in long-term care lines; most do not. Your state insurance department can confirm.
  • Get quotes from more than one carrier. Identical coverage varied by up to 80% between carriers in 2026 pricing.
  • Ask about cognitive screening up front. If an applicant is 60 or older, screening is likely part of the process; knowing what it involves prevents surprises.
  • Do not trade medical care for insurability. Symptoms get evaluated now. Predictive testing can wait for coverage to be in force.
  • If coverage is not available, change the plan, not the goal. Self-funding, home equity, hybrid products, VA benefits, and Medicaid planning are all still on the table. Our sister resource FundingDependency.com walks through the funding paths in plain language.

Families rarely regret buying coverage a few years early. They regret the month they decided to think about it later.

This is educational information, not legal, insurance, or medical advice. State laws vary, underwriting rules differ by carrier, and policy terms control. Talk with a licensed professional about your own situation.

Frequently Asked Questions

Does GINA stop long-term care insurers from using genetic test results?

No. GINA covers health insurance and employment. The National Human Genome Research Institute states that its protections do not extend to long-term care, life, or disability insurance, although some states add their own restrictions in those lines.

Should I apply for long-term care insurance before an Alzheimer's blood test?

Specialists in cognitive underwriting generally advise reviewing your health history first, completing underwriting, and pursuing predictive testing once coverage is in force. This guidance applies to testing in people without symptoms. If someone already has memory symptoms, medical evaluation should not be delayed.

How often are long-term care insurance applications declined?

In an analysis of 2019 applications, 19.4% of individual applicants ages 40 to 49 were declined, rising to 53.6% after age 75. For couples age 75 or older, there is a 78.5% chance at least one spouse is declined.

What does long-term care underwriting actually review?

Detailed health history, cognitive screening for older applicants, physician notes and electronic records, prescription history, and coded information held by the Medical Information Bureau. Applicants age 60 and older are typically screened for cognition, sometimes through an online assessment taking only a few minutes.

How much does long-term care insurance cost in 2026?

For $165,000 in initial benefits, the 2026 AALTCI Price Index puts a couple both age 55 at about $5,010 a year and a couple both age 65 at about $7,030. A single woman at 60 averages $4,450. Carrier spreads reached 80% for virtually identical coverage, so comparing carriers matters.

If I already had a genetic or biomarker test, can I still get covered?

Possibly. Gather all results and physician notes, work with a broker experienced in cognitive underwriting, and answer every application question truthfully. Misrepresenting an application is worse than a decline, because it can void a claim later.

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Sources for this post (all accessed September 2026):