Group Long-Term Care Insurance

Transcription

1 Group Long-Term Care Insurance from Mutual of Omaha Insurance Company For Members of The Features You Want With The Financial Protection You Need

2 Why Do You Need Long-Term Care Protection? When you or a member of your family is stricken with a chronic illness, disability, or just the effects of aging, he or she may need someone to care for personal needs, to enter a nursing home or to receive home health or adult day care services. Recognizing this need, NTEU has teamed up with Mutual of Omaha Insurance Company to offer you group long-term care coverage. A Question and Answer section regarding Long-Term Care insurance is included in this brochure. Who is Eligible? Members of the NTEU under age 80 are eligible for this quality plan. Spouses, parents (including stepparents) and parents-in-law of NTEU members are also eligible. All applicants must be age 79 or less prior to the date each person s coverage is approved and issued. See Effective Date section that follows for details. This coverage is currently not available to Connecticut residents. The parent can be a natural parent, a person who has legally adopted you or your spouse, or any other person who was married to your natural or adoptive parent. Unlike some other group coverages, the Long-Term Care Plan does not require that you enroll in order for your eligible family members to enroll. The acceptance or rejection of your application for Long- Term Care is in no way related to the acceptance or rejection of your spouse s application. Each applicant will be required to provide proof of good health based on a health questionnaire. A copy of this health questionnaire is contained in this brochure. Additional copies may be obtained by calling Mutual of Omaha s Long-Term Care Hotline at Effective Date For applicants age 79 or less, individual coverage will become effective on the first day of the month following the date Mutual of Omaha approves your application, subject to timely payment of the appropriate premium. However, the effective date of coverage will be deferred if the applicant is confined to an institution or disabled at the time coverage would normally begin. Daily Benefit Amount This refers to the maximum dollar amount of benefits payable per day of treatment or service. Your plan will pay covered expenses incurred, up to $100 per day for covered confinement services and up to $50 per day for covered nonconfinement services. Benefit Period A Benefit Period begins on the first day you receive covered services and ends when you go 180 consecutive days without receiving any covered services. No Prior Hospitalization Required You are not required to be hospitalized before becoming eligible to receive benefits from Long-Term Care. This allows you to go directly from your home to a nursing care facility, if necessary, or to receive home health care or adult day care benefits with no prior confinement. Respite Care Benefits Many elderly or disabled individuals are cared for at home by family members or friends. In order to provide relief to these caregivers, benefits are payable for confinement respite services in a nursing care facility or assisted-living facility. Benefits are also payable for overnight respite services provided by a home health care agency. COVERED SERVICES Confinement Benefits Necessary skilled nursing care, intermediate nursing care and custodial care are covered when you are a patient in a nursing care facility. During a Benefit Period Your plan pays 100% of the expense incurred up to the Maximum Daily Benefit for necessary skilled nursing care, intermediate care services and custodial care while confined in a nursing care facility. Benefits are payable after a Waiting Period of 60 days. Nonconfinement Benefits Home health care and adult day care are covered when you are able to take advantage of the health services available to you in your home or in an adult day care center. During a Benefit Period Your plan pays 100% of the expense incurred up to one-half of the Maximum Daily Benefit for each day of adult day care. With regard to home health care call, this plan pays 100% of the expense incurred up to one-half of the Maximum Daily Benefit. A home health care call is defined as four hours or less of home health care services per day. As multiple home health care calls may be required, your plan will reimburse up to the Maximum Daily Benefit. Benefits are payable after a Waiting Period of 30 days

