A major challenge of the current system of care for adults with functional limitations is the inability of middle-income individuals to protect themselves against the financial risk of needing and accessing available supports and services to help them remain in their homes and communities. Over 10 million Americans need supports and services today due to disabling conditions, and this figure will likely grow due to population aging. In 2008, the cost of this care totaled $264 billion, comprising public, private, and in-kind expenditures.
A new era of reforming the system of care for adults with functional needs begins with the Community Living Assistance Services and Supports provision included in the Patient Protection and Affordable Care Act. For the first time, working Americans will have an affordable way to plan for and access supportive services in the setting of their choice without immediately impoverishing themselves to Medicaid eligibility. CLASS fundamentally reframes the concept of living with functional limitations from one of sickness and poverty to one of independence, choice, and personal responsibility.
The law creates the CLASS Independence Benefit Plan, a voluntary, publicly administered long-term care insurance plan for employed individuals with no underwriting or exclusion for pre-existing conditions. Based on a risk pool concept, it offers a lifetime benefit for people with significant difficulty performing daily living tasks. Premiums will be age rated, with younger people paying considerably less and older adults more. People who are fully vested and meet the eligibility threshold for functional impairment will receive a cash benefit that can be used to purchase a variety of supports and services, including personal care, home modifications, adult day programs, or residential care. By law, CLASS is not funded by tax dollars and must be actuarially sound for 75 years.
The Department of Health and Human Services Secretary is tasked with implementing CLASS by October 2012 with many implementation decisions to be considered and made. Full implementation requires knowledge transfer from various sectors, including the research community and existing public programs. On April 7, 2011 The SCAN Foundation launched its CLASS Technical Assistance Brief Series as a way to gather that knowledge from academic, private, and public sector experts on the issues critical to successful implementation. Given the complexity of these pressing issues, each brief in this series of sixteen answers a clear and distinct question pertinent to implementing CLASS.
To build the most consumer-focused benefit, the CLASS Office needs to consider the types of services and supports individuals with disabilities need to remain as independent as possible. Given the many ways one might become disabled, there is not a one-size-fits-all approach to addressing these needs. The first brief describes how the CLASS cash benefit might be used by beneficiaries, outlining a broad range of products, services, technologies, and environmental modifications that should be permitted to purchase through CLASS.
Another set of briefs answers questions from a private long-term care insurance and Medicaid personal care services perspective about systems for determining eligibility for benefits, methods for assessing need, and the ways insurance companies/Medicaid agencies measure activities of daily living and cognitive impairment. In total, these six briefs illustrate current models used for eligibility determination that can inform the critical benefit and eligibility design activities the CLASS Office must develop.
Most current long-term care service programs in either the private or public arena are based on a fixed benefit in which the eligible participant is assessed and receives services appropriate to their needs. CLASS offers a cash benefit, allowing the beneficiary to determine what services they need and are willing to purchase. This approach provides individuals with more flexibility to meet their needs, including paying for care from family members and friends. This can include the responsibility for individuals to serve as “employers,” and requires programmatic capacity to ensure that funds are used appropriately. The CLASS statute also requires that the HHS Secretary establish procedures allowing the use of debit cards to access cash benefits. A series of five briefs thinks through these various issues by authors involved in supporting and evaluating the Cash and Counseling model, now in operation in 15 states as a participant-directed home- and community-based services program.
In order for CLASS to be successful, sufficient enrollment is vital to ensure that the monthly premium is affordable. The more people that enroll, the greater the ability to spread the insurance risk, which can help keep premium costs down and increase its attractiveness to working adults. For people to choose enrollment, they must be aware that CLASS exists and that planning for future long-term care needs is essential. How the CLASS office develops messages and marketing materials for the plan will have a significant impact on enrollment. Marketing messages must not only be targeted to individual purchasers, but also to their employers as potential conduits for outreach. Another set of briefs describes lessons learned from a federal long-term care marketing initiative as well as employer and buyer profiles to identify best practices in achieving strong participation rates and opportunities for cost-effective marketing of CLASS.
The final brief considers a key issue from a supply-side perspective, namely, what workforce infrastructure is needed to meet the new and growing demand for services? CLASS will provide eligible individuals with cash in hand, ready to purchase services, so it is imperative that they be able to buy what they want to remain independent. This brief focuses on “matching service registries.” These are labor market intermediaries that facilitate consumer direction in order to ensure that the personal care attendant workforce is matched appropriately to beneficiaries effectively and efficiently.
CLASS, like most new and innovative efforts in the 21st century, builds on key ideas from times past and charters unknown waters toward the goal of transforming the financing for supportive services from Medicaid as a government safety net toward personal planning, choice, and responsibility. CLASS is fundamentally about ensuring that all Americans have access to services and supports when needed to remain independent members of society. This series will shed light on some key implementation issues that have not yet been addressed in the public debate and foster active discussion about how to pave the way for successful implementation of CLASS so that adults with functional limitations and their families gain financial security while living with independence, dignity, and choice.
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