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Long-term care insurance covers personal assistance, not medical treatment
Policies vary in benefits, limitations and financial feasibility
Since premiums increase over time, the ideal purchase age is 50 to 65

Howard Gleckman is a senior fellow at The Urban Institute in Washington, D.C., where he is affiliated with both the Tax Policy Center and the Program on Retirement Policy. Cynthia McLaughlin and I spoke with Gleckman about the realities of long-term care insurance, including what it covers, common misconceptions, the challenges of qualifying and how it fits into a broader financial plan.
—Charles Rotblut, CFA

Cynthia McLaughlin (CM): What exactly does a long-term care policy cover?

Howard Gleckman: The definition I use for long-term care is that it is the personal assistance people need to live the best life they possibly can.

A lot of people get confused by thinking that long-term care is medical treatment. It is not, even for a chronic condition. Long-term care is personal assistance. Long-term care insurance basically exists to help pay for that personal assistance.

You pay premiums for long-term care insurance over a period of years. You then trigger benefits when you need assistance with at least two of the six activities of daily living (ADLs) or when you have cognitive impairment. The six ADLs are bathing, eating, dressing, transferring, toileting and continence.

Activities of Daily Living

Activities of daily living (ADLs) are basic actions that those without impairments limiting their ability to function are able to perform on a daily basis. Long-term care policies, and many other programs, use a person’s inability to perform a certain number (e.g., two or more) of these ADLs as a qualification for receiving benefits.

The six ADLs are:

Bathing: Includes washing your body and hair as well as getting in or out of a tub or shower
Dressing: Putting on or taking off clothing or braces
Transferring: The ability to move about, such as getting out of a chair or bed
Eating: Consuming food and drink without assistance
Toileting: Getting on and off the toilet and cleaning yourself
Continence: Maintaining control of bowel and bladder function

Source: National Institutes of Health.

The other way that people think about needing long-term care involves instrumental activities or incidental activities of daily living (IADLs). Those are things like balancing a checkbook, cooking and driving. But long-term care insurance policies don’t cover that. They really only focus on the ADLs or cognitive impairment, and you need to have severe cognitive impairment to qualify for assistance.

About half of the people who are qualified for long-term care insurance benefits have cognitive impairment, so it’s an increasingly big deal in the long-term care insurance industry.

Instrumental Activities of Daily Living

Instrumental, or incidental, activities of daily living (IADLs) are tasks and activities required to live independently. A key difference between IADLs and activities of daily living (ADLs) is that ADLs are tasks required for basic living. IADLs require a higher level of cognition to complete. Howard Gleckman points out that long-term care insurance policies don’t cover IADL needs.

There is no fixed list of IADLs, but here are some most often cited:

Cooking: Planning and preparing meals using both cookware and kitchen utensils
Shopping: Knowing what to buy, choosing from among different items and paying
Housekeeping: All aspects, including cleaning, dusting, putting things away, etc.
Managing Finances: Paying bills, balancing a checkbook, understanding credit card statements, etc.
Managing Medications: Taking pills on time and correctly, and refilling prescriptions
Communicating: Answering and making phone calls, and reading and writing emails or letters
Driving or Taking Other Transportation: Includes driving and parking a vehicle, using public transit or using rideshare transit

Source: Howard Gleckman and ClevelandClinic.org.

CM: What are some of the common misconceptions that people have about long-term care insurance?

The biggest misconception people have is that Medicare pays for long-term care. It does not. There are a few limited exceptions such as the Program of All-Inclusive Care for the Elderly (PACE), which combines Medicare and Medicaid. There are special needs plans, which are certain kinds of Medicare Advantage plans that may pay for long-term care, but very few people participate in them. Some Medicare Advantage plans do offer very limited personal assistance benefits.

For the most part, it’s safe to say that traditional Medicare and Medicare Advantage plans do not pay for long-term care. That has confused people for decades, and it still does.

Medicaid, the other big federal health care program that’s for very poor people, will pay for long-term care. However, you need to be very poor and very sick in order to qualify for it. If you’re a middle-income person, it is very unlikely that you have a Medicare plan that will pay for long-term care.

Similarly, people think that the Medicare supplement insurance, sometimes called Medigap, pays for long-term care, but it does not. The only way you’re going to get insurance that covers long-term care is to buy a long-term care insurance policy.

