Tara O'Neill Hayes, Sara Kurtovic February 18,
2020
Executive Summary
·
By 2030, 24 million
Americans will need long-term care (LTC), nearly double the current need, but
the supply of caregivers is shrinking rapidly relative to the demand.
·
The amount and
complexity of care needed per person will also increase, as a result of the
increasing number of chronic conditions per person.
·
An estimated $849
billion worth of LTC was provided in 2018; this study estimates that in 2030,
LTC costs will more than double and may reach as high as $2.5 trillion, yet
plans to pay for this care are woefully insufficient and primarily rely on the
continued provision of unpaid care by family members.
Introduction
An estimated 14 million people in the United
States currently need long-term support services.[1] According to the Department of
Health and Human Services (HHS), 7 in 10 seniors reaching 65
years old are now expected to need some type of long-term care (LTC) before the
end of their life. By 2030, it is estimated that 24 million Americans will need
LTC.[2]
LTC is not the long-term provision of medical
care. Rather, LTC typically refers to assistance with activities of daily living (ADLs),
which are routine activities people do every day to live. There are six basic
ADLs: eating, bathing, getting dressed, toileting, transferring (moving from
one place to another, such as from bed to chair), and continence. The ease with
which individuals can perform these ADLs helps determine what type of LTC they
may need. Individuals may need help with these activities from birth or after a
physical or mental health decline, and they may need these services for the
remainder of their life or only temporarily, such as while recovering from a
medical incident. Of course, an individual may need long-term help with many
other types of activities, too, such as meal preparation, bill payment, and
household chores (sometimes referred to as instrumental activities of daily
living, or IADLs); while these types of services are typically not considered
health care services, a caregiver may assist with these activities, as well.
As the population ages, the need for care and
the cost of providing that care will increase significantly. Men are likely to
need LTC for an average of 2.2 years and women for 3.7 years, according to
HHS’s Administration on Aging.[3] Unfortunately, private insurance for
long-term care is hard to find, public insurance programs offer limited
coverage or have restricted eligibility, and most people have not saved
sufficiently for the cost of such care.
The Cost of Long-Term Care
The cost of LTC in 2018 reached an estimated
$849 billion, according to data from the Kaiser Family
Foundation (KFF) and the American Association of Retired
Persons (AARP), when accounting for both paid services as well as the value of unpaid
care, up from an estimated $725 billion in
2017.[4] Changing demographics and increasing
rates of chronic conditions will drive up these costs over the next few
decades. Health Affairs projects
that 54 percent of seniors will not have sufficient financial resources to pay
for LTC, even though many people pay nothing for their care, at least at the
outset. Unpaid caregivers, typically a family member, provide an estimated 80
percent of care to individuals still living at home.[5] AARP estimated in 2014 that 43.5
million people had served as an unpaid caregiver at some point in the year.[6]
Supply and demand for LTC are moving in opposite
directions. Demand for long-term care will grow as the population ages.
By 2050,
the number of people aged 85 or older will triple and the number of people
using paid LTC services in any setting will nearly double from 14 million in
2018 to 27 million. The amount and complexity of care for each person will
likely increase as well because of the increasing number
of chronic conditions per individual.[7] People with three to four chronic
conditions are three times as likely to need help with ADLs or IADLs as people
with just one or two chronic conditions.[8] The increasing demand will strain
the supply of caregivers due to the caregiver demographic relatively shrinking:
The population aged 64 and younger will only increase by 12 percent during this
period.[9] The number of people aged 45-64 for
each person aged 80 or older will be reduced to three by 2050 (down from a
ratio of 7:1 currently).[10]
More than one-third of seniors will spend time
in a nursing home.[11] According to Genworth’s 2019 Cost
of Care Survey, the median cost for a private room is now over $100,000 per
year.[12] Four out of 10 seniors will opt for
paid care at home with the median annual cost for a home health aide working 40
hours per week nearing $50,000 per year.
Median Costs of Long-Term Care in 2019
|
Home Health Aide
|
Homemaker Services
|
Adult Day Health Care
|
Assisted Living Facility
|
Nursing Home Care
|
|
$47,836 (based on 40 hours/week)
|
$51,480 (based on 44 hours/week)
|
$19,500
|
$48,612
|
$90,156 for semi-private room;
$102,204 for private room
|
Data from Altarum show that prices for nursing
home care increased an average of 2.4 percent annually from 2012-2019, for a
cumulative increase of 20.7 percent during that time; home health care prices
increased 11.1 percent. According to National Health
Expenditure projections, home health care spending will increase 83
percent from 2018 to 2027. Expenditures for nursing homes and other continuing
care retirement communities are projected to increase 58 percent during that
period.
