Long-Term Care Plan

How Your Long-Term Care Insurance (LTC) Plan Works 

Note: This section applies only for Tufts Health Plan employees who enrolled in the LTC Plan before December 31, 2011. Participation in this Plan was no longer available after that date. 

INSURANCE CERTIFICATE AND PLAN ASSISTANCE
The full facts and details concerning the LTC Plan’s operation are contained in the plan’s Insurance Certificate. You should consult this certificate for more comprehensive information about the plan’s operation, including its calculation of benefits and benefit limits. 

You can obtain a copy of the LTC Plan Insurance Certificate by contacting Human Resources. You can also contact John Hancock’s Customer Service Center at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time) if you have a question about the plan and how it works.

WHAT IS “LONG-TERM CARE”?
Long-term care refers to non-hospital care that is provided for persons who need assistance with the activities of daily living due to chronic illness or disability. Some examples of conditions that may require long-term care include Alzheimer’s disease, incapacity due to stroke, or incapacity due to a serious injury. 

Long-term care can be provided in a variety of settings, including: 

  • nursing homes
  • alternate care facilities
  • adult day care centers
  • at home
  • in a hospice 

The goal of long-term care is to help the assisted individual maximize his or her quality of life by meeting health and/or personal needs over an extended period of time.

LTC PLAN OVERVIEW
If you are currently enrolled in the LTC Plan, it can provide a valuable source of supplementary income if you or another covered person requires long-term care due to a chronic illness or disability. 

The amount and duration of your LTC Plan benefit is determined by the benefit options you chose when you enrolled. This is explained in "LTC Plan Benefit Options" and "How LTC Plan Benefits Are Determined" (below). 

There are five important points to remember about the LTC Plan and its operation: 

  • you have a choice of benefit options
  • there are daily and lifetime limits on how much the plan will pay
  • the plan required an “Elimination Period” before benefits began
  • services must be furnished by approved long-term care providers, and under an approved Plan of Care
  • the plan will pay for covered services only
  • the plan has a pre-existing condition limitation 
You can contact John Hancock’s Customer Service Center at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time) for a comprehensive overview of the plan and how it works.

PLAN OF CARE
In order to qualify for LTC Plan benefits, any care, service, or expense that a covered person receives or incurs must be included in a written Plan of Care that is prescribed by a licensed health care practitioner. 

The Plan of Care must specify the following for all long-term care services: 

  • type of care;
  • frequency of care; and
  • type of providers for all services 

Alternate Plan of Care
The Insurance Company may approve an Alternate Plan of Care. An Alternate Plan of Care may specify alternatives to a covered person’s current Plan of Care that appear to be appropriate for that person and cost effective. 

An Alternate Plan of Care is a plan that: 

  • is designed specifically for the covered person;
  • is mutually agreed to by the covered person, his or her health care practitioner, and the Insurance Company;
  • contains recommendations for alternative services or supplies that are not covered by the LTC Plan policy; and
  • may be modified as appropriate. 
You can contact the John Hancock Customer Service Center at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time) if you have any questions about your Plan of Care.

COVERED HEALTH CONDITIONS
In order to qualify for LTC Plan benefits, a licensed health care practitioner must certify that you require: 

  • assistance with at least two Activities of Daily Living which is expected to last for at least 90 days; or
  • substantial supervision due to a cognitive impairment (such as Alzheimer’s disease). 

Activities of Daily Living
For plan purposes, the “Activities of Daily Living” are defined as: 

  • bathing
  • dressing
  • eating
  • maintaining continence
  • toileting
  • transferring (physically moving oneself) 
You should contact John Hancock immediately at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time) if you think that you have a health condition that requires long-term care.

COVERED LONG-TERM CARE SERVICES
The LTC Plan covers long-term care that is provided in a variety of settings, including: 

  • nursing home
  • alternate care facility
  • community based professional care
  • in the covered person’s home
  • in a hospice 

In order to qualify for benefits, the care must be furnished by providers and facilities that are approved by the Insurance Company. 

A more extensive description of the plan’s covered services may be found in the Covered Long-Term Care Expenses section. 

LTC PLAN BENEFIT OPTIONS
The LTC Plan offered you a range of benefit options. These options determined the daily and lifetime benefits that the plan will pay for covered care. 