These policies come in a couple different varieties. You could get a stand-alone long-term care insurance policy, or you can get what is called a combo, or hybrid, policy that combines long-term care with annuities or other kinds of insurance products.

Charles Rotblut (CR): What are the hurdles to getting a long-term care policy? Obviously, it’s going to be tough to get a policy if you have a fatal disease. But, say you’re middle-aged. Would a preexisting condition or a family history of Alzheimer’s disease be a hurdle?

To clarify, if you have a terminal disease, companies are actually okay with selling a policy to you because you’re unlikely to need long-term care for a very long time. Again, it’s very different from health insurance. If you have Stage 4 cancer, they’ll be happy to sell you a long-term care insurance policy because you’re probably not going to live long enough to claim the benefits.

The main things providers of long-term care insurance policies worry about are Alzheimer’s disease or any other kind of dementia, Parkinson’s, and even something like very severe arthritis. These companies will underwrite for your own personal medical conditions. They will also often ask about family medical history in the underwriting process.

There’s a lot of dispute in the scientific world about how much dementia is genetic. The disease is still not understood very well, but the general sense is that some of it is genetic. So, if both of your parents and your sibling have had dementia, the insurance company is probably not going to want to cover you.

If you buy the policy at a young-enough age, like age 40, the chances of being underwritten out of the policy are pretty remote. If you buy at 55, 60 or 65 years old—which is when most people do buy long-term care policies—you have a much higher probability of being underwritten out and being unable to purchase a policy.

If you have a preexisting condition, companies may sell you a policy, but at a higher premium than the standard premium.

CR: To follow up on that, is there an ideal age to consider buying long-term care insurance? Obviously, you can qualify more easily if you’re younger, but then you’re paying premiums for a longer period as well.

That’s exactly right. The problem when you’re younger is the additional years of premium incurred. For example, 40-year-olds these days are very likely still paying off some college loans. They probably have children and are saving for college. They may be paying a home mortgage, life insurance premiums and health insurance premiums. They’ve got all these more immediate things that are consuming their discretionary income. It’s challenging to get a 40-year-old to think about a long-term care need that probably will not arise until 40 years in the future. Typically, people claim long-term care benefits around 80 years old.

So, you’re right. They will be paying premiums for more years, and premiums do rise. But the premiums are quite low for those who buy at 40. The trouble is that people have all this other stuff that gets ahead of the line, so almost nobody buys at 40.

The insurance industry will tell you that the sweet spot is probably 50 or 55 years old. That’s even a little bit young from my experience. People really buy long-term care policies at 60 or 65 years old.

Realistically, the best time to think about buying a long-term care insurance policy is probably after you’ve gotten some of those other expenses out of the way. This is probably in your 50s.

CR: If someone has been paying premiums for many years and they’re faced with either paying substantially higher premiums or taking a reduction in benefits, what should they consider? How does the math work out in such situations?

It depends very much on your personal situation. If paying those higher premiums means that you have to reduce your spending on more immediate needs—for example, medications, heating and cooling, or transportation—then I would say it is probably necessary to make the trade-off and pay the lower premiums in return for the lower benefits. If you have discretionary income and you can afford it, then you may want to keep the policy even with the higher premiums.

The other important thing to think about is that the older policies tend to be more generous than the newer policies. For example, there used to be a time when long-term care insurance companies would sell what they call lifetime benefits. That meant that there was no limit on how many years you could get that $100 or $150 per day [allotted by the typical long-term care insurance policy]. If you have a policy like that, keep it, because you’re never going to get anything that generous again.

On the other hand, if you have a policy that only covers nursing homes, you probably want to get rid of it. Chances are that you will get much of your long-term care at home and not in a nursing home.

The decision really depends a lot on your financial situation and the nature of the policy. Economists always talk about the sunk-cost fallacy—that is, if you already put a lot of money into something, should you keep putting money in or just drop it? When it comes to something like long-term care insurance, it’s more complicated than that.

CR: Some AAII members have mentioned family who experienced difficulties with qualifying for and receiving benefits.

We hear a lot about people who claim and never receive benefits. Surveys have been done about this, and the reality is that most people actually do get their promised benefits. But you need to read the fine print of your policy.

For example, the requirement that you must need assistance with at least two ADLs confuses people because it is unclear what that really means. If someone can’t walk without assistance, what does that actually mean?