3 Benefit Chart This easy-to-read chart outlines the benefits of NTEU s Group Long-Term Care Insurance Plan. GROUP LONG-TERM CARE INSURANCE BENEFITS TYPE OF CARE CONFINEMENT Skilled Nursing Care Intermediate Nursing Care Custodial Care WAITING PERIOD 60 days MAXIMUM DAILY BENEFIT $100 per day MAXIMUM BENEFIT 1,825 Units PREREQUISITES No Prior Hospitalization Required NON-CONFINEMENT Home Health Care Adult Day Care Respite Care 30 days Home Health Care: $50 per call Adult Day Care: $50 per day ½ Unit No Prior Confinement Care Required NOTE: The Maximum Benefit applies to all confinement, non-confinement and respite care services combined. Maximum benefits payable for all covered services received on any one calendar day will not exceed the Maximum Daily Benefit. Coordination of Benefits When an insured is covered under more than one plan providing benefits for the same services, the Coordination of Benefits provision will apply. Under this provision, when there are two plans, the primary plan pays benefits first as if there were no secondary plan. The secondary plan s benefits, when added to the benefits payable by the primary plan, will not exceed 100% of the total covered expense. Waiting Period Before your benefits begin, you must satisfy a Waiting Period as shown above. The days applied toward the Waiting Period can be made up of confinement and/or non-confinement services within the same Benefit Period. Maximum Benefit Once you receive a covered service a Benefit Period begins. After the Waiting Period is satisfied, benefits are payable until you reach the Maximum Benefit. The Benefit Period ends if you go 180 calendar days without receiving any covered service. If this happens, you must satisfy a new Waiting Period and begin a new Benefit Period before benefits are again payable. Your Maximum Benefits does not start over with a new Benefit Period. Once your Maximum Benefit is exhausted, no further benefits are payable. The Maximum Benefit for Long-Term Care is 1,825 units of covered service. This means you could be eligible to receive up to five years of care in a long-term care facility, 10 years of care at home, or any combination of the two. A unit of service is based on a calendar day of confinement in a facility. Each day of confinement for skilled care, intermediate care of custodial care is valued as one unit. Home health care, adult day care and respite care up to 12 consecutive hours are assigned one-half unit value for each day of nonconfinement service. Return of Premium If, for any reason, you decide to discontinue your Long-Term Care coverage, a portion of your premium can be refunded to you or your estate. The portion refunded depends on the amount of benefits paid and the number of years your coverage was in force. Years Portion In Force Refunded* Less than 5 0% 5 to 9 25% 10 to 14 50% 15 to 19 75% 20 or more 100% *The portion refunded is reduced by the amount of any benefits paid or payable

4 Benefit Eligibility Eligibility for benefits is based on both functional necessity and being unable to perform these Activities of Daily Living (ADLs): Eating Bathing Dressing Walking/Transferring Toileting Taking Medication The inability to perform an ADL may be caused by a physical or cognitive impairment, including Alzheimer s disease. Once insured, you are eligible to receive benefits when your doctor certified that the treatment is necessary and appropriate and the ADL test is met. Nursing home care benefits are payable when you are unable to perform three out of six ADLs without assistance. Home health care, adult day care and respite benefits are payable if you are unable to perform two out of six ADLs without assistance. Inflation Protection Each covered family member may independently choose to participate in either of these increase provisions. Automatic Inflation Protection If you choose this option on the application, your daily benefit amount will automatically increase by $5 each year for the next 20 years, up to a maximum increase of $100. This is in addition to any other increases to your daily benefit amount you may qualify for under the Benefit Increase Provision (explained below), and is effective regardless of whether or not you are receiving benefits at the time. If you choose this option, your premium will be slightly more at first, but it will not go up with each automatic benefit increase. Benefit Increase Provision As added protection against inflation, you will be able to increase your daily benefit amount by $20 (including $10 for nonconfinement services) every five years prior to reaching age 66, up to a maximum total increase of $100. Evidence of good health is not required to increase your benefit amount, except after age 65. When you increase your daily benefit amount, your premium for the increased amount will be based on your age at the time of the increase. This increase in coverage cannot be selected if the Benefit Increase Provision election date occurs after the insured s 80 th birthday or during a Benefit Period. The increase will not become effective if you are disabled or confined in a hospital or other health care facility at the time the increase would normally become effective. (See Confinement Rule as defined in the Definitions section.) By utilizing the increases under both of these inflation protection provisions, each insured person could increase his or her maximum daily benefit to a total of $300. Economical Cost In addition to offering you economical group rates, this plan includes the following cost-saving features: Entry Age Premiums. Your premium is based on each applicants age at the time the coverage becomes effective. Premiums may be increased based on a plan experience (utilization of the benefits by all participants), but will not go up just because the applicant gets older or uses the plan. Premiums for increases under the Benefit Increase Provision will be based on your age at the time of each increase selected. However, these increases will not affect the premium rates for previously purchased amounts. You cannot be singled out for a premium rate increase due to changing health or aging. Your coverage cannot be cancelled as long as you continue to pay your premiums. Waiver of Premium. When you are confined in a nursing care facility for 90 continuous days, you do not pay premiums which come due while you are confined. Your insurance coverage will continue without payment of premium as long as your confinement continues and benefits are payable. Your Waiting Period applies toward these 90 days. Plan Termination. In the event that your group s Master Policy is terminated, you can continue coverage by paying premiums directly to Mutual of Omaha Insurance Company. Preexisting Conditions If you receive medical treatment for a condition in the six-month period before becoming insured under the policy; and receive covered long-term care services for that condition or a related condition during the first six months of coverage under this plan, we will not pay benefits for that condition until you have gone 180 consecutive days without receiving covered services and a new Benefit Period begins

