The Need for Long-Term Care (LTC)

Published on Thursday, 13 December 2012 09:43 | Written by Administrator |

PIONEER helps to arrange and offers advice on Long-Term Care financial solutions.

Long-term care insurance (LTCI) is designed to pay out a series of sums of money, usually each month, when a person (usually an elderly person) needs long-term care for either:

Mental or
Physical health reasons.

Long-term care is needed when someone is unable to look after themselves due to poor health. These sums are used to buy care either in the home or in a residential care home. Most policies are designed to pay out for as long as the person needing care lives.

Compared to other countries though, the LTCI is a small market in the UK with less than 36,000 policies in force.

However in the UK, rather than taking out insurance, many people do not plan for long-term care fees at all or would use their investments and/or the value of their own home should the need for care arise in future. Financial solutions other than specific long-term care insurance are more likely to be used.

At present, there are around 3m people in the UK aged 80 or over but by 2060 that figure is projected to increase threefold to nearly 8.65m. At the oldest ages, the trend is even sharper the number of centenarians is projected to increase from 13,000 in 2010 to 456,000 in 2060.

One general trend is towards more care being needed at home this is often the preferred option for older people, although it is not necessarily less expensive than care in a care home and, if extensive care is required, can even be more costly.

Due to changing demographics, the ageing population, figures indicate that the underlying need for advisory and implementation financial solutions to help with long-term care fees is likely to increase in future. To date however, demand for such “pre-funded” care products has been lower than anticipated, partly because many people prefer to wait to see whether care will ever be needed.

The Dilnot Commission reported in December 2010 that the average cost of an older adult residential and nursing care home place is £26,000 a year, while home care costs average at £8,000 a year. Many people pay fees substantially in excess of these, so funding long-term care over a long period can be both very costly and very uncertain (because it can be difficult to estimate how long care may be needed for). The average length of stay in residential care is believed to be around two to four years but for some conditions e.g. dementia, the need for care can be considerable and with little change to life expectancy meaning that care may be needed for much longer.

State provision

Funding long-term care has never been part of the NHS's responsibilities, ever since its establishment in 1948, although prior to 1993 geriatric wards in some NHS hospitals effectively provided long-term care. The NHS is responsible for on-going medical care, but determining what is medical care and what is social care is complex. New rules announced in June 2007 and subsequently do give greater clarity in what is still a very complex area.

Since 1993, local authorities have had responsibility for assessing care needs (and paying for them subject to means testing). The exception to this is in Scotland, where a spouse (but no other relative) can be asked to contribute towards care costs.

The 1999 Royal Commission on Long Term Care recommended “free” personal and nursing care but this has only been adopted in Scotland. In England, a non-means-tested payment towards the cost of nursing care is paid. Originally this had three levels, depending on the need for nursing care, but since October 2007 only one band applies. The situation is also different in Wales and Northern Ireland.

Currently, government help with care fees depends on where you live:

In England, those needing care get £108.70 a week (as at September 2012, with figures usually changing every year, although they were not increased in 2011 or 2012) from their primary care trust (more if they have a high level of need and were assessed before October 2007).
In Wales, the local health board usually pays around £120.55 a week, although each Welsh local health board can set its own figure.
In Northern Ireland, they get up to £100 a week from their health and social care trust.
In Scotland, the figure is £74 a week for nursing care from the local council and £163 a week for personal care, but those needing care are not able to claim either Attendance Allowance or the Care component of disability living allowance.

Despite improved guidance, it is still difficult to work out how much help someone needing care is able to claim and much depends on where they live, their income and other assets values.

Long-term care remains in the political melting pot but, in the absence of any firm commitment from the state to do more, making private provision makes sense for many people - especially as means testing results in anyone with assets of more than £23,250 (in 2012/13, and possibly including the value of their home) not usually getting financial help from their local authority. Those whose assets fall between £14,250 and £23,250 may get help, but on a sliding scale. The respective figures for those in Scotland are£15,250 and £24,750 and for Wales a single £23,250.

An influential report by Sir Derek Wanless (for The King's Fund) was published in March 2006 advocating an abandonment of means testing, but this was not adopted as government policy.
Long-term care benefits are complex and vary considerably depending on where people live, so specialist advice should always be taken.

