A Report on the Actuarial, Marketing, and Legal Analyses of the CLASS Program. Section Seven: Plan Options

10/14/2011

Since the passage of the ACA, numerous CLASS plan options have been considered (see the Actuarial Report on the Development of CLASS Benefit Plans, Appendix O, for the CLASS Chief Actuary’s description of several of the benefit options). Those plan options whose parameters could be well-specified were modeled using the actuarial models described above, or by the Chief Actuary of the CLASS Office, under various assumptions about adverse selection, and different economic and demographic/actuarial parameters. Although a large number of plans have been modeled, the options can be grouped into roughly three categories: (1) those that are closest to the natural reading of the CLASS statute (benefit plan option one below); (2) benefit options that vary in limited, but important ways from the baseline (benefit plan option two below); and (3) benefit designs that vary much more from the baseline, either because of the sheer number of changes or because of modifications to key features of the program (benefit plan options three through eight).

The models described above estimate premiums for plans under a set of specific assumptions. The most critical of these assumptions are the assumptions around participation rates and adverse selection. Given these assumptions, the estimated premiums are, by definition, actuarially sound. However, the question of long-term solvency of the program depends on whether the assumptions around take-up and adverse selection, as well as other model assumptions, are plausible. As neither the CLASS program nor any other program like it has existed before, there is much greater uncertainty around these assumptions than is the case around the corresponding assumptions for either private long-term care insurance or existing programs, such as Social Security and Medicare. As a consequence, less confidence can be placed in actuarial judgments about the long run solvency of the CLASS program than about corresponding assessments of private insurance or existing government programs.

Existing data sources provide an uncertain picture of what the CLASS claims experience would be. Survey data, such as those used in the ARC and Avalere models, provide information on the entire population but do not provide information on the future claims experience of the CLASS program. Private insurers’ claims data provide information for those who qualify for private insurance (either underwritten or large group) but do not provide information for the CLASS benefit, which is very different from the typical private market product and targets a more diverse population.

Table 1 presents a summary of the actuarial model estimates for four representative plan options (Options 1-4) that were either modeled for the TEP meeting in June 2011 and the federal actuaries meeting convened by the CLASS Chief Actuary or estimated over the last few months. Because of the uncertainty around parameter assumptions, a range of average premiums is presented rather than a point estimate. Below, we describe each of these benefit plans, provide estimates of premiums, discuss actuarial soundness, and summarize points made in the discussion of these plan options.

