Long Term Care Issues

One of the two most undersold financial products is long term care insurance. Yet it is a critical need, ranking just below disability insurance in the estimation of most financial planning agencies.



Long Term Care is already a large part of our nation's health care costs. In 2002, the last year I actively worked as a financial planner, in the state of California, approximately 2 percent of the recipients of Medi-Cal (California's version of Medicaid) were in long term care of one sort or another. Those 2 percent used approximately 47 percent of the budget. A little over fifty percent of the population is expected to need long term care of a year or longer, and this percentage has been rising and is expected to rise further. With medical science able to stabilize people to live longer lives, the probability of people living years after they reach that level of frailty rises.



The reason they use so much money is simple. Once you're in them, you tend to be in them for a long time. You may be in the hospital overnight, or for a week, and it costs a thousand dollars or two per day. Long term care may only cost $150 to $200 per day, but it costs that much every day for months, if not years or the rest of your life. So one seventh to one tenth the money per day, but for a hundred or a thousand times longer.



End of life is not the only time someone uses long term care. Approximately 40 percent of the inhabitants of long term care facilities are under the age of 65. For whatever reason, they have a disability or a condition that requires around the clock watchful care.



California licenses two types of residential long term care facility: Skilled Nursing Facilities (SNF), and Residential Care Facilities (RCF). The SNF has more medical requirements to meet, and is therefore the more expensive of the two, both to operate and to reside in. There are also Senior Daycare Centers (much like child daycare centers) and various in-home options.



Many people think that the federal medicare program covers long term care. It doesn't. The Federal Medicare program provides only a very small part of long term care. For a one time stay, it will cover the costs of a stay of up to twenty days, and pick up days 21 through 100 with a copay of about $110 per day. This means that for the first three months, you're out about nearly $9000. After that, you're on your own, as far as the federal government is concerned. So if you're talking about hospice care for a terminal patient, Medicare may or may not stretch to cover it, depending upon how close they were to death when the doctors gave up on curative treatment.



Even so-called "medi-gap" policies only cover a tiny amount of long term care. The reason why is because its costly insurance. So for the same reason you don't find cars on your supermarket shelves across from the bread, you have to go to a special policy to get significant coverage.



The median billing here in California runs about two hundred dollars per day, and it can go much higher for Skilled Nursing Facilities. This works out to $73,000 per year for as long as it lasts. Not a big deal if you're a multi-millionaire, but if all you've managed to save is $150,000, two years and it is gone. So for most folks, self insurance just doesn't cut it.



Now there is one program that will cover Long Term Care - state-run Medicaid (called Medi-Cal here in California). Unfortunately, in order to get coverage, you've got to pay yourself down into practical poverty first. Nor are you allowed to give assets away or put them into trusts. The various states have "lookback" periods ranging from thirty months to five years prior to your application for benefits. Anything given away in that period is subject to asset recovery - in other words, the person you gave it to is going to have to cough it back up, even if it was already spent.



Let me give you an idea of what poverty looks like. Many people make a big deal of the "community spouse" regulations, that permit the keeping of $2000 per month and eighty-some thousand dollars of liquid assets, as well as a life interest for a married couple in one piece of real estate. First concern, let's say hubby goes in to care while wife stays out. Can wife live on $2000 per month? Maybe, if she doesn't have any huge medical problems. But if she's not drawing a pension herself, most of income is likely to be attached for hubby's care, and it doesn't take long to draw down $80,000 in assets when that's all you've got to live on. Plus medicare is not the greatest care in the world, so there is always the need to purchase side items. Also, these places are not high margin. They are not making money hand over fist, and they make a truly rotten investment. Many of them go bankrupt, and the ones that survive and provide good care tend to be in lower cost areas. So if you live in Los Angeles, your spouse could well be in a home in Barstow because that's the only place you could find that had a spare bed. Far away means visitors are rare, and visitors being common is one of the best predictors of how good the treatment will be, and how well they will respond.



Finally, this is just not what happens, statistically speaking. What usually happens is when one spouse gets sick, the healthy spouse takes care of them as well as they can for as long as they can, either with or without assistance. Then the first spouse is gone, and at some later point in time the second spouse becomes ill, and that's when long term care happens. Less that ten percent of the people in long term care have living spouses, and this includes counting the situations where both spouses are in long term care. (this .pdf document has a decent explanation)



Many attorneys will advertise structured trusts and other weird schemes to get you to qualify for Medicaid care while still retaining your assets. Spend a couple of thousand dollars on a one time basis, the pitch goes, and you'll be able to shelter your assets from the state. Unfortunately for this, the states narrow the gaps in the regulations every year, because they want to catch cheaters and people doing precisely this. A good general rule is that if you own the asset, if you control it, or if it can be used for your benefit, the state will force it to be spent or attach it in order to provide your care. Medicaid was meant for the poverty stricken, not to provide medical care for the wealthy. So it's a little change here for $1000, another little change there for $1000, and pretty soon you've spent all your money on the attorney. Best way to nip this in the bud is to ask said attorney point blank: "So you're going to write out a commitment to pay for my care yourself if this doesn't work, right?" Needless to say, this is not going to happen.



Furthermore, assuming it does work out and you manage to retain assets while the state pays for your care. Well then, I say, "Congratulations! You've won WELFARE!", in my best Monty Hall voice, and you can imagine the curtains coming back on "Let's Make A Deal" to reveal their gorgeous hostess, smiling from ear to ear while holding the lead on an old sway-backed donkey.



The medicaid package is not a lavish one. Remember I told you that nursing homes average billing is about $200 per day, and that they go bankrupt a lot? Well here in California, the state will pay about $110 per day for medicaid patients in long term care. You should be able to imagine the implications from there. I've visited a couple of medicaid wings, and the "Eeewww!" factor is significant. It starts with the smell, which hits even people like me who don't have much of a sense of smell, and goes downhill from there.



The final option to avoid this is purchase Long Term Care Insurance. There are two major types, with one subtype available for people who are lucky enough to live in one of four states. There is non-tax-qualified, tax qualified, and for those lucky enough to live in California, Conneticut, New York, and Indiana, there is a superior brand of tax-qualified, Partnership.



Part II on "Long Term Care Insurance: Non-Tax-Qualified versus Tax-Qualified, and Partnership" is here

Part III on "Shopping for Long Term Care Insurance - Who Should and Shouldn't Buy, and Policy Characteristics" is here.

Caveat Emptor

UPDATED here