That’s not a binary thing where I’m either stuck in my chair or I can dance. Say I can get to the front door, but it takes me a long time. Does needing a walker or needing to grab onto furniture because I’m very unsteady on my feet mean that I need help with ambulation? That becomes a question.

The insurance policy will describe what it means by each of these ADLs in the fine print, but how many people actually read the fine print? It’s one of these stories where, for the most part, the insurance companies pay the benefits they promise to pay. The problem is that many of the consumers don’t understand what the promise is.

As painful as it is, my advice to people is to read the policy. And if you can’t read the policy, have somebody you know—maybe even a lawyer or financial adviser—read the policy for you and help you understand exactly what it will and won’t pay for.

VA Aid and Attendance

The U.S. Department of Veterans Affairs’ (VA) Aid and Attendance program provides monthly payments to help with the cost of personal assistance with daily activities. The program is available to qualified veterans and survivors.

Qualifications include having served on active duty for at least one day during a recognized wartime period, not being dishonorably discharged, and meeting annual income and net worth requirements.

In addition, at least one of the following must be true:

You need another person to help you perform daily activities—like bathing, feeding and dressing
You have to stay in bed—or spend a large portion of the day in bed—because of illness
You are a patient in a nursing home due to the loss of mental or physical abilities related to a disability
Your eyesight is limited; even with glasses or contact lenses, you have only 5/200 vision or less in both eyes, or concentric contraction of the visual field to five degrees or less

For more information about the program, go to www.va.gov/pension/aid-attendance-housebound.

Source: U.S. Department of Veterans Affairs, VA.gov.

CM: I keep reading that this industry is fragmented. How would you describe the long-term care landscape?

This is sort of two questions. The problem with the long-term care insurance companies is not so much that they’re fragmented. The problem is that the universe of companies that sell this insurance has shrunk dramatically. Fifteen years ago, there were 100 companies selling long-term care insurance. Now there’s maybe 10, and most of them are mutuals [owned by the policyholders].

If you’re a publicly traded insurance company, your shareholders do not want you selling long-term care policies. It’s too big of a risk, and long-term care insurance is too small a piece of the business to really worry about. I’ve been on shareholder calls where the analysts have basically told the managers of this type of insurance product to get rid of it because it is not worth the risk. So, most companies have gotten rid of it.

Genworth Financial, Northwestern Mutual, MassMutual and a few others still sell long-term care policies, but it’s now down to about 10 companies that are selling worthwhile policies.

The fragmentation, as I understand it, is a different issue. This fragmentation is between long-term care and health care. Think of yourself as an 80-year-old with multiple chronic conditions. Maybe you have heart disease, arthritis, chronic obstructive pulmonary disease (COPD) and some cognitive impairments. For some of this, you need medical treatment. For some of it, you need personal care.

The problem is that those who provide the medical treatment—the doctors and hospitals—don’t know about personal care. If you need it, they usually can’t tell you where to get it. So that means you or your caregiver, often your adult child, have to figure all this out alone. In that way, the industry is exceedingly fragmented. There’s very little communication.

My dad had congestive heart failure, and it was a nightmare trying to organize his personal care. Frankly, the only time it ever really got well-organized was when he was in hospice for the last year of his life. Hospice did a really good job of organizing all of his care. But if you’re not dying, you’re not eligible for hospice, and there’s really no way to do this without hiring a care manager or other expert.

In theory, Medicare Advantage should be able to do all that because it’s managed care. But Medicare Advantage does not work the way we all wish it would. If you’re on traditional Medicare, there’s no hope because traditional Medicare only pays for medical care, so it doesn’t care about your long-term care needs. With limited exceptions, it’s not paying for those needs or organizing them. And doctors often don’t know anything about it.

CR: If someone is trying to figure out whether to self-insure or use a long-term care policy, is there a certain guideline they can use for determining how much money they will need to cover their care expenses?

It’s just a matter of math. To be conservative, figure you’re going to need $200,000 per year if you’re single. You are going to need this amount for a couple of years if you are actuarily average.

The general formula is that your assets throw off 4% per year. So how much money do you need to throw off $200,000 per year? That’s probably the most conservative calculation you can do. If you do that, you never have to dip into the principle. You can just spend the interest and you’re good to go.