Table 1. Summary of CLASS Plans Recently Modeled
Program Features 1. 2. 3. 4a. 4b.
    Enhanced CLASS Plan Family of Options: Variation 1 Family of Options: Variation 1 Family of Options: Variation 2 Family of Options: Variation 2
Basic CLASS Modified CLASS w/Phased Enrollment1 Modified CLASS Increasing Benefits (CLASS Partnership) Enhanced CLASS Plan w/Phased En.1 Increasing Benefits (CLASS Partnership)
Enrollment Requirements:
— Age 18+ Yes Yes Yes Yes Yes Yes Yes
— Taxable Wages/Income Yes Yes Yes Yes Yes Yes Yes
— Actively Employed Yes Yes Yes Yes Yes Yes Yes
— Not in Institution Yes Yes Yes Yes Yes Yes Yes
Coverage/Benefits:
— Primary Benefit Cash Cash Cash Cash Cash Cash Cash
— Daily Benefit Amount (DBA) $50 (Average) $50 (Average) $57.5 (Average)2 $50 (Average) Varies - Up to $1503 $57.5 (Average)2 Varies - Up to $1503
— Unit of Payment Daily or Weekly Daily or Weekly Daily or Weekly Daily or Weekly Daily or Weekly Daily or Weekly Daily or Weekly
— Minimum Duration in Years NA - Lifetime NA - Lifetime NA - Lifetime NA - Lifetime 3 Years NA - Lifetime 3 Years
— Total Value TBD TBD TBD TBD $164,250 TBD $164,250
— Inflation Protection CPI-U (2.8%) CPI (2.8%) CPI (2.8%) CPI (2.8%) CPI (2.8%) CPI (2.8%) CPI (2.8%)
— Advocacy Services Yes Yes TBD Yes TBD TBD TBD
— Advice and Asst. Counseling Yes Yes TBD Yes TBD TBD TBD
Eligibility for Benefits:
— 5 Year Vesting Period Yes Yes Yes Yes Yes Yes Yes
— Work Req. Over Vesting Period At Least 3 Years 5 Years 5 Years 5 Years 5 Years 5 Years 5 Years
— Earnings Req. Over Vesting Period $1,120/ Year $12,000/ Year $12,000/ Year $12,000/ Year $12,000/ Year $12,000/ Year $12,000/ Year
— 24 Months of Prior Prem. Payment Yes Yes Yes Yes Yes Yes Yes
— Minimum Benefit Trigger 2 or 3 of 6 ADLs4 TBD TBD TBD TBD TBD TBD
— Tiered Benefit Yes Yes Yes Yes TBD Yes TBD
— Elimination Period in Days 0 0 0 0 0 0 0
— Presumptive Eligibility Yes - if in Inst.5 Yes - if in Inst.5 Yes - if in Inst.5 Yes - if in Inst.5 Yes - if in Inst.5 Yes - if in Inst.5 Yes - if in Inst.5
— Administrative Expenses 3% 3% 3% 3% 3% 3% 3%
Monthly Premium:
— Underwritten (Other Than Age) No No No No No No No
— Increasing Premium (Indexed) No Yes (2.8%) Yes (2.8%) Yes (2.8%) Yes (2.8%) Yes (2.8%) Yes (2.8%)
— Low Income Premium Yes No No No No No No
— Full Time Student Premium Yes No No No No No No
— Waiver of Premium TBD TBD TBD TBD TBD TBD TBD
— Level Premium After Age 656 After Age 656 After Age 656 After Age 656 After Age 656 After Age 656 After Age 656
1 Initial enrollment limited to group (employer) settings first; individual enrollment will begin after meeting target goals in the group market
2 Initial $50/day cash benefit for persons with 2-3 ADLs; $60/day cash benefit for persons with 4+ ADLs or cognitive impairment; cash benefit is reduced by 80% after five claim years
3 The inflation-adjusted DBA increases over a 25-year period to the final amount: years 0-10=0%; years 11-15=5%; years 16-20=10%; years 21-25=29.5%
4 Or equivalent level of cognitive impairment
5 An active enrollee is presumed to be eligible for benefits if they are a patient in a long-term care hospital, nursing facility, intermediate care facility for the mentally retarded, or an institution for mental disease and are in the process of being discharged, or are within 60 days from the date of discharge
6 Enrollees age 65 and older who have paid premiums for enrollment for 20 years and are not actively employed are exempt from premium increases
  1. BASIC CLASS PLAN

    This plan option is based on the most natural reading of the statute and incorporates the key features of the plan described in law (e.g., eligible enrollees must be at least 18 years old and actively employed; there is no underwriting required for enrollment; the primary benefit is a lifetime $50/day [on average] cash payment; before being eligible to receive a benefit, enrollees must wait five years and meet certain work and earnings requirements; etc.). Estimates for this option were produced by ARC and Avalere Health, and are described in Column 1 of Table 1 (“baseline”). Though the plan’s cash benefit would increase by the annual percentage change in the consumer price index for all urban consumers (CPI-U), the plan modeled by the actuaries assumes that the cash benefit would increase annually by a fixed percentage, 2.8 percent, which is equal to the long-range inflation forecast published in the 2011 OASDI Trustees Report. The actuaries did this because actuarial models cannot easily estimate future costs when benefits increase by an unknown and variable amount. It is important to emphasize that the 2.8 percent inflation adjuster is for actuarial modeling purposes only; for this option it is contemplated that CPI-U would be used for ongoing program operations.

    Under the set of assumptions designated as Scenario II (Expected) (see Appendix Q for Table 2) discussed at the June 2011 TEP meeting, the average premium for a $50/day lifetime benefit with a 2+ ADL trigger (or similar level of cognitive impairment) with full waiver of premium while in claim range from $235/month to $391/month. These estimates are based on a take-up assumption of 2 percent.

