2010 Insurance Benefits Guide www.eip.sc.gov Employee Insurance Program 141
Insurance Benefits Guide 2010 Table of Contents Insurance...143 Important Information About the Plan...143 Plan Details...144 Coverage Amounts...145 Base Plan Features...145 Points to Remember...147 Exclusions...148 Appeals...148 If you kept your long term care policy with Aetna, you can reach Service by calling 800-537-8521. 142 Employee Insurance Program www.eip.sc.gov
2010 Insurance Benefits Guide Insurance What is Insurance? Why Do You Need It? Long term care refers to a broad range of medical, personal and social services provided to people who are unable to care for themselves over an extended period of time. It usually involves help in performing everyday functions, such as toileting, bathing, eating and dressing. Long term care is not limited to care in a nursing home. Services are often provided in an assisted-living facility or at home by caregivers, such as home healthcare workers, nurses or therapists, or in a community setting, such as an adult day care center. By assisting in paying for these services, long term care insurance helps individuals stay independent as long as possible, makes it more likely they can choose where they receive assistance, and helps preserve their assets. As you review this information you may wish to consider some facts about long term care in the United States, what long term care is and what the chances are that you will need it: For more information about Prudential Long Term Care Insurance, contact customer service at 877-214-6588 or at LTC4me@prudential.com. You may be surprised to learn that 40 percent of long term care insurance benefit recipients are younger than age 65. 1 The younger you are when you first purchase long term care insurance, generally the lower your premium for the life of your plan, regardless of your age or health in later years. 2 More than 2 in 5 persons older than age 65 will require nursing home care at some time in their lives. 3 Nursing home care alone can cost, on a national average, $79,000 a year. 4 With Prudential s SM Insurance plan, you select the amounts you would like to be reimbursed for daily nursing home and home and community-based care. The benefits you receive are determined by your Daily Benefit Maximum option and your Lifetime Maximum option. Once you qualify for benefits, you must satisfy the one-time waiting period. Please review the details of your plan. You will also want to familiarize yourself with the features offered through Prudential s plan. They are explained in the Plan Details section, beginning on page 144. 1 Americans for Long-Term Care Security (ALTCS), Did You Know, 2005, http://www.ltcweb.org/learn.html#did. 2 Prudential reserves the right to change premium rates in the future, but only on a class basis. 3 Insurance: Who Really Needs It?, Journal of Financial Planning, Sept. 2004. 4 Prudential Financial Cost Survey, 2008. Important Information About the Plan Premiums Your premium is based on your age when you enroll. If you enroll now, you will pay a lower premium than if you wait until you are older to enroll. This premium can change only if Prudential changes premiums for all members of your insured class. Premium charts are on pages 224-225. Payment Method Insurance premiums may not be paid though payroll or pension deduction under the Employee Insurance Program. Employees, retirees and qualified family members can select a direct billing method, which provides discounts for semi-annual (2.83 percent) and annual (5.58 percent) payments. www.eip.sc.gov Employee Insurance Program 143
Insurance Benefits Guide 2010 You may also select the monthly Electronic Funds Transfer (EFT) option and have the premium withdrawn automatically from your checking or savings account. Portability You may keep this coverage, even if you change jobs or retire. Your coverage will remain in effect as long as you continue to pay your premiums on a timely basis and do not exhaust your benefits. Qualifying For Benefits To qualify for benefits, you must be confirmed as having a Chronic Illness or Disability. A Chronic Illness or Disability is an illness or disability certified by a Licensed Health Care Practitioner in which there is: 1. 2. A loss of the ability to perform, without substantial assistance, at least two of the six Activities of Daily Living. This loss must be expected to continue for 90 days or more. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring. A severe cognitive impairment is one that requires you have substantial supervision to protect you from threats to your health or safety. Once you are determined to be eligible for benefits and have satisfied the waiting period, benefits will be payable according to the plan of care developed for you by the Licensed Health Care Practitioner responsible for your care. Access to Benefits To begin the benefits process, call Prudential s Customer Service Center toll-free at 877-214-6588 before you incur charges for long term care services. You can arrange for your own assessment or Prudential can do it for you. How Do I Enroll? To enroll, log in to Prudential s customized enrollment Web site at www.prudential.com/gltcweb. Group Name: eipltc. Access Code: carolina. Prudential s customer service representatives are there to help if you have any questions or would like to request that a paper enrollment kit be shipped to you. Call Prudential at 877-214-6588. Plan Details Eligibility Eligible participants include: All actively-at-work, full-time, permanent employees Persons who are related to an eligible employee in one of the following ways: spouses, parents, parentsin-law, grandparents, grandparents-in-law, siblings, adult children age 18 and older and their spouses Retirees and their spouses Surviving spouses. Guaranteed Coverage All actively-at-work, full-time, permanent employees who enroll 31 days of their date of hire will be guaranteed coverage without medical evidence of good health. 144 Employee Insurance Program www.eip.sc.gov