If you want to be less conservative, then you have to determine how much you’re getting in Social Security benefits and from pension and/or retirement accounts per year. Then determine how much you have in other financial assets to throw off enough money to make up the difference. These are two ways to do the calculation, but I think either way gives you a good rule of thumb to figure out what you want.

Now, let’s say you’re a couple. It is more complicated. You need to figure out if you both have annuities, long-term care insurance policies, and 401(k)s or individual retirement accounts (IRAs). You need to determine how much Social Security each of you is getting. Other factors—such as what one spouse may get in Social Security survivor benefits—must be considered as well.

To keep it simple, plan on $200,000 per year to be conservative. How much of that can be covered by your retirement income and how much from additional withdrawals? Do you have the additional assets to cover the shortfall without going broke

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Discussion

DONALD P from OH posted over 1 year ago:

Excellent. Very informative!!

COLLEEN M from NC posted over 1 year ago:

We purchased a long term care policy through Genworth twenty years ago. Oh, have times changed since then. The actuaries at numerous long term care insurance companies grossly underestimated their numbers, which got them and all consumers into a difficult corner. We thought we were covered for over $600k, and due to their rising costs, teetering on going out of business, and premiums that are ridiculous with no promise that they won't continue to rise, we've now accepted a payout little more than what we paid in. Important to keep in mind that it's an insurance policy, which means it's a transfer of risk. If investors/retirees have enough money to self-manage their risk, then better to avoid a policy. Either that, or look into a hybrid policy. They're expensive. I also think that over the past 20 years, financial gurus have also participated in underestimating how much health care is going to cost retirees.

THOMAS M from CA posted over 1 year ago:

There still is more questions than answers here. Insurance, is by definition, an economic way for the "many" to support the financial needs of the "few" - in other words, it is a way to cover a personal liability that could bankrupt you, if you have to go it alone. So, the big question is, how much do you have to pay in to cover your risk? And, if you have a significant financial base, without insurance, are you better to just pay your own way? This is not an easy analysis given the available data base, but it is clear that insurance is not a guarantee of $10 of coverage for a $1 payment. The issuing company has to pay for some significant claims over pay-ins, plus administrative cost and profits. Accordingly, the average policy holders are going to get substantial less than they pay in. You need to know where you fall in the risk pool...

BARRY J from TX posted over 1 year ago:

[#1] I counted 9-10 reasons you should expect to pay a very large premium for LTCI and [#2] still expect to face 5-6 exclusions that [#3] will severely increase your coverage. [#4] Charles got the KEY point with his LAST question -- How much will a LTCI cost? Answer: $200K a year AND [#5] you will still face 5-6 exclusions that may severely limit the coverage you NEED. If someone is [#6] "cognitively CAPABLE" enough to ACCUMULATE the recommended $5M WEALTH required to yield the $200K per year premiums LTCI requires AND they should be sufficiently "cognitively CAPABLE" enough to [#7] cognitively COMPREHEND that [#8] they should avoid LTCI and [#9] find an alternative plan. If you buy a LTCI, you really DO have one or more cognitive impairments (or really are receiving really BAD paid/family advisors). [#10] I am surprised that this Catch 22 was not on the list of signs of "cognitive impairment." And as Edith Ann (Lilly Tomlin) said, "and that's the truth."

BARRY J from TX posted over 1 year ago:

Charles and Cynthia, #1 I just can’t get the enormous cost burden a Long Term Health Insurance (LTCI) policy requires out of my mind. I find the data egregious. #2 I heavily discount Mr Gleckman's independence since he gets paid to advise LTCI industry providers for his employer. #3 AAIIers need comparative data of alternatives. #4 So I found some. Source #1 This one is not apples to apples, but it does put LTCI living costs into perspective. The article lists – by state – how much social security income + the income generated by $1M assets will buy outside the LTCI market. “How Far $1 Million Gets You in Retirement, by U.S State “ @How Far $1 Million Gets You in Retirement, by U.S State. A table with data for every US state and an accompanying US state graphic illustrate how many YEARS income consisting only of SSI benefits + $1M can be expected to last. Data is from GOBankingRates. Costs include HH expenses, HC expenses + groceries + utilities + transportation and miscellaneous expenses. State Abbrev // Annual COL After Benefits (USD) // How Long $1M + SSI Lasts (Yrs) // HI 80K 12 CA 61K 16 MA 52K 19 WA 46K 22 NJ 41K 24 CO 40K 25 NH 38K 26 UT 38K 26 OR 37K 27 RI 37K 27 AK 36K 28 CT 34K 29 NY 35K 29 ID 32K 31 NV 32K 31 AZ 31K 32 MD 31K 32 MT 32K 32 ME 30K 33 VT 30K 33 FL 29K 34 VA 29K 35 DE 28K 36 WY 25K 40 MN 25K 41 GA 23K 43 NC 23K 43 WI 22K 45 SD 21K 47 TX 21K 47 NM 21K 48 SC 21K 49 TN 20K 49 IL 20K 50 ND 19K 53 PA 19K 53 NE 18K 55 IN 17K 59 MI 17K 60 MO 16K 61 OH 16K 62 KS 15K 65 IA 15K 66 AL 15K 67 KY 14K 69 OK 14K 71 AR 13K 77 LA 13K 77 MI 11K 87 WV 11K 89 Source #2: A Sept. 11, 2022 Wall Street Journal article, “How Much Can You Spend in Retirement? Answer These Questions First,” by Dr. Shlomo Benartzi (@shlomobenartzi) a professor and co-head of the behavioral decision-making group at UCLA Anderson School of Management, frequent contributor to Journal Reports, and long-time collaborator with Nobelist Richard Thaler. https://www.wsj.com/articles/how-much-can-you-spend-in-RT-questions-to-answer-11662487918?st=fai6jdaj2wwdkyg&reflink=desktopwebshare_permalink I am looking for more. Stay tuned.

CRAIG B from WI posted over 1 year ago:

Those with moderate assets, say $500k-$1 million, generally cannot afford the $22k/year premiums in my state and which only covers 25% to maybe 50% of those assets. Much above $1 million in assets and my calculations show self-insurance is a viable option. Above $2 million assets and it's a no-brainer. I converted some aging life insurance policies into Second-To-Die policies with cash value buildup. In Wisconsin, nursing homes cannot touch life insurance proceeds as long as the beneficiaries were designated at least five years before the person enters into SNF care. We use this insurance as a legacy gift that in the absolute worst case scenario, the grandkids would get at least something of significant value. I'd rather pay $22k/year in whole life premiums that build cash value than on LTC insurance products which protect but a mere fraction of our joint assets. My estate planning attorney and accountant both agree with this analysis. At least for now...

CHARLES R from IL posted over 1 year ago:

Hi Colleen,
My parents had a Genworth LTC policy as well. They eventually took a cash settlement from the company after the premiums became unaffordable.
-Charles

Michael D from NH posted over 1 year ago:

I have an LTC policy, and I also have concerns about the difficulties my wife would encounter claiming LTC benefits for me, should that be needed. I have advised her to engage an "LTC claims assistant", who would manage the LTC claims process for her. A couple of examples are Family Solutions for Care, and Mrs LTC. This is not a recommendation for these companies - I have no experience with them - I mention them only as examples. I gather, from online reviews, that they can be expensive (annually charge the equivalent of one months benefits?). Personally, I think that may be worth it, knowing that my wife would be relieved of the aggravation and frustration during a stressful time. Apparently, the American Association for Long Term Care Insurance (AALTCI) can also direct you to a “local” LTC claims assistant organization (I suspect they get some type of referral compensation for that). Food for thought.

ROBERT A from NC posted over 1 year ago:

Too complicated and too many unknowns. I'll just pay as I go.

David B from UT posted over 1 year ago:

Nice article and thanks to all the commenters for their observations. I have an LTCI plan for both me and my spouse. Last year, the company gave me a choice between keeping my current plan with a significant increase in premiums or same premium and reduced benefits. I took the latter since I've been torturing myself over the value of any LTCI plan since I started paying into it some ten years ago. Right now, I view it as a helper since I can likely afford to self insure one of us...time will tell.

KEITH B from NV posted over 1 year ago:

I’ll just have to crawl under a tree and die.

