Unless you maintain your health and mobility for the rest of your life, chances are you’ll eventually need some form of long-term care. Government estimates suggest that as many as 70% of older adults develop a need for long-term services and support before they die. Yet most adults haven’t taken any steps to prepare for it, according to a survey by the Kaiser Family Foundation.
The numbers are daunting. The average cost of a private room in a nursing home exceeds $100,000 a year, according to the Genworth Cost of Care survey. The cost of a home health aide averages more than $60,000. Medicare doesn’t cover long-term-care expenses, so many Americans are on their own to fund their care. The options include traditional long-term-care insurance (purchased on the private market or as an employee benefit), a hybrid insurance policy or annuity with a long-term-care component, or self-funding care from your savings — or, if you deplete your assets, you may qualify for Medicaid.
If you can’t adequately fund long-term-care expenses, you may have to rely on your family for care, which could disrupt their lives and jeopardize their own financial security. Here, we’ll walk you through ways that you can cover the costs.
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Traditional insurance
The LTC insurance market is suitable for a small percentage of consumers, says Jesse Slome, director of the American Association for Long-Term Care Insurance (AALTCI). And insurance trade association LIMRA estimates that just 3% to 4% of people 50 and older have long-term-care insurance. “First, you have to apply at an age where you can get the insurance,” says Slome. “You have to be in good health, and you have to have the financial wherewithal.” You also, he says, have to be a person who plans ahead.
The cost of long-term care insurance
A major deterrent is cost. Stand-alone long-term-care insurance is expensive and difficult to get on the open market. Poor pricing decisions and inaccurate forecasts of policyholder dropout rates, longevity, and need for care whittled down the number of insurers that offer new long-term-care insurance policies. According to the AALTCI, just six companies now sell stand-alone policies: Mutual of Omaha, Thrivent, National Guardian Life, New York Life, Northwestern and Bankers Life.
If you want to buy LTC insurance, getting a policy when you’re in your forties or early fifties can keep the premium down. The older you are when you apply, the more you’ll pay for premiums, and the more likely you won’t be able to buy insurance at all. An estimated 13.9% of people in their fifties are denied LTC insurance, compared with nearly 45% of people in their seventies, according to the AALTCI. An insurance provider may require medical records and a home interview to assess your health.
The AALTCI estimates that a 55-year-old man can expect to pay about $950 a year and a same-aged woman about $1,500 annually for an initial policy benefit (the pot of money the policy will pay out) worth $165,000. A man who purchases a policy of the same value at age 65 can expect to pay $1,700 yearly, and a 65-year-old woman would pay $2,700. For a larger benefit, premiums may run significantly higher.
Over time, monthly premiums are likely to increase. One analysis of thousands of rate increases found the average LTC insurance policy rate rose by 112% over about 25 years, although premiums may have risen less sharply in recent years as the companies that remain in the market have gotten better at pricing policies.
What happens when a policy becomes unaffordable?
If you buy a policy and find yourself unable to continue paying premiums, you could lose coverage or be forced to reduce the amount of coverage, even if you’ve been paying premiums for years.
For example, retired pharmacist Marie Marhan Dropkin, 64, can attest to the risk that a policy may become unaffordable. Now divorced, Dropkin, who lives near Schroon Lake, N.Y., and her then-husband purchased long-term-care insurance through Genworth Life Insurance more than 15 years ago, when she was in her late forties. The annual premium was about $3,500 a year for each of them for unlimited lifetime coverage. “The policy was great,” she says, because it “covered so much.” After about 10 years, the company increased their premiums to about $5,000 each, “but I could still afford it,” she says. She was given the choice between paying higher rates to keep the same benefits or paying less for reduced benefits. She decided to go with the higher rates.
A few more years passed, and the rates increased to about $9,000 a year. By then, Dropkin’s circumstances had changed, so she elected to stop paying premiums. The amount she has already paid will be available to cover long-term care when she needs it. The grand total, she says, is $68,534.
Genworth has faced multiple class-action lawsuits contending that it failed to notify policyholders of its plans to increase rates substantially. Recently, Dropkin was notified that a lawsuit involving her policy had settled. She was sorting through her options. At first impression, she says, it looks as if “there’s no difference between the options, except with one I get $1,250 back due to the lawsuit.” The notice also refers to a potential rate increase of 143% and that the company had only “a marginal ability to meet its obligations.”
Strategies to cut costs
Besides getting a policy at a younger age, there are other ways to reduce the cost of long-term-care insurance. For example, according to the AALTCI, married people and even unmarried adults who live together may be offered discounts if they both purchase coverage. They could also look into buying a joint policy with a shared benefit, which allows them to pool their benefits. If one spouse exhausts his or her benefits, he or she can use the other spouse’s share.
Another strategy is to incorporate a longer elimination period into your coverage. This is a waiting period, often of about 30 to 90 days, during which you become eligible for coverage but pay the costs of care yourself, delaying the time before your insurance kicks in. A longer elimination period typically results in a lower annual premium.
You could further limit costs by selecting coverage for a specific period instead of lifetime coverage. According to the AALTCI, a policy that pays for up to five years of care, for example, will cost between 16% and 27% less yearly than a policy with an unlimited lifetime benefit. And you might be able to get a discount of as much as 8% if you agree to pay your premium once a year instead of monthly. The AALTCI offers more tips to reduce costs at www.aaltci.org.
Employer benefits
One option that might allow you to get long-term-care insurance without undergoing a health assessment is to buy it through your workplace. A recent employer survey from the Society for Human Resource Management found that 20% of companies provide the option for employees, although it’s unclear how many of the employers subsidize coverage. If you have a health issue or a family history that suggests you might eventually need long-term care, it might be easier to get a policy through your employer than on your own, Slome says. The policies are generally portable, which means you can keep them after you leave your job, though you’d have to continue paying the premiums to maintain coverage.