Calculating the “Cost” of Unpaid Care
Spending would be significantly higher without
the billions of
hours of unpaid care provided each year. Estimates suggest that
between 26 and 40 million individuals provide unpaid care annually,
and that, on average, each provides between 16 and 24 hours of care per week.[13] In a study using the Panel Study of
Income Dynamics (PSID), directed by faculty at the University
of Michigan, researchers estimated that between 2015 and 2017, 26 million
family caregivers provided an average of 17.8 hours of care per week and that
the average hourly wage of caregivers was $28. An estimated 70 percent of
caregivers are between the ages of 50-64; according to the Bureau of Labor
Statistics, the average wage for people in this age bracket is $25 per
hour. [14], [15]
This unpaid work is likely to impact these
individuals’ ability to work in a paid position full-time, which may lead to
additional financial burdens for the family, possibly even after an individual
is no longer providing care. Data in the PSID show that 25 percent of working
caregivers missed work in the past year because someone else was ill. A 2015
estimate found that a caregiver’s lost earnings over their lifetime averaged
more than $300,000.[16]
Estimating Current Total Costs
This study estimates that the true cost of LTC
in 2018—based on the cost of living in a nursing home or assisted living
facility, receiving home health care, or regularly spending time at an adult
day care center, as well as the “cost” of unpaid care—totaled between $758
billion and $1.4 trillion. This estimate is based on Genworth’s annual Cost of Care
Survey, utilization rates for various types of LTC based on data
from AARP and
the Centers for
Disease Control and Prevention, and varying values placed on the
time of unpaid care caregivers. This estimate does not include the costs of the
various Medicaid waiver programs discussed below.
The cost of paid care is estimated to have
totaled roughly $293 billion. This assumes the following: of the nearly 1.4
million individuals estimated to live in a nursing home, half had a private
room and 70 percent were there for a full year; an estimated 821,000
individuals resided in an assisted living facility with 70 percent there for
the entire year; 290,000 people used adult day care services for 40 hours per
week; and 4.5 million people received 30 hours of care from a home health aide
each week.
The value of unpaid care provided by tens of
millions of people in 2018 is estimated between $471 billion and $1.1 trillion.
AARP estimates the value of unpaid care at $470 billion in 2017 based on 41
million people providing 16 hours of care per week and an hourly value of that
work of $13.81. But this may significantly underestimate the value of unpaid
care given other estimates of hours of care provided and the expected wage of
the average caregiver.[17] Based on the PSID figures
referenced above, the annual value of caregivers’ time is estimated at $673.8
billion.[18] Using an hourly rate of $22 per
hour and the high-end of the estimates for hours of care provided—24 hours per
week— by 41 million individuals places the value of such care at $1.1 trillion.[19]
Estimating Future Costs
In 2030, an estimated 18.7 million individuals
will need some type of paid LTC while millions more will likely receive unpaid
care based on projected population growth. Given historical cost growth tracked
by Genworth and Altarum, the total value of LTC provided in 2030 could reach
between $1.3 trillion and $2.5 trillion.[20]
It is estimated that the cost of paid care will
be roughly $414 billion. This estimate assumes the same utilization rates
described above. The cost of nursing home care is assumed to increase an
average of 2.8 percent per year, for a cumulative increase of 36.4 percent by
2030; assisted living costs will increase 46.9 percent; adult day care costs
will increase 45.7 percent; home health aide costs will increase 20 percent.
The value of unpaid care, increasing at a rate
equal to the Social Security Trustees’ estimated future increases in the
national average wage
index—roughly 4 percent per year—will reach between $880.9 billion
and $2.1 trillion.
Given the likelihood that LTC utilization rates
will increase as the rate of people with multiple chronic conditions increases,
this estimate likely represents a lower bound.
Household Financial Burden
Most of the financial burden will fall on
middle-income seniors—who are too wealthy to qualify for Medicaid but not
wealthy enough to comfortably afford their expenses—and taxpayers. By 2029
there will be a projected 14.4 million
middle-income seniors, 60 percent of whom will have mobility limitations
and 20 percent of whom will have high health care and functional needs.