PEDRO D from FL posted over 1 year ago:

Most people nowadays have access to a CCRC (Continuing Care Retirement Communities) that provide the services paid by Long Term Care Insurance, in a community setting which is more cost effective than home care. CCRCs can be non-profit or commercial. You do not need Long Term Care Insurance to join one. You can start as an Independent Living status in your own apartment with meals, and other facilities and services provided; when needed move to Assisted Living and in some places they may have Memory Care Units for people that develop dementia. Another article on the services provided by these communities would be helpful.

CRAIG B from WI posted over 1 year ago:

Annual premium costs vs. lifetime maximum benefits was not discussed. It would cost my wife and I around $28k/year and the policies we looked at had a maximum payout of just under $300k. So ten years of premiums and I'm fully self-insured, which is what we chose. We converted some old universal life policies into Second-to-die policies for our heirs and which cannot be touched by nursing homes, at least in Wisconsin if the beneficiary has been in place for five years. We will use our savings and SS to pay our own way and if the kids get our home and life insurance, it's a lot more than either of us received from our parents' estates. But not reviewing maximum coverage could be a huge surprise and an even larger mistake to make.

JOSEPH M from OR posted over 1 year ago:

AAII, you can do better than this.

Kurt M from TX posted over 1 year ago:

I am disappointed with the quality of this article. I was hoping for much more when I read the title. It says that the typical LT policy pays $100-150 per day ($36,500-54,700) per year and it says you should plan on a cost of $200k per year. It does not mention anything about planning for the uninsured gap. It suggests that you should plan on withdrawing 4% of savings annually and supplement with Social Security and other income during LTC if you plan to self-insure. It does not consider that I might want to dip into the capital for my last few years of life. If I am 90 years old moving into LTC with an average of 2 years to live, why would I limit myself to withdrawal of 4% of my savings? I love my kids, but not that much.

THOMAS M from IL posted over 1 year ago:

When we received notice that our Genworth premiums would increase dramatically over a three-year period, we did some research (not much out there to research) and quite a bit of spreadsheet work and decided to cancel the policies and self-insure. A couple of our key considerations were that not everyone ends up in LTC, and those of us who do may not claim anywhere near the policy maximum before we die. If we were closer to the edge of LTC affordability, we would have kept the policies in place, which were through a professional organization and just affordable enough until the increases. I got the impression that underwriting LTCI relied on a Magic 8 Ball or throwing bones, until Baby Boomers began claiming on their policies and gave the insurers a dose of reality.

JEROME K from WI posted over 1 year ago:

I would love to see a detailed breakdown of the makeup of the $200,000 annual expense estimate we are told to conservatively budget for if single for LTC costs. My brother bought a policy from one of the 10 remaining companies still writing policies years ago. As an older policy, yes rates started to increase and when they were really going to jump he surrendered part of the policy benefit to maintain an affordable premium. But he was able to keep a reasonable waiting period, and lifetime unlimited benefits. His daily policy limit is near $300/day and increases each year with inflation. I doubt anyone sells policies like this anymore. But expense wise, my brother is now in a memory care facility which provides a private room, administers medications, provide all meals and has activities to engage residents. Granted he is early to mid-dementia but his care is all-in at under $7,000 month, prescriptions run about $125/month additional and of course he has expenses for Medicare premiums and Medigap policy he pays about $400/month for. Unless I am missing something I see his entire cost, Memory care facility, meds, insurance all in under $100,000 per year, or less than half of what we are told to conservatively estimate in the article. Where is the other $100,000 of expenses? On a side note, each month his LTC policy reimburses him for the prior month memory care facility charge of $7,000. So he is just covering med, insurance and incidentals out of pocket. I guess they don't sell LTC policies like this anymore. But, the question still remains how is he able to get it all covered for under $100,000 year in gross expenses (prior to LTC reimbursement of about $84,000/year = net cost about $16,000) when the article says you need $200,000 if self insuring? I would like to see a detailed accounting of the $200,000 estimated annual costs. If self insuring it would seem a social security benefit of about $45,000 (not unreasonable) would make your gap you need to cover only about $55,000, less if you have guaranteed sources of income such as a pension or annuity.

CHARLES R from IL posted over 1 year ago:

Hi Jerome,
Costs depend on where one lives. Near the end of her life, my mother-in-law was in memory care at ~$13,000 a month. We were also spending $24,000 per month for full-time caretakers. The nursing facility we looked at for her would have required us to spend $100,000 before accepting Medicaid.
-Charles

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Understanding the Role of Long-Term Care Insurance

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