The CLASS Act Health Reform Adds a Twist to Long-term Care Insurance

Imagine that long-term care insurance meets Medicaid, and you will begin to have some idea about the new CLASS Act. CLASS is a program established by the new health care reform law, and it stands for Community Living Assistance Services and Supports.

At a time when long-term care costs are expensive and only becoming more so, the program represents the first major attempt of the federal government to provide long-term care benefits. The program went into effect on Jan. 1, 2011, but it is unlikely that you’ll be able to enroll before 2012 because a number of details still need to be ironed out.

The program will be administered by the federal Department of Health and Human Services (HHS) and its secretary, Kathleen Sebelius. CLASS is completely voluntary and is meant to provide cash benefits to working adults who become functionally disabled.

The program is similar to private long-term care insurance because you pay the premiums. It resembles Medicaid, however, in that it offers lifetime benefits and can’t exclude people with pre-existing conditions.

Who Can Enroll?

Any working adult can participate. You must be over 18 years old and actively employed. The details of what constitutes actively employed will be determined by the HHS, but will include part-time employees who earn enough to pay Social Security taxes, or about $1,120 per year. It will also include self-employed people. Retirees, unless they continue to work part-time, will not be eligible. Patients in nursing homes and other institutions, as well as incarcerated people, will be eligible to enroll. The most attractive part of CLASS is that you are not ineligible if you already have health issues.

One major drawback of private long-term care insurance is that you are often disqualified for pre-existing conditions. The CLASS legislation prohibits this kind of underwriting. As long as you can pay the premiums for five years and continue to work at least part-time during three of those years, you can enroll, and you won’t be excluded from receiving benefits. You can either become enrolled through your employer, or you can enroll on your own if your employer decides not to participate. The method for enrolling on your own hasn’t yet been determined, but it will be up to HHS to institute that. If your employer signs up, then all employees will be automatically included. Nevertheless, you can always choose to opt out of the system.

How Much Will It Cost?

Payments for the cost of the premiums will be deducted directly from your paycheck if you enroll through your employer. When the Congressional Budget Office analyzed the legislation, it estimated that monthly premiums would average around $120. This means that, if you get paid weekly, about $30 will come out of each paycheck to pay the premiums for your coverage. Your employer will have the option of deciding whether it wants to cover any of the cost of the premiums. If you’re lucky, your employer may decide to do so as an additional part of the benefits package it offers to employees.

Under the law, premiums can be lower for younger people and higher for older participants. Generally, this makes sense because younger people will usually be paying the premiums for a longer period of time. Additionally, there are some very attractive provisions: premiums are intended to remain the same throughout a person’s lifetime, and people with health issues cannot be charged higher premiums. For people below the federal poverty line and for working students, there will be a special low premium that may be as little as $5 per month. All the premium information has to be determined by HHS by October 2012. Until then, no one knows for sure how much CLASS will cost.

How Do I Get Benefits?

The CLASS Act has various vesting requirements that you must meet before you can become eligible for benefits. First of all, you must pay the premiums for at least five years before you are eligible for benefits. Second, you must have been actively working at least three of those five years. Special rules will apply if you drop out of the program and then subsequently reapply. If you re-enroll within 90 days, your premiums will not change. After 90 days, however, the premium may be adjusted based on your current age. So if you join the program when you are 22, drop out for more than three months when you are 40, then re-enroll a year later, your new premium will be based on your current age of 40, and it is sure to be higher than the premium you had at age 22.

In addition to meeting the vesting requirements, you must have a qualifying level of disability to begin receiving benefits. The benefits granted by the program will depend on the level of physical and/or cognitive disability. The qualifying level of disability is defined as being unable to perform at least two or three of the Activities of Daily Living (ADLs), which include eating, bathing, and dressing yourself. Alternatively, the qualifying level of disability can be met if you require substantial supervision due to cognitive impairment. The disability must occur for at least 90 days consecutively to qualify. But as long as a qualifying level of disability exists, you can continue to receive benefits.

How Large Are the Benefits?

CLASS will pay a cash benefit of no less than $50 per day on average. This means that some people will receive more than $50 and some will receive less, but the average amount paid out cannot be less than $50. The benefit will depend on the level of disability and will increase annually to keep up with inflation. The beauty of CLASS is that there is no lifetime limit on benefits. If you’re eligible for benefits under CLASS and you get into a car accident at age 40 resulting in the need for care for the rest of your life, you’ll get a payment from the government every month, adjusted for inflation, as long as you live.

One criticism of the program is that CLASS could never cover the entire cost of long-term care in a nursing home. Although that is likely to be true, even $50 a day will help finance extra help at home, or take care of part of the cost of assisted living or adult day care. With the cost of a private room in a nursing home averaging over $9,700 per month in Massachusetts in 2010, every little bit helps.

CLASS can provide assistance to people who have pre-existing conditions and would never be able to obtain long-term care insurance. It can also provide benefits to those who make too much money to qualify for Medicaid but not enough to pay the premiums on private insurance. The bottom line is that CLASS is likely to be a winner because it will cost less than long-term care insurance, while providing benefits to more people. v

Julie R. Lackner, Esq. is an associate attorney with the Springfield-based law firm Bacon Wilson, P.C. She handles all aspects of estate planning and elder law; (413) 781-0560; baconwilson.com; bwlaw.blogs.com