5 How to Apply Find your age in the rate chart on Page 6. This will be your premium rate per month. You (or the person applying) will be billed directly on a quarterly basis. For the quarterly rate, multiply the monthly rate by three. Parents and parents-in-law are automatically direct-billed on a quarterly basis. Premium rates are based on the applicant s age on the effective date of coverage. Below is an example of how you would figure your premium (shown with or without Automatic Inflation protection (AIP)). Remember, rates are locked in at each participant s age at the time coverage becomes effective. There are no rate increases based on age once you are enrolled. All applicants must fill out an application. NTEU members enrolling anyone in the Long-Term Care Plan, even if you are not enrolling yourself, must complete and submit the Enrollment Form to enable us to verify the applicants eligibility. This is because enrollment is limited to NTEU members and their families. Submit the enclosed Enrollment Form and Application to: Mutual of Omaha Insurance Company S1-Group Individual Underwriting Dept. Mutual of Omaha Plaza Omaha, NE Additional copies of the application can be made if required. Direct Bill Quarterly Rate Without AIP With AIP Your Age 46 $84 $132 Spouse s Age 43 $66 $102 Father-in-law s Age 68 $504 $732 Additional Features Your coverage cannot be cancelled as long as you continue to pay your premium. Your premium rate is based on your age on the date your coverage becomes effective. You are not required to be hospitalized before becoming eligible to receive confinement benefits. Nursing home care is not required before becoming eligible for home health care, adult day care or respite care benefits. After 90 days of continuous nursing home confinement for which you received benefits or which is applied toward your Waiting Period, your premium is waived for as long as your remain confined and we continue to pay benefits. You can t be singled out for a premium increase due to health changes. The plan covers Alzheimer s disease, subject to the preexisting conditions provision. If your employment terminates with National Treasury Employees Union, you and your covered dependents may continue coverage by paying premium directly to Mutual of Omaha. Except for annual payments there is a $5.00 fee per billing statement sent to your home address

6 Plan Exclusions and Limitations The plan does not cover any expense, loss or charge: a) for any injuries or sickness for which the insured is entitled to benefits under a workers compensation or occupational disease law; b) which exceeds usual and customary charges; c) for services or supplies not recommended by a physician or not reasonably necessary in treating the condition; d) for services or supplies provided by a person who lives with you or is part of your family; e) which results from an intentionally selfinflicted injury or sickness, or suicide or attempted suicide while sane or insane; f) resulting from participation in a riot or in the commission of a felony; g) for which the insured does not have to pay; h) for services or supplies which are not provided in accord with generally accepted professional medical standards, or which are for experimental treatment or are investigative and not proven save or effective. i) incurred due to alcohol or drug abuse; j) incurred due to mental disorders, except Alzheimer s disease or similar forms of senility or irreversible dementia; k) incurred outside the United States, its territories or possessions; l) which is paid by any other provision of the group health plan (whether insured or self-funded) provided by the Policyholder; m) incurred after insurance ends; n) for services or supplies provided or paid for by the federal government or its agencies; except for: the Veterans Administration, when services are provided to a veteran for a disability which is not service-connected; a military hospital or facility, when services are provided to a retiree (or dependent of a retiree) from the armed services; or a group health plan established by a government for its own civilian employees and their dependents; o) resulting from an act of declared or undeclared war or armed aggression; p) for which any governmental body or its agencies are liable while on active duty or training in the Armed Forces, National Guard or Reserves of any state or country. Misstatements Misstatements or omissions in your application may be used to contest the validity of insurance, reduce coverage or deny a claim in the first two years your certificate is in force. There is no time limit on the right to contest insurance or deny a claim if you were not eligible for the coverage. Notice of Information Practices We routinely need information about you in order to underwrite and administer your insurance coverage. You are our most important source of information, but we may obtain additional information from third parties. For example, we may ask physicians, hospitals, or another insurance company to confirm or add to the information you have given us. Personal Information Personal information obtained about you is treated in a confidential manner. It will be used only to the extent necessary for the conduct of our business. This information will not be disclosed to other persons or organizations without your written authorization. If you ask Mutual of Omaha Insurance Company in writing, you can: a) get recorded personal information in our files about yourself; b) offer reasons to correct, amend or delete such recorded personal information; and c) file your own statement of facts if you think our information is incorrect. Information Disclosure In most cases, the information we gathered about you will be sent to third parties only if you authorize us to do so. In all cases, we reserve the right to disclose medical information to a physician designated by you. In some instances, where disclosure is required by law or is necessary for us to conduct business, we may send that information to third parties without your consent. Obtaining Additional Information If you or your family would like to receive a more detailed explanation of practices, please write to: Mutual of Omaha Insurance Co. Attn: S-1 Group Individual Underwriting Department Mutual of Omaha Plaza Omaha, NE Please include your full name, Social Security Number, address and date of birth. Specify the policyholder (NTEU) and policy number (GMLC-4A84). Toll-Free Customer Service Line A Mutual of Omaha Long-Term Care Customer Service Representative is available to answer your questions about this plan during business hours (8 a.m. to 4:30 p.m. Central Time, Monday-Friday, except holidays):