In July 2009, the then government published a Green Paper, Shaping the Future of Care Together, which consulted on a number of aspects of care provision in England, including funding. The paper set out a number of options but the three favoured options were:

Partnership. The government would pay a quarter or a third of costs, with the balance being means tested or paid by the person needing care.
Insurance. Either state run or in partnership with the private sector, but with a similar level of state help as partnership.
Comprehensive. Everyone over retirement age would be required to pay into a state insurance scheme. This might require a payment of £17-20,000 to cover a typical £30,000 of care expenditure.

In order to fund such schemes, people may use Home Equity Release so that instead of paying out of their income or capital, they create a lien against their property, repayable on death. Again, the need for financial advice in this complex area is essential.

The Dilnot Report - 2011

In July 2010 a new independent commission, under academic and economist Andrew Dilnot, was set up to recommend an affordable and sustainable system of funding long term care. The commission published its findings in July 2011.

The Commission's main recommendations included:

Capping the lifetime contribution to adult social care costs that any individual needs to make at between £25,000 and £50,000, with a suggestion that £35,000 would be the right figure. Currently, costs are uncapped. Younger people would effectively have a zero maximum contribution, with a sliding scale from age 40 to 65.
Means testing should continue and the current £23,500 threshold (in England-the report does not make any recommendations about other countries in the UK, all of which have different rules on care funding) should be increased to £100,000.
Universal disability benefits for people of all ages should continue, but benefits should be better aligned and Attendance Allowance should be renamed, as people do not understand the term, under-claim for it and do not always use it for the purpose intended.
People should be expected to contribute a standard amount to cover their general living costs as otherwise those moving into residential care gain an advantage relative to those having domiciliary care (care in their own home). That figure would be set at between £7-10,000 a year.
Eligibility criteria should be on a standardised national basis and be portable (i.e. would continue, until reassessment, if someone moves e.g. to be closer to their children). At present, each local authority can and does adopt its own rules.
A new social care statute (as recommended by the Law Commission) should place duties on local authorities to give information, advice and assistance services in their area and stimulate and shape the market for services.
The Government should set up an awareness campaign and develop a major new information and advice strategy, produced in conjunction with charities, local government and the financial services sector.

Under the report's proposals, no one would spend more than 30% of their assets on care costs. That contrasts to the present system, where in some cases, someone could spend over 80% of their assets on care (typically, those with assets of £100-200K). If adopted, it is likely that pre-funded long term care insurance and other solutions would be developed by care insurers. As the individual's share of their long term care costs would in effect be limited, such solutions should be less expensive than previous generations of LTCI.

The report points out that 1 in 10 people, at age 65, face future lifetime care costs of more than £100,000 (based on modelling work carried out for the Commission by ESHCRU (at the University of York, LSE and University of Kent), adding that 'data on the costs of social care is poor'.

The Commission also estimates that a quarter of people aged 65 will need to spend very little on care over the rest of their lives, and half can expect care costs of up to £20,000 but it added: 'some could spend hundreds of thousands of pounds. There is no way of predicting in advance what the costs might be for any one person'.

In July 2012, the government responded by publishing a White Paper called Caring for our future: reforming care and support. In essence the response broadly supports the Dilnot proposals, plus publishes a draft Care and Support Bill. However, any decisions relating to funding, and especially extra funding, were deferred until the next government spending review.

The Dilnot principle of a “partnership” between the Individual and the State was generally accepted in the White Paper. Overall, while few would argue that the State should pay for all long term care (it never has and the cost would be prohibitive) few people support either the current rules or would argue that the State should do less. One hope going forward is that there will be all-party support for any proposals in order that older people and their families (and also the financial services community) can develop appropriate plans in the knowledge that the rules will not be changed at the whim of the government of the day.
The ABI (Association of British Insurers) has published various papers on LTC including A Sustainable Future for Long Term Care (2010), which sets out the role of the insurance industry in providing expertise and products and how the industry has the potential to play a major role. And A Brief Guide to Long Term Care Insurance explains the main types of LTCI cover and the need for them and Consumer attitudes towards long-term care (2011) published research findings on the public's views and concerns.