Medicare beneficiaries who live in LTC
facilities spend significantly more out-of-pocket (OOP) than the average
beneficiary, particularly if they do not receive Medicaid coverage: $41,782
spent OOP on LTC for beneficiaries living in a LTC facility without Medicaid
and $19,632 for those with Medicaid coverage versus $1,014 OOP for a temporary
stay in a LTC facility.[21] According to a study by Vanguard
Research and Mercer Health and Benefits, 48 percent of people now 65 and older
are expected to incur no LTC costs while 15 percent of individuals will likely
incur more than $250,000 in costs.[22]
The cost of LTC has a serious impact on the
effective wealth of households, as well. The average total household wealth in
homes with individuals with no limitations on their ADLs is nearly twice that
of households where an individual has two or more ADL limitations, according to
one study.[23] Interestingly, this difference in
financial wellbeing begins well before retirement and is not simply a result of
having high-cost needs and having to expend one’s wealth: the Urban Institute
found the “median household income in 1991 among adults ages 51 to 59 who did
not report any ADL limitations in 2010 (when they were ages 70 to 78) exceeded
by nearly 50 percent the median income received by their counterparts who
reported two or more ADL limitations in 2010” but also had no ADL limitations
in their 50s.[24] This finding suggests low-income
individuals are more likely to develop ADL limitations; as a result, those most
likely to need LTC in the future are unlikely to be able to save enough to
finance their future LTC needs.
These LTC costs are, of course, in addition to
the primary health care costs individuals will likely have. Fidelity estimates that
a couple reaching age 65 in 2019 will need approximately $285,000 in savings to
cover health care costs in retirement, and that figure assumes both individuals
have Medicare coverage.
Paying for Long-Term Care
Despite not being medical care, most LTC is paid
for through our public health insurance programs, Medicare and Medicaid, with
Medicaid being the largest financier of LTC benefits. Medicare’s coverage of
LTC services is limited to certain types of care in certain circumstances. A
small number of employers offer LTC insurance to their employees and a handful
of private insurance companies offer plans for individuals to purchase.
The fact that non-medical care is primarily
financed through our health insurance programs reflects the country’s
long-standing failure to address the need for such care. The one time Congress
passed a law to establish a public LTC insurance option—the CLASS Act included
in the Affordable Care Act in 2010—it ultimately had to be repealed due to an
inability to find any option to make the program fiscally sustainable and
affordable to potential buyers. Thus, to date, the following options are the
few choices available to finance LTC besides paying wholly out-of-pocket.
Medicare Coverage
Fee-for-Service (FFS) Medicare Part A only
provides facility-based LTC coverage for skilled nursing services and various
types of therapy if a beneficiary 1) has had a hospital admission with an
inpatient stay of at least three days, 2) is admitted to a Medicare-certified
skilled nursing facility (SNF) within 30 days of that hospital admission, and
3) a doctor prescribes such services as necessary to treat an illness or
injury. Medicare Part A also covers the cost of services provided in a
long-term care hospital, but these hospitals are for patients with multiple
serious health conditions who need long-term medical care in a hospital; they
do not provide individuals with the type of custodial care that is typically
referred to as LTC.
A SNF is a special facility or part of a
hospital that provides medically necessary professional services from a variety
of specialists to provide around-the-clock assistance with health care
and ADLs. The services covered by Medicare, in addition to the cost of the
room and meals at the facility, includes skilled nursing care; physical and
occupational therapy; medical social services; medical supplies and
medications; ambulance transportation; dietary counseling; and, sometimes, SNF-level
care provided at a critical access
hospital.[25] Medicare will continue to cover
these services, subject to the limits discussed below, so long as they remain
medically necessary and a physician reorders them after 60 days.
If the previously listed conditions are met,
Medicare will pay 100 percent of costs for the first 20 days in the facility.
Between days 21 through 100, Medicare requires the beneficiary to pay a daily copayment,
which is $176 in 2020.[26] By day 100, the beneficiary will
have incurred costs of $14,080. Medicare provides no coverage after 100 days;
the beneficiary will be responsible for all remaining costs at this point,
unless they have supplemental insurance, such as Medigap.[27]
|
Length of Stay
|
What You Pay (2020)
|
|
Days 1-20
|
$0
|
|
Days 21-100
|
$176 per day
|
|
Days 100+
|
All Costs
|
While Medicare covers medical services provided
to someone living in a nursing home or assisted living facility, Medicare does
not cover non-skilled assistance with ADLs nor any of the costs of staying in
such a facility.