7 Monthly Premium Rates for the National Treasury Employees Union Initial Maximum Daily Benefit: $100 Maximum Benefit: 1,825 Units of Service Waiting Period: 60 Days for Confinement Benefits 30 Days for Non-Confinement Benefits Age Long-Term Care Long-Term Care with Automatic Inflation Protection* Age Long-Term Care Long-Term Care with Automatic Inflation Protection* $34.00 $38.00 $40.00 $44.00 $48.00 $56.00 $62.00 $66.00 $72.00 $ $18.00 $ $52.00 $56.00 $62.00 $66.00 $72.00 $84.00 $90.00 $98.00 $ $ $18.00 $18.00 $20.00 $20.00 $ $78.00 $86.00 $94.00 $ $ $ $ $ $ $ $18.00 $18.00 $18.00 $22.00 $24.00 $26.00 $26.00 $ $ $ $ $ $ $ $ $ $ $ $20.00 $20.00 $22.00 $22.00 $22.00 $30.00 $30.00 $34.00 $34.00 $ $ $ $ $ $ $ $ $ $ $ $26.00 $28.00 $28.00 $30.00 $32.00 $40.00 $44.00 $44.00 $48.00 $ $ $ $ $ $ $ $ $ $ $ *Automatically increases your maximum daily benefit every year for twenty years

8 Questions and Answers 1. What is long-term care? Long-term care is defined as the kinds of services that may be needed if a chronic illness or disability occurs which makes it impossible for individuals to live independently. This care may be provided by family members, health care professionals, or both. 2. How is a long-term care facility different from a nursing home? Usually, the only difference is the name. But, because so many people think of a nursing home as a place where the very old go until they die, many health care professionals began to refer to them as long-term care facilities. Today the concept of a long-term care facility combines some of the best features of a hospital and a nursing home. It has become a place for people to go for only a few days or a few weeks following a hospital stay, until they are able to go home and function on their own. 3. How much does long-term care cost? The cost of one year of nursing come care averages $50,000 and can exceed $70,000 in some metropolitan areas. Home health care services may be less expensive, but sill average about $15,000. The length of time many people require for home or community-based care can be long, particularly for those with permanently disabling injuries or conditions such as Alzheimer s disease. 4. What is respite care? Many elderly or disabled individuals are cared for at home by family members or friends. Respite care is an in-home service which involves a health care aide who comes to the home to relieve the patient s caregivers. Respite care may be provided for as little as several hours, or it may allow the caregiver to take a longer break or vacation. 5. How is respite care different than home health care? Respite care is one kind of home health care. Home health care can include a wide range of services, including skilled nursing care, rehabilitation therapies, or assistance in various aspects of daily life. Like the care offered by a nursing home, home health services can range from highly skilled to custodial. Often, the home caregiver has little or no medical training. When that caregiver needs time away from the patient, respite care services can usually be provided by a home health care aide, who has minimal medical training. The aide may come into the home and take charge of the patient, much in the same way a sitter assumes responsibility for young children. Depending on the patient s health care needs, the services of the aide may be supplemented by a more highly trained individual. 6. Do I have to be confined to a hospital before becoming eligible for long-term care benefits? No. Most patients confined to long-term care facilities are not hospitalized first. The Long-Term Care Plan has been designed to meet the needs of those chronically disabled who do not necessarily require the services of an acute care facility like a hospital. By the same token, an individual is not required to be confined in a nursing home in order to be eligible for home health, respite or adult day care benefits. As long as the care is necessary, it will be covered. 7. How long will the Plan pay benefits? The Long-Term Care Plan will pay a maximum of 1,825 units of long-term care service. This maximum benefit is payable during the insured s lifetime, while the coverage is in force. 8. What is a unit of service? A unit of service is based on a calendar day of confinement in a facility. Each day of confinement is valued at one unit. Home health care and adult day care are assigned one-half unit value for each day of service. 9. If I become eligible to receive long-term care benefits, will I have to keep paying my premium? After you have received services in a longterm care facility for 90 consecutive days, future premiums due will be waived. You will not be required to resume premium payments until you are discharged from the long-term care facility. If you are receiving nonconfinement services, you are still required to pay the premium. 10. Will my premiums increase if I use the Plan? No. Your premium cost will not increase just because you receive benefits. Premiums are based on your age at the time your coverage becomes effective and should remain constant throughout your lifetime. However, Mutual of Omaha will periodically review the experience of Long- Term Care Plan participants and may adjust the Plan s premium rates, either up or down, based on this information. 11. What if I never use the Plan? Have I thrown my money away? No. If you never need the coverage, or need it only for a short time, the Long- Term Care Plan will refund to you (or to your estate) a percentage of your premiums paid. This is called Return of Premium. The percentage is based on the length of time you were covered by the Plan (at least five years) and is reduced by any benefits paid