2010 Insurance Benefits Guide Medical Evidence of Good Health Requirements Eligible applicants, other than those described under Guaranteed Coverage, may enroll at any time but must provide medical evidence of good health. Note: Applicants age 72 and older will receive an in-person assessment to supplement the information provided on the enrollment form. Coverage Amounts Plans Nursing Home Care & Assisted Living Daily Benefit Maximum 1 Home & Community- Based Care Daily Benefit Maximum 1 Lifetime Maximum 2 Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 11 Plan 12 $100 $150 $200 $250 $300 $350 $ 50 $ 75 $100 $125 $150 $175 $182,500 $273,750 $365,000 $456,250 $547,500 $638,750 $100 $150 $200 $250 $300 $350 $100 $150 $200 $250 $300 $350 $182,500 $273,750 $365,000 $456,250 $547,500 $638,750 1 Benefi ts are paid, up to the Daily Benefi t Maximum. 2 All benefi ts paid will be deducted from the Lifetime Maximum. For Plans 1-6, the Home & Community-Based Care Daily Benefit Maximum is 50 percent of the Nursing Home Care Daily Benefit Maximum. For Plans 7-12, the Home & Community-Based Care Daily Benefit Maximum is 100 percent of the Nursing Home Care Daily Benefit Maximum. Base Plan Features Alternate Plan of Care This insurance plan takes into account the institutional and home and community-based care settings that are now available. Prudential will consider a claim for benefits for care received in an alternate setting or for non-institutional services designed to help you remain independent in your home. Determination of eligibility for this benefit amount will be made on an individual basis at the sole discretion of Prudential. Bed Reservation Benefit Families may spend a great deal of time locating a suitable nursing home or assisted living/residential care facility, only to lose the bed because of a short absence due to a hospital stay. This benefit helps reserve your bed in a nursing home or assisted living/residential care facility for up to 21 days per calendar year, if you require a hospital stay. Benefit Waiting/Elimination Period Before benefits are payable, you must satisfy the 90-day Benefit Waiting/Elimination Period. The period is counted in calendar days and begins on the date you are assessed (assuming you are determined to be eligible for benefits). You do NOT need to receive formal long term care services to satisfy the waiting period. This waiting period needs to be satisfied only once during your lifetime. Note: There is no waiting period for hospice care, independence support, caregiver training, information referral services or private care management. www.eip.sc.gov Employee Insurance Program 145
Insurance Benefits Guide 2010 Private Care Management If you decide you would rather use care management services other than Prudential Care Counselors, Prudential will reimburse you for eligible charges up to the benefit limit for private care management in a calendar year. That limit is 12 times the Daily Benefit Maximum. Caregiver Training If someone who will provide care for the insured requires caregiver training, there is a benefit equal to five times the Daily Benefit Maximum you selected, and no waiting period is required. In certain situations, caregiver training may be applied toward requirements for state licensure or certification. A licensed or statecertified caregiver may then be eligible for benefits under the Home & Community-Based Care benefit. For more information, contact Prudential at 877-214-6588. Cash Alternative This feature provides you with an option to address your long term care needs in any manner you choose. It provides a monthly fixed benefit in lieu of reimbursement for eligible charges for Home & Community- Based Care. The benefit is equal to 50 percent of the Daily Benefit Maximum for Home & Communitybased Care. The Cash Alternative benefit will reduce the Lifetime Maximum Benefit and is subject to the Elimination Period. Death Benefit A portion of premiums an insured has already paid into the plan is returned if the insured dies. The refund of premiums is based on the insured s age at death and is decreased by any benefits paid under the plan. There is a 100 percent refund through age 64, reduced by 10 percent each year, starting at age 65. Independence Support Benefit Often a few modifications to your residence can mean the difference between going to a nursing home and remaining at home. This benefit allows you, when not in a nursing home, to receive benefits for expenses, such as home modifications or medical alert systems, to help you maintain your independence. You must meet Prudential s benefit eligibility criteria to be eligible. No waiting period is required. The benefit is limited to 50 times the elected Daily Benefit Maximum and is deducted from the Lifetime Maximum. Information/Referral Services Prudential is dedicated to helping provide you with as much freedom as possible in making long term care decisions. Information/Referral Services, advice and care counseling, are provided by Prudential Care Counselors, who are available to you at any time, even if you have not been determined to be eligible to receive benefits. Prudential Care Counselors may be reached toll-free at 877-214-6588. International Coverage Benefit To meet the needs of diverse and geographically dispersed families, you can receive reimbursement for eligible charges up to 75 percent of the Daily Benefit Maximum for facility care, or 75 percent of the Home & Community-Based Care Daily Benefit Maximum for home care, for up to 365 days, for care received outside the U.S. International coverage will reduce the Lifetime Maximum and is subject to the waiting period. The exclusion for services and supplies outside the U.S. does not apply to the International Coverage Benefit. Marital Discount A married person who buys long term care insurance receives a 10 percent premium discount, regardless of whether the spouse is covered under the plan. 146 Employee Insurance Program www.eip.sc.gov