Medicare Parts A and B also cover some home
health services, hospice, and respite care.[28] In order to qualify for home health
care coverage, a doctor must develop a treatment plan for the beneficiary and
certify that the patient is homebound and in need of physical or occupational
therapy or speech-language pathology services. Home health care coverage
includes part-time or intermittent skilled nursing care or home health
services; physical or occupational therapy; speech-language pathology services;
and medical social services. FFS Medicare does not cover meal delivery,
custodial care, or 24-hour home health care.
Medicare Advantage plans also cover some LTC
services, though, their ability to provide such benefits is relatively new: In
2018, the Centers for Medicare and Medicaid Services (CMS) amended the rules
governing allowable supplemental benefits to no longer ban coverage of
long-term services and supports, such as adult day care, in-home assistance,
and support for family caregivers.[29] The CHRONIC Care Act,
passed in 2018 as part of the Bipartisan Budget Act, also allows for increased
use of supplemental benefits, specifically for enrollees with multiple chronic
conditions. In 2021, under the proposed rule, plans will be able to offer more
benefits tailored to enrollees’ specific needs that are not “primarily
health related,” such as structural home modifications, general supports for
living (which may include subsidies for assisted living communities), and
services supporting self-direction (such as financial literacy classes).[30]
Medicaid
Medicaid pays for the largest share of LTC
costs, as the benefits it covers are much more comprehensive than those covered
by Medicare. To qualify for Medicaid, an individual must meet income and
certain other requirements, which vary from state to state. If the individual
qualifies, Medicaid covers LTC services in nursing homes, intermediate care
facilities, as well as at home, including custodial (non-medical) care provided
by non-licensed caregivers.
More than one-fifth of Medicaid’s benefit
payments were for LTC provided to FFS Medicaid beneficiaries in 2016; it is
unclear what share of the capitated payments for managed care went to LTC
services.[31] According to the CMS Medicaid
Actuarial Report from 2017, Medicaid spending on LTC is expected to grow 3.2
percent annually, on average, from 2017 through 2026, when it will reach $158.7
billion.[32] KFF, however, estimates that in
2018, Medicaid spent $196.9 billion on LTC.[33] Medicaid covered 36.8 percent of
all freestanding home health care costs and 30.7 percent of all nursing home
care (supporting 62 percent of nursing home residents) in addition to 56.7
percent of other health, personal, and residential care in 2016.[34]
There are several programs within Medicaid
specifically designed for individuals in need of LTC, each aiming to increase
individuals’ ability to live at home where they are more comfortable rather
than in an institution. A survey conducted by AARP found
that 90 percent of seniors prefer staying in their homes as they age versus
going to an assisted-living facility. Data suggest these programs are
influencing program spending: Expenditures for home- and community-based care
have been growing more quickly than expenditures for institutional-based care
in recent years.[35]
PACE Programs
The Programs of
All-Inclusive Care for the Elderly (PACE) covers individuals
eligible for either Medicare or Medicaid who are at least 55 years old and in
need of nursing-home level care but able to live safely in the community with
help from PACE. Of course, the patient also must live within the service area
of a PACE provider. PACE providers offer patients a team of care providers that
may see patients in their home, at a PACE center, or elsewhere in the
community. PACE offers patients comprehensive medical care and prescription
drug coverage, as well as adult day care and other social services, such as
respite care, caregiver training, nutritional counseling, and transportation to
appointments. A patient’s cost depends on the individual’s income level: If the
patient qualifies for Medicaid, he or she owes nothing other than what might
otherwise be required for a minimal monthly Medicaid premium.[36] If a beneficiary does not qualify
for Medicaid, the beneficiary must pay a monthly premium to cover the long-term
care costs and for their Part D prescription drug coverage; no deductibles or
cost-sharing are charged.
HCBS Waivers
Section 1915 of the Medicaid law, adopted in
1983, allows states to seek waivers from the standard Medicaid rules to develop
programs that allow beneficiaries to receive home and
community-based services (HCBS) for the provision of their
long-term care. HCBS waivers also allow states to expand financial eligibility
while simultaneously capping enrollment (unlike traditional Medicaid rules
which require states to cover all individuals who qualify). Most of the
services offered through an HCBS waiver are benefits the states are choosing to
offer beyond the program’s mandatory benefits. Common service offerings include
additional therapy services, meal preparation, and housekeeping; some states
also cover nutrition counseling and aid at the beneficiary’s work site.[37] In 2018, roughly 4.3 million people
received care through an HCBS waiver program at a cost of $92 billion; another
707,000 individuals were on state waiting lists, as of 2017.[38], [39]
Money Follows the Person Demonstration
With similar goals, Congress created the Money Follows
the Person (MFP) demonstration in 2005. This program provides
states with grants to transition individuals out of nursing homes and other
long-term care institutions and back into their homes or other community-based
residences. It also offers greater flexibility in how existing funds may be
used to provide LTC in those settings. To date, more than 90,000 individuals
have benefitted from the MFP program, a majority of whom had moderate to high
level of care needs and moderate to severe cognitive impairment. Participants
of the program have tended to be younger, male, and disproportionately
minorities.
