A Report on the Actuarial, Marketing, and Legal Analyses of the CLASS Program. Introduction

10/14/2011

The mandated benefit triggers for the Community Living Assistance Services and Support (CLASS) Program legislation are clearly intended to include people with cognitive impairment. One of the two specified benefit triggers explicitly identifies as eligible an individual who “requires substantial supervision to protect the individual from threats to health and safety due to substantial cognitive impairment.” In addition, some people with cognitive impairment will be eligible based on the other specified benefit trigger, inability to perform at least 2 or 3 activities of daily living (ADLs) without substantial assistance from another person. Over time, for example, virtually all people who have progressive neurological diseases and conditions that cause cognitive impairment, e.g., people with Alzheimer’s disease, Huntington’s disease, and Amyotrophic Lateral Sclerosis (ALS), will need assistance from another person with all 6 ADLs listed in the legislation, unless they die first from another cause.

The CLASS Program benefit trigger that identifies individuals as eligible based on need for supervision to protect them from threats to their health and safety was probably intended by Congress to target people with cognitive impairment due to Alzheimer’s disease and other dementias that mainly affect older people. Certainly, however, some adults of all ages who have cognitive impairment due to other diseases and conditions, e.g., people with mental retardation, other intellectual disabilities, severe mental illness, traumatic brain injury and acquired immunodeficiency syndrome, could also be eligible based on this trigger. Likewise, some adults with cognitive impairment due to any of these diseases and conditions could be eligible based on inability to perform ADLs. Adults with cognitive impairment due to diseases and conditions that preclude them from working throughout their adult lives may not be able to enroll in the CLASS Program because of the work and earned income requirements for enrollment. Nevertheless, in developing regulations to operationalize and implement the CLASS Program benefit triggers, it is important to consider the relevance and impact of proposed regulations for adults with cognitive impairment due to diseases and conditions beyond the targeted group of older people with Alzheimer’s and other dementias.

There is currently a very large and growing body of research on cognitive impairment, measurement of cognitive impairment, and the need for and use of long-term services and supports by people with cognitive impairment. This research, as well as clinical and practice-based experience in determining eligibility for long-term services and supports, suggests various approaches for operationalizing and implementing the mandated CLASS Program benefit triggers as they pertain to people with cognitive impairment. To focus the discussion of findings from these sources, this paper begins by identifying the concepts and wording in the CLASS Program benefit triggers that are particularly important for people with cognitive impairment. The paper then compares the wording and concepts in the CLASS Program benefit triggers with the wording and concepts in the required benefit triggers for qualified long term care insurance policies under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Federal Long-Term Care Insurance Program and summarizes the limited amount of published information about individuals with cognitive impairment who receive long-term services and supports funded at least in part through these policies. Later sections of the paper discuss the relationship of cognitive impairment and need for and use of long-term services and supports and approaches for operationalizing and measuring the relevant concepts in the CLASS Program benefit triggers based on need for supervision to protect an individual from threats to health and safety and inability to perform ADLs. The CLASS Program legislation includes a third, unspecified benefit trigger, and the last section of the paper suggests options the Secretary might consider for this benefit trigger. Throughout the paper, recommendations for the Secretary are noted in text boxes.

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