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SECTION
FIVE
Long Term Care
Long
term care refers to a wide range of personal care, health care and social
services for people of all ages who suffer a chronic disease or long-lasting
disability. This type of care, often called custodial care, can be provided
in a nursing facility, an adult day care center or at home. Most of the
cost of long term care is not covered by health insurance plans or by
Medicare. The State of Ohio Long Term Care (LTC) Plan is specifically
designed to help cover these costs.
The
Long Term Care Plan provides insurance that state employees and certain
other eligible individuals may purchase. The insurance covers long term
care expenses that result from a loss of functional capacity. The loss
of functional capacity must have occurred after the effective date of
your long term care insurance.
The
following information is only a summary of this benefit. For complete
information, request an enrollment kit by calling Aetna, the long term
care administrator, at (800) 537-8521. Be sure to mention that you are
interested in the State of Ohio plan.
Eligibility
You may be eligible for long term care benefits if you are either:
- Permanent
full-time employee
- Permanent part-time
employee working 20 or more hours per week
If you
are eligible for long term care insurance benefits, the following are also eligible:
- Spouse
- Parents
- Parents-in-law
- Adult children
Your
spouse, parents and other eligible individuals may enroll for long term
care even if you do not.
Enrollment
If you are eligible, you may initially enroll within 60 days of the date
you were hired by the State of Ohio. 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.
Group
Advantages and Individual Policy Flexibility
Each individual who enrolls for long term care coverage has their own
individual contract. Therefore a wife may have a three-year plan while
the husband has selected a five-year plan. One may select to have the
return of contribution benefit while the other does not. This flexibility
is available at group rates and with the stability of a large group plan.
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% 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.
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.
Qualifying
to receive care
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.
Optional
Coverages
- Three- or
Five-year plan. You choose a three- 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 to have Return of Contribution or not.
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.
How
to determine your premium
Your monthly premium depends on your age, the daily benefit allowance
and lifetime maxiumum benefit (three or five years) you select and whether
you select the Return of Contribution optional feature.
For an exact
rate, call Aetna at (800) 537-8521 and ask about the State of Ohio plan
or visit the Aetna U.S. Healthcare Web site at www.aetna.com/group/stateofohio/.
Payments
If you are eligible for the Long Term Care Plan and elect to take advantage
of the benefits, you will pay the full cost of the insurance premiums.
Employees
and their spouses pay through payroll deduction. Other eligible persons
make direct payments to Aetna.
Information
and Referral
There are savings opportunities for claimants and plan members through
Aetna's Information and Referral and Consultation services along with
national provider discounts. If you need information on nursing homes,
adult day care, etc., please call the Long Term Care hotline at (800)
537-8521 for more information.
Filing
a Claim
Your request for benefits begins with a phone call to the toll-free Long
Term Care hotline, (800) 537-8521. You will receive 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. Our case managers are registered
nurses and professional social workers who are specially trained to help
you and your relatives through the claims process.
Receiving
Benefits Payments
In order 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 and of each month, either by check or
via direct deposit to your bank account.
- Payments can
be assigned to a provider as long as the daily benefit amount is less
than or equal to the daily charge.
Benefit
increase opportunities to keep pace with inflation
Plan members have two ways to keep pace with rising costs of long term
care:
- You may take
advantage of inflation protection increase opportunities while you
are receiving benefit payments as long as you have not declined a
previous offer.
- To keep up with
inflation, you will have opportunities to buy more coverage every
two years with no medical review. The increased amount available
will be a minimum of $1, up to 5 percent of the plan maximum daily
benefit amount, compounded annually.
- You may apply
to increase your daily benefit amount anytime that you are not receiving
benefits. This increase is only with Aetna’s written consent
and upon providing proof of good health. Coverage may be increased
up to the maximum daily benefit amount. The cost of any additional
coverage will be based on the plan member’s age at the time of
purchase. This amount will be added to the original premium.
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.
Exclusions
The 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 which 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
- War
Aetna
Customer Service
If you have questions about the State of Ohio Long Term Care Plan, or
would like enrollment materials or need to initiate a claim, you may call
Aetna’s toll-free customer service hotline at (800) 537-8521 Monday
through Friday from 8 a.m. to 5 p.m. EST.
Customer
service representatives who are familiar with the State of Ohio plan are
available during those hours. Callers at other times may leave a message
on Aetna’s voice mail system and will receive a call back the next
business day.
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