Insurance from Prudential Insurance Company of America
State of Ohio employees may purchase long-term care through Prudential, the state's long-term care administrator. Long-term care refers to a wide range of personal care, health care and social services for people of all ages who have a chronic disease or long-lasting disability. Long-term care is sometimes referred to as custodial care and can be provided in a nursing facility, an adult day care center or at home. This insurance covers qualifying expenses that result from a loss of functional capacity, which must have occurred after the effective date of your long-term care insurance.
Each individual who enrolls for long-term care coverage has their own individual contract, resulting in individual policy flexibility. This flexibility is available at group rates and with the stability of a large group plan.
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Eligibility
Important Plan Features
Qualifying For Benefits
Using Long-Term Care Benefits
Coverage Options
Exclusions
Conclusion of Coverage
Vendor Contact Information
Prudential Fast Facts
Prudential Long-Term Care Certificate
Eligibility
You may be eligible for long-term care benefits if you are between the ages of 18 and 84 and either a permanent full-time employee or a permanent part-time employee working 20 hours or more per week. If you are eligible for long term-care, your spouse, parents, parents-in-law, grandparents and grandparents-in-law, sibling and adult children are also eligible. These eligible individuals may enroll for long-term care even if you do not.
Important Plan Features
- Facility Daily Benefit Allowance. Enrollees may select a daily allowance from $100 to $300 in $50 increments.
- Restoration of Benefits. The lifetime maximum benefit will be restored if you have received benefits, then recover and resume premium payments.
- Premiums do not increase as you age. The monthly premium is based on your age at the time you enroll. Premiums do not increase with age or because you use your benefits.
- Inflation protection. You will be offered opportunities to increase coverage without evidence of insurability.
- Bed Reservation. If hospitalized, you may use up to 60 days of benefits to reserve a nursing home or assisted living facility bed for your use upon hospital discharge.
- Assisted Living Facility. This coverage provides payment at 100 percent of the daily benefit allowance.
- Monthly Cash Alternative Daily Benefit. Equal to 50 percent of your Home Health Care Benefit.
- Lifetime Deductible (Waiting) Period. There is a waiting period before benefits begin. Only one 90-day waiting period is applicable to the life of the plan.
- Federally qualified plan. Premiums you pay for this policy will be treated as a medical expense for the purpose of itemizing medical deductions. Premiums may be tax deductible (see plan for details). Benefits paid by a qualified long-term care policy are not taxable income (subject to limitations).
How Do I Qualify to Receive Care Benefits?
This plan will provide the daily cash allowance you have selected if you become unable to perform two of the five following activities of daily living without substantial assistance (i.e., hands-on assistance or standby assistance) from another person:
- Eating
- Bathing
- Transferring (getting in and out of a bed, chair or wheelchair)
- Dressing
- Continence
- Toileting
This inability to perform can be caused by an injury or an illness. The plan also will provide benefits as a result of a severe cognitive impairment that requires substantial supervision or verbal direction from another person in order to protect the individual and others from serious injury. To be determined to have suffered a qualifying loss of functional capacity, a person must have the certification of a licensed health care practitioner within the preceding 12-month period.
How Do I Use My Long-Term Care Benefits?
1. Enroll
If you are eligible, you may initially enroll within 31 days of the date you were hired by the state. If you enroll in this time period, you will not have to provide proof of good health. If you do not enroll when initially eligible, you may apply for long-term care insurance anytime. You must provide proof of good health, however, and be approved by the insurance carrier, Prudential Life Insurance Company of America, to obtain coverage.
2. File a Claim
Filing a Claim: Call the toll-free Long-term Care customer service unit at 1.800.732.0416 and request a Benefit Request Form to be completed by you and a Prudential physician. In addition, a Prudential case manager will be assigned to assist you. Case managers are registered nurses and professional social workers who are specially trained to help you and your relatives through the claims process.