9 12. Do the benefits increase with inflation? The Plan contains a Benefit Increase Provision which allows you and each of your covered family members to increase your daily benefit amount by $20 (up to a maximum total increase of $100, allowing your daily benefit amount to increase to $200). To be eligible, an insured cannot have had covered services within the last six months. This option will be available after the Plan has been in force for five years and will be offered every five years thereafter. The rates for each increase will be based on your age at the time of the increase. Another feature is the Automatic Inflation Protection option. This option will automatically increase your maximum daily benefit by $5 each year for 20 years, to a maximum increase of $ What are the differences between the Benefit Increase Provision and the Automatic Inflation Protection option? The Benefit Increase Provision is already incorporated into the Plan. You don t have to make a decision about this now. At each five-year anniversary of the Plan, you have the choice of increasing your daily benefit amount by $20. Your premium for the increased amount will be based on your age at the time of the increase. (The cost of your initial coverage will not be affected by your decision.) However, for this increase to become effective, you must not be confined to a hospital or long-term care facility or be receiving at-home assistance with ADLs (Activities of Daily Living). In addition, you must not be in a Benefit Period (180 days after confinement ends) in order for the Benefit Increase Provision to become effective. The Automatic Inflation Protection option is a choice you make at the time of enrollment. You will pay a slightly higher premium from the beginning, but the rates for the automatic increase are based on your age at the time your coverage becomes effective. Each $5 increase to your maximum daily benefit is automatic even if you are receiving benefits at the time. This means you don t have to provide evidence of good health at the time of any of the increases, regardless of your age or current health. Each applicant can decide whether or not to choose this option at the time of enrollment. If you decide to add it later, evidence of good health will be required, and the cost of the option will be based on your age at that time. 14. Who is eligible to enroll in the Long-Term Care Plan? The Long-Term Care Plan is being offered to members of the National Treasury Employees Union (NTEU) and their spouses, parents (or stepparents) and parents-in-law. You must be a member of NTEU in good standing to apply for coverage for yourself. The current spouse of the member may enroll for coverage. Each member and/or spouse is limited to enrolling two parents ; that is, each can enroll one male and one female parent; or one parent and one stepparent; or two stepparents. 15. Are there any age limits for enrollment? The maximum age at which you may be accepted into the Plan is 79. Each applicant must be less than 80 years old on the date his or her coverage becomes effective. Dependent children are not eligible for the Plan, regardless of age. 16. Does the age 79 limit restrict benefits after I become 80? No. Once you have purchased the coverage, your coverage continues in force as long as you pay your premiums of until all plan benefits are exhausted. 17. Why isn t the Plan being offered to people age 80 or over? The cost to cover someone age 80 or order would be extremely high. Therefore, only those who considered it very likely they would use the coverage would purchase it. 18. Why isn t coverage being offered for dependent children? The principal reason this coverage is being offered, even to younger age adults, is to provide an affordable form of protection against the cost of long-term care, the likelihood of which increased as you age. Survey results indicate this coverage has limited appeal for the very young unless the child already has a condition requiring long-term care. 19. When will my coverage be effective? For members and spouses, parents and parents-in-law age 79 or less, individual coverage will become effective on the first day of the policy month following the date Mutual of Omaha approves the application. This date will appear on your Certificate Validation Form which accompanies your Certificate booklet. However, the effective date of coverage will be deferred if the applicant is confined or disabled on the date coverage would normally begin. 20. When is the enrollment period for the Long-Term Care Plan? You and each family member can enroll at any time, as long as you are an NTEU member in good standing and all applicants are 79 or less. 21. Will any kind of health statement be required? All members, spouses and parents, stepparents and parents-in-law are required to complete a brief health questionnaire. Mutual of Omaha reserves the right to request additional medical information