Law and regulation

Most LTCI products available in the UK are written as long-term insurance policies by UK-regulated insurers. Insofar as such products constitute "designated investments" (LTCI investment bonds and "immediate care" annuities) their sale and marketing has been regulated for some time by the Financial Services Authority (FSA). The sale and marketing of LTCI pure protection products fell outside the remit of the FSA until November 2004, from when the sale and marketing of all LTCI products has been regulated by the FSA. As this is a product that is typically sold to elderly and potentially vulnerable consumers, special rules apply to the marketing of all LTCI policies:

All LTCI advisers and supervisors are subject to enhanced training and competence requirements including a specific LTCI examination. All existing advisers already deemed competent to advise on LTCI now also need to pass this exam.
All LTCI sales are subject to special rules. These include additional pre- and post-sale information and risk warnings to help consumers make informed choices about the type of product and amount of cover they need.
New claims-handling rules have increased consumer protection at the point of claim, when consumers may be particularly vulnerable.
All LTCI products now come under the compulsory jurisdiction of the Financial Ombudsman Service (FOS) and the Financial Services Compensation Scheme.

In 2007 the FSA consulted on changes to its regulatory rule books as part of its plans to move towards more “principles-based” regulation. Changes to the rule books were introduced in January 2008.
Prior to November 2004, the sale and marketing of LTCI products issued by Association of British Insurers (ABI) member companies was subject to an ABI code of practice. In effect, this required providers to treat LTCI as though it were regulated and to consider whether the Intermediary was competent to sell LTCI.

Some LTCI business has been written by offshore insurers. Such policies do not enjoy the legal protection that UK-based policies do, although most such policies are marketed by subsidiaries of well-known insurers that are regulated in the UK. These policies are usually written under trust in order to secure inheritance tax advantages.

When reviewing long-term care planning, it is recommended that you consider having a lasting power of attorney (LPA). This (and its forerunner the enduring power of attorney (EPA)) allows a nominated individual to act on behalf of the person setting up the LPA, should they no longer be able to manage their own affairs. In the absence of an LPA it may be difficult for contracts to be entered into or papers signed without the authorisation of the courts - potentially a complex, time-consuming and expensive exercise. Independent legal advice should always be sought before setting up an LPA, or making changes to an EPA .

LTCI benefits are not usually subject to income tax or capital gains tax (but any associated investment product may be). Tax rules can be complex and can change at any time so professional advice should be taken where appropriate or if in any doubt.

Insurance companies

Most LTCI insurers are UK based and authorised by the FSA. In some cases, usually to secure tax advantages, an insurer may be based offshore. Care should always be exercised when choosing to insure with any offshore insurer, as the legal protection outside the UK may not be as great. Factors to take into account include:

Who ultimately owns the insurer?
What legal jurisdiction is the insurer based in (some jurisdictions have tighter legal controls than others)?
What legal remedies (including any arbitration facilities) would apply if a dispute arose?
What is the track record and history of the insurer?

Most LTCI solutions are arranged by Independent Financial Advisers (IFAs), many of whom are members of the Personal Finance Society.

Types of insurance

LTCI divides into two main categories:

1. Pre-funded - this subdivides into pure protection and investment linked
2. Point of need - also known as "immediate needs/care".

1. Pre-funded

By late 2012, no major insurer was actively marketing prefunded LTCI, although existing policies still exist and some could be changed or increased in future, so the following information may still be relevant. It is also likely that new LTCI products will be developed and an understanding of previous generation products can help assess any new offerings.

Pure protection

Pure protection policies are taken out before care is needed and pay out a monthly sum should long-term care be needed at some point in the future. Benefit is then paid for up to a fixed term (often three to five years) or until death. Payment stops if there is no longer a need for care. Benefit may be paid to the insured or direct to the care provider.

Premiums are paid on a regular (monthly or annual premium) or single-premium basis.

In the event of death or cancellation, usually no benefit is payable.

In 2007, one insurer launched a product that paid a cash lump sum on diagnosis of Alzheimer's disease, motor neurone disease, Parkinson's disease or on the insured failing three out of five activities of daily living. These are all conditions that can lead to a need for long-term care. In effect, the product is a cross between critical illness insurance and long-term care insurance.

Investment linked

Investment-linked policies combine the elements of single-premium investment bonds and protection insurance. A typical arrangement would involve a single-premium investment where the objective is growth over time. From the investment fund, regular deductions are taken to fund the protection element of the arrangement. If care is needed, the protection element may pay the whole benefit or part only, with withdrawals from the investment element making up the balance.

In the case of offshore funds, the bond may be written in trust to secure inheritance tax advantages.

Depending on the split between the different elements of the arrangement it may be possible, if growth on the investment element exceeds deductions for the protection element, for the whole investment to grow while still enjoying the benefit of the protection. This will not be guaranteed and will be subject to a range of factors, the most important of which is the actual growth achieved in the underlying investment fund(s).