    In the current private long-term care insurance market, most buyers choose products that provide a substantial daily benefit (e.g., $150/day to $200/day) for three to five years of coverage--daily benefit amounts that are significantly higher than the $50/day lifetime benefit. This could be an issue for marketing CLASS to a broad population as participants in focus groups specifically mentioned that they preferred a benefit that covered more of the total cost of long-term care. Moreover, premiums for products similar to the CLASS benefit, when they are sold to an underwritten population in the private market, would cost much less than the estimated premiums above. Thus, most discussion of this Basic CLASS Plan suggested that the assumed take-up rates used to compute premiums could not be achieved and were not plausible.

  2. MODIFIED CLASS PLAN OPTION

    The benefit plan shown in Column 2 modifies three key aspects (highlighted in yellow [ROWS are "Eligibility for Benefits"/"Work Req. Over Vesting Period" and "Earnings Req. Over Vesting Period", COLS are 2 through 4b]) of the baseline CLASS benefit: first, the work requirement during the vesting period is increased from at least three of five years to five of five years; second, the earnings requirement during the vesting period is increased from $1,120 per year to $12,000 per year (the amount of earnings that SSA uses to determine whether a nonblind person is engaged in “substantial gainful activity”); and finally, the monthly premium is increased annually by a fixed percentage (modeled at 2.8 percent in this example). The latter feature is sometimes referred to as an increasing premium schedule or “indexed” premium.

    Increasing the work and earnings requirement over the vesting period significantly mitigates adverse selection, thus reducing the average premium. In addition, moving to an indexed premium instead of a constant (level) premium lowers the initial premium required to balance expected costs and expected income.

    Under the set of assumptions designated as Scenario II (Expected) discussed at the June 2011 TEP meeting, the average premium for a $50/day lifetime benefit with a 2+ ADL trigger (or similar level of cognitive impairment) with full waiver of premium while in claim declines significantly; premium estimates range from $114/month to $160/month. These estimates assume a take-up rate of 2 percent.

    The reduction in premiums achieved under this option make the take-up assumption more plausible for the Modified CLASS Plan than for the Basic CLASS Plan. However, the ultimate take-up level is still unknown. The daily benefit amount remains lower than what is prevalent in the private market, which likely increases the risk of low participation rates, especially by those who are able to purchase private policies. In addition, as the federal actuaries noted, the statutory 3 percent limit on administrative costs could make it very challenging to market the product and achieve the expected level of participation. Thus, while the assumed take-up rate used to compute premiums under this model is plausible, there is a high degree of uncertainty about the long-run solvency of this option.

  3. ENHANCED CLASS PLAN WITH PHASED ENROLLMENT

    Column 3 of Table 1 shows the key features of a benefit option described in detail in the Actuarial Report on the Development of CLASS Benefit Plans. In various documents it is referred to as the Enhanced CLASS Plan with Phased Enrollment or simply Phased Enrollment. This benefit plan builds off the Modified CLASS Plan, but differs in two important respects (highlighted in blue [ROW "Coverage/Benefits"/"Daily Benefit Amount", COLUMNS "Phased Enrollment"]). First, it uses an explicit two-tiered benefit structure for the first five years that a person is on claim:

    • an initial $50/day cash benefit for persons with 2-3 limitations in ADLs
    • an initial $60/day cash benefit for persons with 4+ limitations in ADLs or cognitive impairment.

    After the fifth year, the daily benefit amount declines by 80 percent. Beneficiaries would therefore receive $10/day and $12/day for the above two tiers, respectively. For modeling purposes, it is assumed that the amount of the cash benefit is equivalent to a lifetime $57.50 daily benefit.

    The second difference between the Modified Class Plan and the Enhanced CLASS Plan is that initial enrollment in the program would be limited to certain group settings first, such as large employers; individual enrollment would begin after “group enrollment meets a pre-set threshold,” explained in more detail by the CLASS Chief Actuary on page 10, Actuarial Report on the Development of CLASS Benefit Plans, Appendix O).