2010 Insurance Benefits Guide Periodic Inflation Protection Inflation protection will be offered at least every three years to anyone who does not elect optional Automatic Inflation Protection. No medical evidence of good health is required unless you decline two consecutive inflation offerings. Coverage amounts are increased by at least 5 percent per year, compounded annually. Rates for this additional coverage are based on your age at the time the inflation offer is accepted. Optional Automatic Compound 5 Percent Inflation Protection It is likely that you will not use your long term care insurance coverage for 10, 20 or even 30 years. For this reason, Prudential offers you the choice of inflation protection. This feature will help protect your benefits against inflation, regardless of changes in your health. If you elect this option, plan benefits will increase 5 percent per year, compounded annually. These increases occur without a premium increase if you elect Automatic Inflation Protection. However, your initial premium will be higher than it would be without this feature. If you do not elect this option, Prudential will offer you opportunities to increase your coverage over time, but the rates for the increase will be based on your age when the increase takes effect. Respite Care Most people would rather be taken care of by someone they know. This benefit provides relief for a family member who normally provides you with unpaid care. Prudential s plan pays for up to 21 days of respite care per calendar year, 100 days per lifetime. The benefits are paid up to the elected Daily Benefit Maximum, regardless of the type of services used, and will be deducted from the Lifetime Maximum. To receive this benefit, Prudential must be notified before you use services. Restoration of Benefits If, after submitting a claim, you return to normal activities (no activity of daily living limitations or cognitive impairment) for at least six consecutive months, your Lifetime Maximum will be restored to the level in effect before you made a claim. Waiver of Premium Once you meet the benefit eligibility criteria and satisfy the Benefit Waiting/Elimination Period, Prudential will waive your premium payments. Points to Remember Deferred Effective Date If you are an employee, your coverage will be delayed if you are not actively at work on the day your insurance would otherwise become effective. If you are confined for medical care or treatment on the day the insurance is to be effective, your effective date will be delayed until the first day of the month after the date you are discharged and are no longer receiving such care. Coordination of Benefits Your benefits under this plan may be coordinated with other coverage that provides benefits for the same services covered by this insurance. Consult your insurance certificate for more information. www.eip.sc.gov Employee Insurance Program 147
Insurance Benefits Guide 2010 Exclusions This plan is designed to provide coverage for the long term care you need when you need it. However, there are some circumstances in which benefits are limited or excluded under this plan. While state variations may apply to specific limitations and exclusions, generally, no benefits will be payable in any of these situations: Work-connected Conditions Charge A charge covered by a workers compensation law, an occupational disease law or a similar law. Government Plan Charge A charge for a service or supply: (a) furnished by or for the United States government or any other government, unless payment of the charge is required by law; or (b) to the extent that the service or supply, or any benefit for the charge, is provided by any law or governmental plan under which the patient is, or could be, covered. This (b) 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-governmental program. When this (b) is applied to Medicare, the benefits provided by Medicare will be deemed to include any amount that would have been payable by Medicare in the absence of a deductible or coinsurance requirement under that program. In other words: Your long term care plan will not reimburse you for any services or supplies covered by Medicare or any other government program, unless required to do so by law. Self-inflicted Injury or Suicide Charges arising from intentionally self-inflicted injury or attempted suicide, while sane or suffering from inorganic-based insanity. Services and Supplies Outside the United States Charges for services or supplies outside the U.S., except as described in the International Coverage Benefit. Treatment for Chronic Alcoholism or Chemical Dependency Charges in connection with the treatment of chronic alcoholism or chemical dependency. War, Felony, Riot or Insurrection Charges for a condition due to war or any act of war while you are insured or due to the insured s participation in an act of felony, riot or insurrection. War means declared or undeclared war and includes resistance to armed aggression. Riot means a wild, violent, public disturbance of the peace. Appeals You have the right to appeal decisions made about your claims. The Explanation of Benefits will explain the procedure you should follow if you choose to appeal a claim decision. Prudential will send you a written acknowledgment of your appeal. If no additional information is required and the appeal is denied, the acknowledgment will include a detailed explanation of the reasons for the denial. If additional information is required, Prudential will explain what information is needed. Upon receipt and review of the additional information, Prudential will notify you in writing of the results of the review. If you still disagree with the decision, you can request in writing within 60 days of the decision that the matter be submitted to the Claim Appeal Committee. This committee includes, but is not limited to, clinical consultants, legal consultants and product management staff. After a thorough review, the committee will send you written notification of its decision. 148 Employee Insurance Program www.eip.sc.gov