Unsettled investment markets in recent years have resulted in funding concerns on some policies (especially if the investment element could quickly fall as sums are taken out to pay for the protection element). As a result most insurers no longer offer this type of arrangement.

2. Point of need

One disadvantage of pre-funded LTCI is that (as with all protection insurance) if no claim is made, premiums paid may be perceived as being lost or "wasted". Point-of-need policies avoid that because they are only taken out once the need for care has arisen. At that point the key financial issue is how long the insured will live, as care fees will be payable until they die. If they live longer than expected, there may be a considerable financial drain on their estate.

With a point-of-need policy, a single premium is paid into what is effectively an enhanced (or impaired-life) annuity (although for technical reasons, the policy may not necessarily be written as an annuity). This takes account of any reduction in the life expectancy of the insured. The insurer pays a regular monthly benefit, usually direct to the care provider, and takes the risk that the insured will live longer than expected. The insured takes the risk that they will die before the insurer expects them to and so will have obtained poor value from their investment. It may be possible to guarantee that payments will continue for a predetermined period even if the insured dies, but this will reduce the monthly benefit otherwise payable.

As an alternative to a point-of-need policy, a customer may choose to have an impaired-life or enhanced annuity. Such products provide a higher benefit or income, reflecting the insured's shorter life expectancy. However, some conditions, such as dementia, may lead to a high or growing need for care but may not necessarily lead to a shorter life expectancy.

State benefits and inheritance tax implications

Any arrangement to pay long-term care fees may have implications for any State Benefits to which the client may be entitled. There may also be Inheritance Tax implications.

Clients are advised always to take independent legal advice to ensure that they understand fully the implications of such arrangements. Organisations such as age-associated Charities and Citizens Advice Bureaux may also be able to provide general or specialist advice, information and help. For example, Age UK provides detailed information and factsheets online.

Characteristics of Long-Term Care Insurance

When is benefit paid?

Benefit is usually paid if a certain number of Activities of Daily Living (ADLs) can no longer be performed, or on Cognitive Impairment. Most policies pay on the failure of two or three out of six ADLs. These are:

Washing
Dressing
Feeding
Toileting (using the lavatory and controlling bowel and bladder function)
Mobility (moving from room to room on level surfaces)
Transferring (moving to or from a bed to a chair or wheelchair).

The ABI has drawn up model ADL definitions, which are used by most insurers.

Alternatively, the insurer may pay either a cash lump sum if the policyholder needs residential care or periodic payments for care at home. Instead of an ADL definition of disability, the insurer may require that the claimant needs the intervention of a registered nurse in planning, providing, delegating and supervising care, on at least a daily basis.

Geographic coverage

Policies usually pay out benefit to a provider of care in the UK. In some cases the policy will pay out direct to the insured, in which case care may be bought in any country, subject to the insurer having adequate medical evidence to confirm the claim.

Exclusions

Most policies have Exclusions and these may include:

Alcohol or drug abuse
Criminal acts
Flying (except as a passenger in a commercially licensed aircraft)
Hazardous sports and pastimes
HIV/AIDS (except in certain circumstances, for example if contracted from a UK blood transfusion)
Living abroad (outside the EU for more than 13 consecutive weeks in any 12 months)
Self-inflicted injury
Unreasonable failure to follow medical advice
War and civil commotion.

Benefit is usually subject to a three-month deferred period before a claim is paid, although help to pay for assistive devices may be paid out earlier than that.

Increasing benefits

Benefits can usually be increased without further medical evidence every year, usually in line with increases in average prices or earnings, sometimes subject to a maximum annual increase (often 10% a year).
In the case of point-of-need policies, there may be provision for the benefit level to increase if the need for care increases.

Group schemes

Although group business has been written it has not proved popular in the UK, although in France it accounts for half of all new LTCI business.

Product developments and innovation

LTCI was introduced in the UK in 1991. In the first half of the 1990s product development was often highly innovative. Since then, the pace of development has slowed dramatically, largely because sales failed to take off.

