rely predominantly on institutional services.27 Numerous proposals exist for expanding the availability of long-term care insurance. Yet further research is needed to determine the costs and benefits of each. In particular, studies should evaluate the following aspects of each proposal: • Affordability for Consumers and Taxpayers: How likely is each proposal to generate affordable coverage for those who require long-term care while reducing the expanding burden of public spending on long-term care? • Eligibility: How will each proposal ensure that those who need long-term care can access it? How many activities of daily living (ADL) should trigger eligibility for tax credits or social insurance? How long must an individual require assistance prior to eligibility? What should the standards be for determining individuals’ likely needs for future assistance? How should mental health status inform eligibility decisions? • Coverage: How likely is each proposal to ensure that insurance covers an adequate mix of LTSS? LTSS could include skilled nursing facility care; home health care; personal care attendants; care management and coordination; adult day centers; and respite options for family and volunteer caregivers. • Quality: How will the proposal affect the quality of LTSS delivery? How likely is each proposal to incentivize coordinated, patient-centered care? Addressing the Health Needs of an Aging America | 30 28 U.S. Senate, Commission on Long-Term Care, Report to Congress, September 2013, pp. 66-67. 29 J. Wiener et al.,Medicaid Spend Down: New Estimates and Implications for Long-Term Services and Supports Financing Reform, Prepared for the SCAN Foundation by RTI International, March 2013, available from: http://www.thescanfoundation.org/rtiinternational-medicaid-spend-down-new-estimates-and-implications-long-term-services-and-supports C. Eng et al., Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing, Journal of the American Geriatric Society 1997 Feb;45(2):223-32. 31 G.L. Gross et al., The Growing Pains of Integrated Health Care for the Elderly: Lessons from the Expansion of PACE, Milbank Quarterly 2004 Jun; 82(2): 257–282. 32 M. Cohen et al., The Historical Development of Benefit Eligibility Triggers Underlying the CLASS Plan. The SCAN Foundation, Spring 2011, available from:.pdf Long-Term Care Insurance Proposals Federal Policy Levers Medicare Part A Expansion: This option, financed through the Medicare payroll tax and new premiums, would create a comprehensive LTSS benefit that would be triggered when physicians certify that individuals meet eligibility criteria. One proposal advanced by the Senate Commission on Long-Term Care would provide benefits to individuals who require assistance with at least two activities of daily living, have needed assistance for 90 days, and are likely to continue to need services. These benefits would be financed through the Medicare payroll tax and new premiums and would include “skilled nursing facility care or daily skilled care; home healthcare without the need for a skilled service; personal care attendant services; care management and coordination; adult day center services, respite care options to support family or other volunteer caregiver; outpatient therapies; and other reasonable and necessary services.”28 Catastrophic Coverage: This option would create a Medicare Part A benefit that covers out-of-pocket expenses after a lengthy waiting period defined either in time (beneficiary has paid for three years of home care services) or expenditures (beneficiary has paid for $50,000 in home care services). One study found that it took 6.8 years, on average, for LTSS users to spend down their assets and become Medicaid eligible.29 Medicare Advantage Coverage: Incorporating LTSS coverage as a supplemental benefit in Medicare Advantage (MA) plans would highlight new methods of organizing care and emphasize the potential benefits of care integration. An example of an integrated program is the Program of All-Inclusive Care for the Elderly (PACE), which integrates acute and long term care for enrollees and is financed through capitated payments from Medicare and