10 22. What if I apply for this coverage for my spouse and parents-in-law, then get divorced? The coverage is guaranteed renewable, as long as premiums are paid in a timely manner. Your divorced spouse and parents-in-law will be allowed to continue their coverage by continuing their premium payments. 23. What will happen if I remarry? Can I cover my new spouse? Yes. Both your new spouse and new parents-in-law will be eligible for the Long- Term Care Plan, as long as they are 79 or less. 24. If my spouse applies for coverage and is declined due to the health history, can my parents-in-law still be considered for coverage? Yes, Your spouse was eligible for the Plan, provided you are a member of NTEU in good standing. Your parents-in-law are eligible regardless of whether or you or your spouse enrolls as long as they are less then 80 years of age. 25. My father has had some health problems in the past. Does that mean he will be turned down for coverage? Not necessarily. Underwriting approval is based on many factors. Let s say, for example, your father has high blood pressure. If his blood pressure problem is controlled by medication and he has not had other serious health problems, he may be accepted. On the other hand, if his blood pressure is not under control or he has a history of erratic blood pressure readings, coverage could be declined. Underwriting decisions will be based on the information provided on the application. If you or a family member has some significant health history, you may want to submit an attending physician s statement with the application. This will help Mutual of Omaha underwriters to make a more informed decision. 26. I wanted to hear about this for my parents. They have always said they don t want their children to provide for them, but I m reasonably sure they don t have this kind of insurance. Could I purchase this without them knowing? No, because they have to sign the application and answer medical questions that have to be asked. Your parents must be involved. You can pay the quarterly premiums for them, if you choose, but they do have to be involved. 27. If a person has medical conditions the insurance company is not willing to cover, can the coverage be issued with a rider excluding those conditions? No. The coverage will be issued in total or declined. Preexisting conditions may not cause declination but may limit benefits payable by the Plan. 28. How does the preexisting conditions limitation work? Preexisting conditions are conditions that warranted medical attention prior to the effective date of coverage. Benefits for preexisting conditions will be paid if you do not require long-term care services for at least six months after coverage becomes effective. This means that if you purchase coverage and need services for a preexisting condition within six months of your effective date, the Plan will not pay. The limitation will remain in effect until you go six months without long-term care services for that or a related condition. If everyone who already needed long-term care purchase coverage, premiums would not be affordable for the rest of us. The purpose of the preexisting conditions limitation is to discourage people from enrolling for coverage because they know they need long-term care. 29. Is Alzheimer s disease covered? Yes, but the disease must manifest itself after the effective date of coverage. Because of the progressive nature of the disease, victims of Alzheimer s become unable to perform several or all of the Activities of Daily Living and are, therefore, unable to care for themselves appropriately. 30. What about AIDS and AIDS Related Complex (ARC)? As long as they are not preexisting conditions, AIDS and ARC will be covered. 31. How do I enroll? Just complete the enrollment form, applications included in this brochure and submit them to: Mutual of Omaha Insurance Co. S1-Group Individual Underwriting Department Mutual of Omaha Plaza Omaha, NE To whom can I talk if I have more questions about long-term care coverage? Mutual of Omaha Insurance Company has set up a Long-Term Care Hotline. If you have additional questions or need more information, please call (8:00 a.m. to 4:30 p.m., Central Time, Monday Friday, except holidays). This brochure is a summary of some of the principal provisions of the group insurance program offered to members of NTEU. It is not a Contract for Insurance. The complete terms of the program are set forth in the Group Policy GMLC-4A84 booklet issued by Mutual of Omaha Insurance Company to NTEU