Selecting a Level of Coverage (Facility Daily Benefit Allowance)
The plan offers a range of daily benefit allowances. Prior to enrolling, you can select the daily cash benefit you wish to receive each day you qualify for benefits. You may select any whole-dollar amount from $100 to $300 per day in $50 increments. Individuals who receive care in an eligible nursing or assisted living facility are eligible for the full selected daily benefit allowance. Those who receive care in an assisted living facility receive payment of 100 percent of the daily benefit allowance. Care in the home or in other informal settings is eligible for 50 percent of the selected daily benefit allowance.
Coverage Options: Three-year or Five-year plan
You choose a three-year or five-year plan. Your lifetime maximum will be an amount equal to the number of days in three years (1,095 days) or five years (1,825 days) multiplied by your chosen Facility Daily Benefit Allowance. Benefits (at a reduced daily level) will last longer when care is received outside a nursing or assisted living facility (therefore, benefits under a three-year plan, for example, may extend beyond three years).
Premium Refund Available at Death (Return of Contribution)
You choose whether or not to have Return of Contribution. This optional coverage provides that premiums paid are returned to a beneficiary if the member dies. For employees, the amount returned decreases 10 percent per year after age 65.
Future Purchase Inflation Protection Increases
To help you keep pace with the rising cost of long-term care, you may increase your coverage every 3 years without proof of good health. Prudential will continue to offer you this increase opportunity every three years, even if you declined prior offers. The amount you will be able to purchase is $1 up to 5% compounded annually based on your current Facility Daily Benefit Allowance at the time of the offer.
When you purchase more coverage, you will pay additional premium at a rate based on your age as of the date Prudential receives your request for the increased coverage amount.
Automatic Inflation Protection Increases
You may choose the automatic inflation protection option, which will automatically increase your daily benefit amount every year on an annual compounded basis. This option is an alternative to the Future Purchase Inflation Protection. Rates are available from Prudential for this option.
Exclusions
Each plan member receives an insurance certificate that includes full details of plan exclusions. These exclusions are outlined below:
- A charge covered by a workers’ compensation law, occupational disease law or similar law.
- War or an act of war, whether declared or undeclared, while you are insured.
- Your participation in a felony, riot or insurrection.
- Alcoholism and drug addition.
- Treatment provided in a government facility, unless payment of the charge is required by law or services provided by any law or government plan under which you are covered. This does not apply to a state plan under Medicaid or to any law or plan when, by law, its benefits are excess to those of any private insurance program or other non-government program.
- Charges for services or supplies for which no charge would be made in the absence of insurance.
- Care or treatment outside of the United States except as described in the International Coverage benefit.
- Intentionally self-inflicted injury or attempted suicide.
Conclusion of Coverage
Portability
If an individual is no longer eligible as an employee, or if the group contract is discontinued for new enrollees, plan members may continue coverage at the group rate by paying premiums directly to Prudential. If the state employee dies or is divorced from their spouse, the spouse and other eligible individuals may continue coverage by continuing to pay their premiums
Non-Forfeiture Option
A Non-Forfeiture Benefit Option (Shortened Benefit Period) is also available.
If elected, under the Non-Forfeiture Benefit, benefits will be payable based on the Facility, Assisted Living Facility and Home Care Daily Benefits in effect on the date your Coverage would otherwise have ended. However, there will be a reduced Lifetime Maximum. A reduced Lifetime Maximum will be equal to the greater of items 1 or 2.
- 30 times the Facility Care Daily Benefit in effect at the time your Coverage ends, up to the Lifetime Maximum in effect on the date your coverage would otherwise have ended.
- The total amount of premiums paid for your Coverage, and any options, less the sum of all benefits paid on your behalf, while your Coverage is in effect.
Vendor Contact Information
For questions about long term care, contact Prudential at 1.800.732.0416 between the hours of 8 a.m. and 8 p.m. Monday through Friday ET.