Hybrid insurance
Colorado Insurance Commissioner Michael Conway, who chairs the long-term-care insurance committee of the National Association of Insurance Commissioners, says that as the number of companies offering traditional long-term-care insurance has declined, more companies are incorporating long-term-care coverage into other kinds of insurance policies.
Primarily, this is taking the form of life insurance with a long-term-care component. With these policies, if you need long-term care, you use some or all of the death benefit to pay for it. If you pass away without needing long-term care, your heirs receive the full death benefit.
These policies tend to be more expensive than stand-alone LTC insurance, but they’re more widely available. And because life insurance rates depend heavily on interest-related investments by insurers, Slome says, rates actually went down this year. A 55-year-old male and female could expect to pay an estimated $3,540 and $3,265 a year, respectively, for a $165,000 policy benefit. Because they tend to live longer (and need care longer), women pay more than men for stand-alone LTC policies. But because they pay life insurance premiums longer, women pay less for life insurance, Slome says.
According to LIMRA, consumers purchased more than 11 times more hybrid policies (415,000) than standard policies (37,000) in 2022, the most recent data available at press time. Altogether, consumers spent $138 million on stand-alone policies in 2022, compared with more than $4 billion for premiums spent on hybrid policies.
Conway says consumers should talk to a financial adviser or insurance broker to determine which product best meets their needs.
The annuity option
Another hybrid product is an income annuity that includes a provision to increase your payout in the event you need long-term care. However, the payout may not cover the full cost of care, and the added cost of this provision, known as a rider, can reduce the standard payout from the annuity. The most recent LIMRA data for this, from 2021, reflected a total of $462 million in sales involving 3,587 policies.
Slome sees the annuity option as potentially more beneficial to retirees than hybrid life insurance because they can collect annuity payments while they’re alive regardless of whether they need long-term care. In addition, it can be easier to get an annuity with a rider than a stand-alone LTC policy because you are less likely to face stringent health requirements to qualify for coverage, Slome says. “This is especially important because people often wait to explore LTC financial planning until they have experienced a health scare.”
He says annuities are also easier to purchase at more-advanced ages. Traditional long-term-care insurance accepts new applicants up to age 75, he says, while annuities with long-term-care riders accept applicants up to age 85.
The pros and cons of self-insuring
Some retirees have sufficient assets to self-insure, meaning that they pay the cost of any needed long-term care out of pocket without relying on an insurance policy. When you self-insure, you’re essentially betting that you won’t require a prolonged stay in a nursing home. According to the Administration for Community Living, most people who go into a nursing home stay for less than 12 months. People are likely, however, to need some sort of in-home care.
To self-insure, “generally, one should have anywhere from $300,000 to $700,000 in liquid, cashable assets,” Slome says. This may include funds from your traditional and Roth IRAs, 401(k) plans, and taxable accounts. You can also factor in income from Social Security and a pension, if you have one. The value of your home doesn’t count as a liquid asset, although you may want to calculate how selling your home could boost your ability to pay for long-term care. If you’ve built substantial home equity, downsizing to a smaller home could free up significant cash. And if you end up moving into assisted living or a nursing home, home-sale proceeds could help cover the cost of care.
Make sure to factor in future taxation of the assets you plan to liquidate to pay long-term-care bills, Slome says. You’ll have to account for income taxes on withdrawals from traditional 401(k)s and IRAs, for example.
Make use of an HSA
If you have a high-deductible health insurance plan, funding a health savings account is one way to save for long-term-care expenses and minimize the tax bite. Contributions are pretax (or tax-deductible if you open an HSA on your own), your investments grow tax-free, and withdrawals aren’t taxed if you use them for qualified medical expenses, including costs for long-term care. You can also use HSA money tax-free to pay premiums for long-term-care insurance; the amount you can withdraw annually depends on your age. For 2024, HSA contribution limits allow you to deposit up to $4,150 if you have individual coverage or $8,300 if you have family coverage.
When deciding whether to self-insure, you should also think about whether you can stomach the high cost of footing the bills yourself, Slome says. Are you willing to pay $30 an hour for a home health aide, or will you balk because you remember earning $30 a week in your first job?
Consider the role of family
A final factor to consider is that you may end up relying on your family for care if your funds fall short, says Slome. Long-term care in the U.S. is provided overwhelmingly by unpaid loved ones. According to the Department of Health and Human Services, the average lifetime value of unpaid care after age 50 among those who receive care is $168,000. Nearly one-fourth of care recipients receive unpaid care valued at $250,000 or more.
Nancy Yung, 96, who formerly owned a laundry business and restaurant in Bloomingdale, Ill., raised five children as a single mother after her husband died more than 45 years ago. Yung’s daughter, Mary Fus, 53, has been her mother’s caregiver for 14 years. She is working with other family members to enable her mother, who has Alzheimer’s disease, to remain in her townhome.
Fus says her mother fell last year and broke her hip. She has a medical bed where the dining room used to be so she doesn’t have to climb stairs to go to her bedroom. Fus’s siblings assist with her care, too. They have arranged for someone to go to the house to help during weekdays when siblings are working. A brother checks in at night, and a nephew sleeps in the home. Fus goes to her mother’s home when she can, preparing her mother’s meals, pureeing her food, getting her supplies and helping her with bathing and hygiene. “As long as we’re able, we’d like to keep her at home,” Fus says.
As much of an effort as it all is, Fus says it’s not a hard decision because her mother cared for so many people. “We’re lucky we do have other people who will step up and help. A lot of people don’t.”
Note: This item first appeared in Kiplinger's Personal Finance Magazine, a monthly, trustworthy source of advice and guidance. Subscribe to help you make more money and keep more of the money you make here.
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