11 Definitions Some Terms You Should Know Activities of Daily Living Walking, bathing, dressing, eating taking medications, and toileting. Adult Day Care Usually a daytime program for adults, including medical, personal and recreational services. Benefit Period Begins on the first day you received covered services and ends when you go for 180 continuous days without receiving covered services. Confinement Rule At the time coverage (or any increase to coverage from the Benefit Increase Provision) becomes effective, you must not be confined to a hospital or a long-term care facility, or receiving at-home assistance with performing ADLs (Activities of Daily Living). In addition, you must wait 180 days after your confinement ends and until your Benefit Period is complete before the Benefit Increase Provision can be added to your maximum daily benefit. If you are in a Benefit Period, you are not eligible to elect the Benefit Increase Provision. The Confinement Rule does not affect the Automatic Inflation Protection option. This automatic increase to your daily benefit becomes effective regardless of services or benefits you may be receiving. Confinement Services Necessary skilled nursing care, intermediate care and custodial care in a nursing home. Custodial Care Assistance with personal care which can be provided by someone without professional skills or training. Expense the expense incurred for a covered service or supply. A physician has to order or prescribe the service or supply. Expense is considered incurred on the date the service or supply is received. Expense does not include any charge: (a) for a service or supply which is not necessary; or (b) which is in excess of the usual and customary charge for that service or supply. Home Health Care Provided at home, this may include personal care, skilled nursing care, speech therapy, physical therapy, social services of the services of a home health aide. This can also include respite care (see definition below). Intermediate Care Occasional nursing and rehabilitation care provided by skilled medical personnel for those not needing round-the-clock skilled nursing care. Maximum Benefit The NTEU Long- Term Care Plan has a maximum of 1,825 units of service (see definition below). Long-Term Care Facility A statelicensed inpatient facility providing a program of nursing care and related services. Generally, these requirements are not met by retirement homes, rest homes, mental institutions or sheltered living homes. Necessity In order for the patient to receive benefits, a physician must certify that the treatment is necessary and appropriate. The Plan does not require an injury or an illness in order for benefits to be payable. Nonconfinement Services Includes home health care, adult day care and respite care. Nursing Home Care Skilled or intermediate nursing care of custodial care for inpatients in a long-term care facility. Preexisting Condition A condition for which the patient received treatment or service in the six-month period before becoming insured. Benefits are not payable for a preexisting condition until no expense (covered by the Plan) is incurred for that condition or a related condition for 180 consecutive days. Respite Care Respite care is a type of home health care designed to relieve the patient s caregiver(s). An aide comes to the home to provide respite care for as little as a few hours, or up to several days to allow the caregiver a longer vacation. Skilled Nursing Care 24-hour-a-day care, performed under the supervision of a licensed physician, consists of nursing and rehabilitation services administered by registered nurses, licensed practical nurses or physical therapists. Unit of Service Each unit of service is based on a calendar day of confinement in a facility. Each day of confinement for skilled care, intermediate care or custodial care is valued as one unit. Home health care, adult day care and respite care up to 12 consecutive hours are assigned one-half unit value for each day of nonconfinement service. Waiting Period The number of days confined in a facility or the number of home care visits or adult day care services provided before the Plan pays benefits. You must satisfy a Waiting Period of 60 days for confinement benefits and 30 days for nonconfinement benefits. The days applied toward the Waiting Period can be made up of confinement and/or nonconfinement services within the same Benefit Period

12 National Treasury Employees Union GROUP LONG-TERM CARE ENROLLMENT FORM HOME OFFICE USE ONLY Division Class Effective Date Group Name National Treasury Employees Union Policy No. GMLC-4A84 Please Print 1. SPONSORING MEMBER INFORMATION Social Security No. Sex: Male Female Name Residence Address Mailing Address Last First M.I. Street City State Zip Street City State Zip Date of Birth Daytime Phone No. ( ) Month Day Year 2. I AM APPLYING FOR COVERAGE FOR: Myself My Spouse (name) Social Security No. My Mother or Stepmother (name) Social Security No. My Father or Stepfather (name) Social Security No. My Spouse s Father or Stepfather (name) Social Security No. My Spouse s Mother or Stepmother (name) Social Security No. Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year I understand that, in order to be considered for coverage, a health questionnaire must be completed by each applicant I am enrolling. Coverage will not become effective until approved by Mutual of Omaha. I understand the certificate is subject to all policy provisions including payment of premium. (Signature of Applicant) (Date) Send this Enrollment Form and an Application for each applicant to: Mutual of Omaha Insurance Company Attn: S1-Group Individual Underwriting Department Mutual of Omaha Plaza Omaha, NE 68175