All major insurers have now pulled out of the prefunded market. There are four main reasons for the general lack of interest by insurers in pre-funded policies:

The difficulty of obtaining reassurance terms and support;
The fact that many investment-linked plans did not work well due to stock market volatility;
A lack of sales, which reflects both intermediaries' lack of interest in the market and consumers' preference not to commit to what may be perceived as expensive insurance that they may never claim on;
A concern that LTCI regulation adds another layer of costs for products that may already be unprofitable and that advisers may decide not to bother marketing such plans due to the higher training and competence requirements (in fact, many advisers have yet to pass the necessary examination to advise on LTCI contracts and so have effectively elected not to be in this market);
Concern that regulation would become more onerous in future, especially as many customers are old and frail and so may be deemed vulnerable.
The main market now is for point-of-need plans. The logic is that whilst this solution may ultimately be more expensive for the one in four people who will, on average, need long-term care before they die, the three in four who do not need it will avoid having to pay for insurance that they end up not needing.

Questions and answers

Q: Should the insured benefit be equal to the care fees that are payable now or that are likely to be payable in future?

A: No. Usually Attendance Allowance is payable and, depending on which country of the UK the insured is resident in, a contribution towards their personal and/or nursing care may be paid by the state, but only for care received in a registered care home. In addition, pension and other income may be used towards paying the cost of care. Typically, insurance is needed for half or less of the actual fees payable.

Q: Must care be received in a care home?

A: Usually no. Most people choose to have care at home if possible, while those already living in a residential care home may prefer to have treatment there rather than move to a nursing care home (which, by law, must provide round-the-clock nursing care if required).

Q: What is the advantage of having a care counselling service, which may be built into an LTCI policy?

A: Such services can help the insured and/or their family choose the right care package (in conjunction with the insured's medical advisors), negotiate terms with suppliers, advise on state and other benefits and generally provide help and advice at what can be a very difficult time for all concerned. Making decisions without advice and experience can be very time consuming and counselling may be expensive if obtained on a stand-alone basis.

Q: Do insurers negotiate better terms with care providers?

A: Usually no. In some cases, the fact that an individual has LTCI can reduce the financial risk to the care home owner and this may be reflected in their fees or in any agreement with regard to future fee increases. Some financial advisers will negotiate with the care home owner in such situations

Q: What underwriting considerations apply?

A: Underwriters are most interested in the applicant's age, health (including mental health) and medical history. The applicant's life expectancy, rather than their health as such, is the key factor that will determine the underwriting decision. Usually this is assessed through a paramedical examination (undertaken by a nurse in the customer's own home and not involving potentially "embarrassing" actions such as undressing to be examined) or GP report. In the event of a non-standard risk, the underwriter may impose a higher premium or limit or refuse cover.

Useful publications

The Protection Review. Cheltenham, Gloucestershire: Protection Review Limited. Annual review of protection insurance markets, including LTCI. For further information see www.protectionreview.co.uk.
Securing good care for older people: taking a long-term view. Wanless Social Care Review; author, Sir Derek Wanless. London: King's Fund, 2006.

Shaping the future of care together. London: Stationery Office, 2009.

With respect to old age: long term care - rights and responsibilities. Royal Commission on Long Term Care. London: Stationery Office, 1999.

The Dilnot Commission has its own website, at www.dilnotcommission.dh.gov.uk at which the report and other papers have been published.

Caring for our future: reforming care and support. Government White Paper, London: Stationery Office, 2012.

Useful websites

Age UK
Financial Ombudsman Service
Financial Services Authority
Financial Services Compensation Scheme

In Summary

LTCI remains a small market in the UK with around 36,000 policies in force. Very few pre-funded plans are now written. In France, however, around 5 million people (15% of the population) have LTCI. In other countries too, LTCI is a much more significant market than it is in the UK (e.g. 5% of US citizens have LTCI).
LTCI may be taken out before care is needed but is now usually taken out only once care is actually required.
The insured benefit is usually half or less of the estimated or actual cost of care.
Plans usually pay benefit for as long as the insured fails a set number of ADLs or on cognitive impairment. One insurer's claims criteria require a need for daily care and 24-hour access to a registered nurse.
Point-of-need plans are taken out to "crystallise" or make certain the financial risk of needing long-term care for a long time, requiring a single premium rather than regular payments.
All LTCI policies have been subject to FSA regulation since November 2004, and special rules are in place for this class of business.
The Dilnot Commission was set up to advise the coalition government how best to fund long-term care in future. Its recommendations were published in July 2011.
Among them were caps on how much individuals should be expected to contribute to their long term care costs.
In July 2012, the government responded by publishing a White paper on LTC funding. However, no new money has been allocated in the short term.

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