    Early modeling of the Enhanced CLASS Plan with Phased Enrollment using the ARC Long-Term Care Premium Model produced an average indexed premium that ranges from $99/month to $106/month for a $57.50/day lifetime benefit with full waiver of premium. A preliminary comparison of age-specific premiums is also shown on p. 14 of the Actuarial Report on the Development of CLASS Benefit Plans.

    As observed by the CLASS Chief Actuary, this plan achieves a greater reduction in premiums than does the Modified CLASS Benefit. The range of estimated premiums is also more similar to what is observed in the private LTC insurance market, although the daily benefit is lower in CLASS. Successfully marketing the program remains a serious challenge due to the changing benefit amounts for beneficiaries. The phased enrollment approach could substantially reduce the degree of uncertainty around the rates of enrollment by healthier individuals. By opening the program to individual subscribers only when take-up has reached a threshold level, this approach could manage the risk of adverse selection and potential insolvency.

  4. FAMILY OF OPTIONS: MODIFIED CLASS PLAN & SCHEDULED INCREASING BENEFITS

    Columns 4a and 4b of Table 1 describe a set of benefit plans referred to as the “Family of Options.” One of the options would be consistent with the CLASS statute (e.g., the Modified CLASS Plan in the case of Variation 1). The structure of the other options would vary more extensively, but would continue to incorporate similar requirements for enrollment; a primary benefit that is cash; a five year vesting period; and no underwriting except for age. The Family of Options would be structured to offer either one or two tiers of eligibility for benefits. The Family of Options would be actuarially sound, either at the individual option level or, through cross-subsidization in their entirety. Finally, one of the options within the family would be designed so that purchasers could buy a private (underwritten) insurance product to “wrap around” this option and provide a higher level of benefit.

    Column 4a shows one variation of the Family of Options that includes the Modified CLASS Plan and the Scheduled Increasing Benefits Plan discussed above. (Column 4b shows the corresponding Family of Options with the Enhanced Class Plan with Phased Enrollment paired with the increasing benefit option.) Several features of this plan (highlighted in orange [ROWS "Coverage/Benefits"/"Daily Benefit Amount" and "Minimum Duration in Years", COLUMNS "Family of Options: Variation 1: Increasing Benefits" and "Family of Options: Variation 2: Increasing Benefits"]) differ from aspects of the plans presented in Column 1 and Column 2. Specifically, the daily benefit amount increases the longer the CLASS policy is held without going into claim, rising from approximately $20/day after the vesting period to $150/day after 25 years. Also, the duration of coverage is limited to three years, although the expected payout for this benefit option could be designed in such a way as to be actuarially equivalent to that of the Modified CLASS Plan.

    Figure 1 illustrates how the basic daily benefit amount (dark blue area) increases over a 25-year period to $150/day (see Appendix R for Figure 1). This plan is sometimes referred to as the “CLASS Partnership” because the structure of the benefit provides an opportunity for private insurers to develop products that would naturally “wrap around” and supplement the underlying basic benefit (light blue area in Figure 1).

    If there is no subsidization across benefits options, then the individual plans that make up any set of Family of Options can be priced independently (although specific assumptions related to participation and adverse selection could be adjusted to take into account expected interactions). The range of estimates for an average premium at 2 percent participation assuming a 2+ ADL trigger (or similar level of cognitive impairment) with full waiver of premium is $112 per month to $148 per month. These estimates do not include the cost of a supplemental policy. The total cost of an initial combined policy, for example, for a 50 year old enrollee who could pass underwriting, is currently estimated to be $154 per month ($118 per month for the basic policy and $36 per month for the supplement).

    This model achieves a somewhat greater reduction in premiums than does the Modified CLASS Plan. Because of the choice of benefit structure, this option offers benefits more similar to those available in the private market. With private supplementation, purchasers could achieve coverage comparable to that in the private market at similar prices. The design significantly mitigates adverse selection, and premiums do not vary much even under alternative assumptions about take-up rates.3 There were varying opinions about the marketability of the Family of Options design. Some believed that offering choice would be attractive; others thought that it would be burdensome and confusing, especially since the low administrative load for marketing permitted under CLASS would limit the ability to explain the plan. The great uncertainty about the marketability of this option means that uncertainty about the long run solvency of this option is very high.