13 National Treasury Employees Union GROUP LONG-TERM CARE APPLICATION HOME OFFICE USE ONLY Division Class Effective Date Group Name National Treasury Employees Union Policy No. GMLC-4A84 Member Name Member Soc. Sec. No. In order to be eligible for this group long-term care coverage, you must be a member of NTEU in good standing, or the spouse, parent or parent-inlaw of that member. Please Print 1. APPLICANT INFORMATION Applicant Soc. Sec. No. Height Weight Sex Name Residence Address Mailing Address Last First M.I. Relationship to Member Street City State Zip Street City State Zip Date of Birth Home Phone No. ( ) Month Day Year Place of Birth Daytime Phone No. ( ) City State Marital Status Premium Payment: (select one) I wish to pay my premium by: Quarterly Direct Bill 2. LONG-TERM CARE PLAN Minimum Daily Benefit Maximum Benefit Waiting Period Automatic Inflation Protection? $100 1,825 units 60 days confinement Yes No 30 days non-confinement 3. HEALTH INFORMATION (a) Have you ever had, been advised by a physician that you had or received advice or treatment for: (Circle conditions answered YES and give details in the space provided on the back of this form.) (1) High blood pressure, chest pain, heart attack or stroke? (2) Alzheimer s disease, seizures or convulsions, paralysis, mental or nervous disorder, or brain disease or disorder? (3) Cancer, leukemia, malignant growth or any form of tumor? (4) Diabetes, kidney disease or disorder, or any other disorder of the urinary system? (5) Asthma, emphysema or any lung disease or other respiratory disorder? (6) Arthritis, neuritis, rheumatism, gout or any disease of, disorder or injury to the back, spine, bones muscles or joints? (7) Alcohol abuse, drug abuse, Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)? (8) Any loss of hearing, or loss of or partial loss of use of any eye, limb, hand or foot? (b) Have you ever used a wheelchair, crutches, cane, walker or other mobility aid (i.e. braces, prosthesis, etc.)? If Yes give details in the space provided on the back of this form. (c) Within the past 12 months, have you used medication, received medical treatment or been confined to a hospital, nursing home or convalescent facility? If Yes, give details in the space provided on the back of this form. YES NO

14 Yes No (d) Within the past five years, have your had any mental or physical disorder or bodily injury not listed above? If Yes, give details below. Ques. No. Condition, Injury, Symptoms of Ill Health or Findings of Examination (if Operation Performed, State Type) Month and Year Duration Degree of Recovery Name, Address and ZIP Code of Hospital and Attending Physician (e) Can you perform each of the activities of daily living listed below without physical or mechanical assistance or supervision? (If any question is answered No, give details below.) Yes No Yes No (1) Get in or out of bed (4) Dress (2) Take medications (5) Toilet (3) Eat, prepare meals (6) Bathe Details for No answers: (f) Are you living with another adult? Yes No If Yes : (1) for how long? (2) age of the other adult? (g) Is this insurance being purchased in addition to or to replace any existing accident and sickness insurance? Yes No If Yes, please list all such coverages below. Indicate if any such coverage is to be replaced by the insurance applied for with this application. Company Name Policy No. (if known) Coverage Replaced Yes Yes No No STATEMENT OF APPLICATION I apply for Long-Term Care insurance for myself. I understand that insurance will not begin until Mutual of Omaha approves me for such insurance. I have given the above answers to obtain this insurance. These answers are true and complete to the best of my knowledge and belief. I know that insurance could be void if answers are not true and complete. I understand I cannot make changes to my coverage except as provided by the policy. To: Physicians, Hospitals and Other Providers of Health Care Services, Insurers, Employers and Group Policyholders You may give Mutual of Omaha health, job status or other insurance information about me. You may also give this information to Mutual of Omaha s reinsurer or to the Policy Administrator. Health information includes all records about: (a) physical and mental health, (b) medical history and (c) drug and alcohol use. This information will be used to evaluate my application. This form will be valid for 30 months from when it is signed. A photocopy of this form is as valid as the original. A copy of this form will be provided and will be made a part of my certificate. I understand the certificate is subject to all policy provisions including payment of premium. I have a copy of Mutual of Omaha s Notice of Information Practices. I, the undersigned application, certify that I have read the above completed application and realize any false statements or misrepresentations in the application may result in loss of coverage under the policy. (Signature of Applicant) (Date

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