State of Ohio employees may purchase long term care through Aetna, 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
Eligibility
You may be eligible for long term care benefits if you are 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 and adult children are also eligible. These eligible individuals may enroll for long term care even if you do not.
Important Plan Features
- Daily Benefit Allowance. Enrollees may select a daily allowance from $60 to $300.
- 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.
- Inflation protection. You will be offered opportunities to increase coverage without evidence of insurability.
- Bed Reservation. If hospitalized, you may use up to 21 days of benefits to reserve a nursing home bed for your use upon hospital discharge.
- Assisted Living Facility. This coverage provides payment at 80 percent of the daily benefit allowance.
- 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).
- Premiums do not increase with age or because you use your benefits.
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
- 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 60 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, Aetna Life Insurance Company, to obtain coverage.
2. File a Claim
Filing a Claim: Call the toll-free Long Term Care hotline at 1.800.537.8521 and request a Benefit Request Form to be completed by you and an Aetna physician. In addition, an Aetna 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.
3. Receive Long Term Care Benefits
To make things easier for you at a difficult time, we make the benefits payment process easy. Once you qualify to receive benefits under the plan:
- No bill is required from a provider.
- Benefits are paid directly to you at the end of each month, either by check or via direct deposit to your bank account.
- Payments can be paid directly to a provider as long as the daily benefit amount is less than or equal to the daily charge.
Selecting a Level of Coverage (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 $60 to $300 per day in $1 increments. Individuals who receive care in an eligible nursing facility are eligible for the full selected daily benefit allowance. Those who receive care in an assisted living facility receive payment of 80 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 daily benefit amount. Benefits (at a reduced daily level) will last longer when care is received outside a nursing facility (therefore, benefits under a three-year plan, for example, may extend beyond three years).
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 or upon retirement, whichever is later.
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. Aetna will continue to offer you this increase opportunity every three years, even if you declined prior offers. The only time Aetna will not make you such offers is when you are in claim and you had declined any previous offer. The amount you will be able to purchase is $1 up to 5% per year of your current daily benefit amount. This option is included in the plan.
When you purchase more coverage, you will pay additional premium at a rate based on your age as of the date Aetna 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 Aetna for this option.
Exclusions
The long term care plan will not pay benefits for a “loss of functional capacity” if that loss begins before coverage goes into effect. Therefore, anyone who has a loss of functional capacity before the effective date of the coverage would not be eligible for benefits and should not apply for coverage.
Each plan member receives an insurance certificate that includes full details of plan exclusions. In addition, the plan does not pay benefits for certain standard exclusions, such as losses due to:
- Certain hospital days covered under a medical plan
- Certain confinements in government institutions
- Self-inflicted injuries
- Treatment received outside the United States
- Treatments covered by workers’ compensation or similar laws or
- War.
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 Aetna. If the state employee dies or is divorced from their spouse, the spouse and other eligible individuals may continue coverage. Contact Aetna to make necessary arrangements.
Nonforfeiture
If you choose to cancel your state-sponsored Long Term Care insurance coverage, you may elect one of the following options:
- Extended term insurance allows coverage to continue for a specific amount of time with no reduction in the daily benefit amount. Aetna will calculate the duration of the extended coverage at the time of cancellation.
- A reduced, paid-up benefit is available to provide coverage for life if Aetna’s calculation is sufficient to produce a daily benefit of at least $20. The amount of the paid-up benefit will be less than the amount of coverage in effect while paying premiums.
Vendor Contact Information
For questions about long term care, contact Aetna at 1.800.537.8521.