  5. TEMPORARY EXCLUSION PLAN

    This benefit option addresses adverse selection through the claims process rather than the enrollment process. Specifically, any person who meets the enrollment requirements could join CLASS, but no benefits would be paid for the first fifteen years in the program if a limitation in ADLs or cognitive impairment during this period resulted from a serious medical condition that existed at the time of enrollment. The CLASS program would provide enrollees with a list of possibly exclusionary medical conditions, but no health information would be collected at enrollment. Only when a person sought benefits would a review of medical records occur to ensure that the limitation was not the result of an underlying condition at enrollment. Existing data available to the modeling team did not provide sufficient longitudinal information about underlying conditions and subsequent disability to model this option.

    This plan would likely reduce premiums substantially because potential buyers with existing health conditions would recognize that they would not be able to claim for pre-existing conditions for fifteen years. There was concern that uncertainty about future benefit receipt would make it challenging to market this option (as purchasers could not be certain that a subsequent disability would not be tied to an underlying condition). Those who could meet an underwriting standard would likely prefer to buy a policy where there was no subsequent uncertainty. See Appendix O (Actuarial Report on the Development of CLASS Benefit Plan) for additional information on this plan option.

  6. TEMPORARY EXCLUSION PLAN WITH PHASED ENROLLMENT

    This benefit option combines the features of Temporary Exclusion with phased enrollment as described above. Because the Temporary Exclusion Plan was not modeled, this option was not modeled either. Clearly, the combination of temporary exclusion and phased enrollment would provide substantial protection for the program against actuarial risk. It might, however, be challenging to market this package. See Appendix O (Actuarial Report on the Development of CLASS Benefit Plan) for additional information on this plan option.

  7. LIMITED INITIAL BENEFIT PLAN WITH PHASED ENROLLMENT

    This benefit option is analogous to the Enhanced CLASS Plan with Phased Enrollment but has a different benefit structure. While the Enhanced CLASS Plan has a two-tiered benefit that is reduced after five years on claim, this benefit option starts with a low daily benefit amount (e.g., $5 per day or $10 per day) for a fixed period of time (e.g., 20 years) before increasing to its ultimate $50 per day value.

    This plan was not formally modeled. While the approach would certainly mitigate adverse selection to a great extent, the initial low benefit and extended period before the benefit increases are unlikely to be very attractive, especially to healthy older workers. See Appendix O (Actuarial Report on the Development of CLASS Benefit Plan) for additional information on this plan option.

  8. PRE-PAID BENEFIT PLAN

    Under extreme levels of adverse selection when 100 percent of the enrolled population is eligible for benefits, the monthly premium is essentially the amount that is required for enrollees to pre-pay their future benefit. Because the cost of a pre-paid plan is too high to make it marketable, it is not a viable benefit design. However, the exercise of determining the cost of a pre-paid plan can be instructive, since it provides us with the high end of the range of costs for a plan. The Chief Actuary of the CLASS Office estimated that a pre-paid plan would cost approximately $3,000 per month in premiums. Because enrollees are essentially pre-paying their future long-term care costs, this plan does not include a nominal premium for low income persons and full-time students. See Appendix O (Actuarial Report on the Development of CLASS Benefit Plan) for additional information on this plan option.

In addition to evaluating the formal benefit options discussed above, HHS staff also considered several features, either individually or together, to determine their impact on premiums and program dynamics. The goal was to add specific aspects that would mitigate adverse selection, lower premiums, and increase the marketability of the CLASS program. These features included adding incentive payments for delaying claim, combining CLASS with disability insurance, using variable inflation protection for the benefit instead of a fixed percentage, and possibly returning all or a portion of an enrollee’s accumulated premiums if he or she died at an early age before going on to claim. Most of the features were eventually discarded because they either did not significantly lower premiums or were deemed to be too complicated to implement.

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