A report from
HHS in 2017 found that the program had led to savings of at least 23 percent,
or more than $21,000 per individual, in the first year following their
transition; individuals with intellectual disabilities who transitioned out of
institutional care had reduced spending of 30 percent, or more than $48,000, in
the first year. Total first-year post-transition savings reached $978 million
by 2013. Quality of care evaluations have also found that individuals
transitioning through the MFP program are less likely to be readmitted to
institutional care, possibly because of the program’s ability to help people
stay connected to medical and social services. Quality of life surveys also
indicate that individuals participating in MFP have greater satisfaction across
seven different categories, and that improved quality of life continued through
two years post-transition.
Other Coverage Options
Less than 1 percent of employers offered LTC
insurance to their employees in 2016, and only 5 to 7 percent of employees
enrolled.[40] If there is LTC coverage included
in traditional employer-sponsored health insurance plans, it is typically only
for skilled care provided for a limited time.
Individuals may purchase private LTC insurance
plans, though there are limited choices. As of 2014, there were fewer than 15
stand-alone LTC insurance options, down from 125 in 2000.[41] The premium for these types of
insurance plans are typically based on the enrollee’s health status, and
insurers may deny coverage if the applicant is not healthy enough. In 2019,
more than half of applicants aged 75 or older and 44 percent of applicants aged
70-74 were denied coverage.[42]
The following average premium amounts offer an
initial pool of lifetime benefits equal to $164,000; when the policyholder
reaches age 85, the value of benefits equals $386,500 each.
|
Annual Premium
|
|||
|
Single Male, Age 55
|
$2,050
|
Single Male, Age 60
|
$1,925
|
|
Single Female, Age 55
|
$2,700
|
Single Female, Age 60
|
$3,050
|
|
Couple, Age 55
|
$3,050
|
Couple, Age 60
|
$3,400
|
Source:
2019 American Association for LTC Insurance Annual Price Index Survey
Federal employees, including retirees, and
certain relatives are eligible to enroll in the Federal Long
Term Care Insurance Program. This program offers comprehensive LTC
insurance, including room and board at nursing homes and assisted living
facilities and home care services. Roughly 268,000 people are currently
enrolled.[43] Premiums for a 65-year-old range
from $131 per month to $1,260 per month, and lifetime benefits range from
$109,500 to $821,250, depending on daily benefit amounts, length of coverage,
and inflation protection method.[44] A 90-day waiting period is required
before coverage begins (except for hospice care); once coverage begins and a
patient is receiving benefits, they are no longer required to pay premiums. If
the individual recovers, has not exhausted their lifetime benefits limit, and
wishes to maintain coverage, the enrollee must resume paying premiums. Patients
starting coverage must also have a licensed health care professional certify
within the past year that the patient is unable to perform at least two ADLs
for an expected period of at least 90 days or that the patient requires
substantial supervision due to severe cognitive impairment. The health care
provider must then establish an approved care plan.
Workforce Problems
Aside from the financing problem, there is also
a worsening shortage of LTC workers who can meet the needs of older adults. The
LTC workforce is made up of licensed professionals and unlicensed direct care
workers who provide care in nursing homes, assisted-living facilities, and
other residential and community-based care settings as well as private in-home
care. Much of the emerging crisis is driven by low wages—averaging $12.18 an hour as of
May 2018.
Turnover across the LTC sector is estimated to
range from 45 to 66 percent.
It is reported that one in four nursing
assistants and one in five home health aides are actively looking for another
job. One in two workers
leave jobs in home care within 12 months. Annual certified
nursing assistant turnover is at 97 percent, registered nurse turnover is at
52.5 percent, and overall staff turnover is at 69 percent. Between 2016 and 2026,
more home care jobs are projected to be added than any other occupation.
One study has
calculated that maintaining the current ratio of paid long-term care personnel
to those over 85 would require the long-term care workforce to grow by 2
percent per year from now until 2050, and ultimately adding more than four
million new long-term care personnel.
