Group plans may or may not be guaranteed renewable or tax qualified. Some group plans include language allowing the insurance company to replace the policy with a similar policy and to change the premiums at that time. Some group plans can be canceled by the insurance company. To compensate for the higher insurance risk group plans may have higher deductibles and lower benefits than individual plans. Some group plans have a 3 ADL (activities of daily living) requirement for nursing care. The Consolidated Omnibus Budget Reconciliation Act (COBRA) provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. Retirement systems such as CalPERS may offer long-term care insurance similar to a group plan. These organizations are not regulated by the state insurance departments. They can increase rates and make changes to policies without state scrutiny and approval. Long-term care insurance rates are determined by six main factors: the person's age, the daily (or monthly) benefit, how long the benefits pay, the elimination period, inflation protection, and the health rating (preferred, standard, sub-standard). Most companies will offer couples and multi-life discounts on individual policies. Some companies define "couples" not only to spouses, but also to two people who meet criteria for living together in a committed relationship and sharing basic living expenses. The average age of purchasers has dropped from 68 years in 1990 to 61 years in 2005, and the number of purchasers who are under age 65 has increased significantly. Most companies offer multiple premium payment modes: annual, semi-annual, quarterly, and monthly. Companies may add a percentage for more frequent payment than annual. Options such as spousal survivorship, non-forfeiture, restoration of benefits and return of premium are available with most plans. The Deficit Reduction Act of 2005 makes Partnership plans available to all states. Partnership provides "lifetime asset protection" from the Medicaid spend-down requirement. As of March 2014, 41 states had active Long Term Care Insurance Partnership programs. Benefit eligibility and deductibles Most policies pay benefits when the policyholder needs help with two or more of six ADLs or when a cognitive impairment is present. According to the US Department of Health and Human Services all tax-qualified long-term care insurance plans have the same trigger. Most policies have an elimination period or waiting period similar to a deductible. This is the period of time that you pay