The instability in
the LTC workforce has caused myriad problems, including: service-access
challenges for consumers; lower safety and quality of care and life; higher
provider costs due to the need for constant hiring and training of new staff;
and higher workloads for nurses and other staff. The result has been inadequate
supervision, more accidents, and higher injury rates.
The workforce problems and resulting quality
challenges may be a significant reason that family members provide so much LTC.
Of course, the opposite dynamic may also be at work: Because individuals have
found that they can provide the care themselves, they don’t see much value in
paying someone else to do it, depressing demand and wages.
Conclusion
The
LTC crisis faced by the United States is significant and rapidly worsening.
Millions of people—from those needing care to their families and employers—will
experience hardship, and the burden on taxpayers will only rise. Yet most are
unprepared. The reality of the ballooning costs of LTC calls for a sober
evaluation of the facts and clear-eyed financial planning and policy
formulation.
[1] https://www.aarp.org/content/dam/aarp/ppi/2019/08/long-term-services-and-supports.doi.10.26419-2Fppi.00079.001.pdf
[4] https://bipartisanpolicy.org/wp-content/uploads/2019/03/BPC-Health-Financing-Long-Term-Services-and-Supports.pdf
[7] https://cvshealth.com/thought-leadership/by-the-numbers-the-impact-of-chronic-disease-on-aging-americans
[9] https://www.aarp.org/content/dam/aarp/ppi/2018/08/across-the-states-profiles-of-long-term-services-and-supports-full-report.pdf
[10] https://www.aarp.org/content/dam/aarp/ppi/2018/08/across-the-states-profiles-of-long-term-services-and-supports-full-report.pdf
[11] https://www.kff.org/medicare/issue-brief/how-much-do-medicare-beneficiaries-spend-out-of-pocket-on-health-care/
[13] https://www.aarp.org/content/dam/aarp/ppi/2019/11/valuing-the-invaluable-2019-update-charting-a-path-forward.doi.10.26419-2Fppi.00082.001.pdf , https://www.caregiver.org/caregiver-statistics-demographics
[17] https://www.aarp.org/content/dam/aarp/ppi/2019/11/valuing-the-invaluable-2019-update-charting-a-path-forward.doi.10.26419-2Fppi.00082.001.pdf
[18] Freedman,
Vicki A., Jennifer Wolff. Forthcoming. The Changing Landscape of Family
Caregiving in the United States. In Sawhill, Isabelle and Betsey
Stevenson (Eds). Caregiving Leave. Washington DC: AEI/Brookings,
2020.
[19] $22
per hour is the weighted average wage of individuals based on age and average
wage for individuals of that age. https://www.bls.gov/oes/current/oes_nat.htm#00-0000
[20] Estimates
regarding the percentage of people needing LTC and the distribution of persons
in various age groups using various types of services are based on this AARP report and
this CDC report.
Projected growth rates for the costs of care are based on the Genworth’s
annual Cost of Care
Surveys and Altarum’s Health Sector
Economic Indicators Briefs.
[21] https://www.kff.org/medicare/issue-brief/how-much-do-medicare-beneficiaries-spend-out-of-pocket-on-health-care/
[22] https://pressroom.vanguard.com/nonindexed/Research-Planning-for-healthcare-costs-in-retirement_061918.pdf
[23] https://www.urban.org/sites/default/files/publication/24456/904599-Income-and-Wealth-of-Older-Adults-Needing-Long-Term-Services-and-Supports.PDF
[24] https://www.urban.org/sites/default/files/publication/24456/904599-Income-and-Wealth-of-Older-Adults-Needing-Long-Term-Services-and-Supports.PDF
[29] https://www.aarp.org/content/dam/aarp/ppi/2018/10/reinterpretation-of-primarily-health-related-for-supplemental-benefits.pdf
[31] https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2017.pdf
[32] https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2017.pdf (pg.
10)
[33] https://www.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/
[35] https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2017.pdf
[36] States
may charge Medicaid enrollees a small monthly premium, not to exceed 2 percent
of an individual’s income; no additional premium would be owed for the
long-term care benefits.
[37] https://www.kff.org/report-section/key-state-policy-choices-about-medicaid-home-and-community-based-services-issue-brief/
[38] https://www.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/
[39] https://www.kff.org/medicaid/issue-brief/key-questions-about-medicaid-home-and-community-based-services-waiver-waiting-lists/
https://www.americanactionforum.org/research/the-ballooning-costs-of-long-term-care/#ixzz6EQX9gzjt
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