You had a choice of: 

  • two Certificate Limit options; and
  • five Daily Benefit options. 

Certificate Limit Options
The Certificate Limit determines the maximum payment period for each covered person. 

There are two Certificate Limit options: 

  • the three year option (1,095 days*); or
  • the five year option (1,825 days*). 

*Under certain circumstances, this period can be longer than the maximum number of days shown. This is explained in the How the Long-Term Care Insurance (LTC) Plan Works section. 

Daily Benefit Options
The Daily Benefit determines the maximum amount that the plan will pay for each day of covered care. 

There are five Daily Benefit options (amount paid by the plan for each day of covered care): 

  • $100
  • $150
  • $200
  • $250
  • $300 
There are a number of resources available to help you decide on the LTC Plan benefit options that are best for you and your family. John Hancock customer service representatives are available to assist you at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time).

GUARANTEED PURCHASE OPTION
As an LTC Plan participant, you have the option of purchasing additional amounts of coverage every three years. The amount of each available addition will increase your Daily Benefit by at least 5%, compounded annually over the three-year period. 

HOW LTC PLAN BENEFITS ARE DETERMINED
In general, the amount that the LTC Plan will pay is determined by your choice of: 
       

  • the Certificate Limit option (three or five year payment period ); and
  • the Daily Benefit option (maximum amount paid for each day of covered care). 

As this chart shows, the Certificate Limit and Daily Benefit options that you choose will determine the maximum daily and lifetime benefits that the plan will pay for each covered person: 

Daily Benefit
 Option Informal Care Daily
 Benefit* Certificate Limit
 (maximum payment period)
3-year Option
 (1,095 days) 5-year Option â€¨(1,825 days)
$100 $25.00 $109,500 $182,500
$150 $37.50 $164,250 $273,750
$200 $50.00 $219,000 $365,000
$250 $62.50 $273,750 $456,250
$300 $75.00 $328,500 $547,500

*Informal care refers to certain custodial and homemaker services that are performed in the covered person’s home. This is explained in the Covered Long-Term Care Expenses section. 

Here’s an Example: Assume that you elect: 

  • the $200 Daily Benefit option; and
  • the 5-year Certificate Limit option. 

If you suffer a chronic illness or disability that requires long-term care, the plan will pay up to $200 per day towards the cost of your care for a maximum of 5 years (1,825 days). The maximum amount that the plan will pay is $365,000 ($200 per day x 1,825 days = $365,000). 

Payment Period Extension
Under certain circumstances, the plan’s 3 or 5 year maximum payment period may be extended if less expensive care is used, or you don’t receive care every day. 

Here’s an Example: Assume that: 

  • you elected the $100 Daily Benefit option with a 3-year Certificate Limit; and
  • you receive care in your home every day, at a cost of $50 per day.       

In this case, you would be eligible for up to 6 years (2,190 days) of LTC Plan benefit payments, at the rate of $50 per day. In other words, 

             Maximum Payment
    (3-year Certificate Limit option)                                    Actual Daily Payment 
                     $109,500*                            divided by                      $50                            =               2,190 days**
                                                                                                                                                          (6 years of payment)              

*$100 per day Daily Benefit x 1,095 days = $109,500

**2,190 days x $50 per day = $109,500

You can contact the John Hancock Customer Service Center at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time) if you have any questions about your LTC Plan benefits and how they are determined. You can also consult the LTC Plan Insurance Certificate for more complete information.

ELIMINATION PERIOD
The LTC Plan will not pay any benefits for your first 90 days of covered long-term care services. This 90-day period is called the “Elimination Period.” Your plan benefits will begin as of the next day following the end of the Elimination Period. 

Only one complete Elimination Period must be satisfied while your LTC Plan coverage is continuously in force. The days used to satisfy your Elimination Period do not need to be consecutive and may be satisfied under separate claims. 

Elimination Period Exceptions
Your benefits will not be subject to the Elimination Period if: 

  • you are receiving Stay at Home care; or
  • you are diagnosed as terminally ill and confined to a hospice. 
You can contact the John Hancock Customer Service Center at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time) if you have any questions about the plan’s Elimination Period requirement and how it works.

INCREASING OR DECREASING YOUR BENEFIT AMOUNT
You can make a written election to decrease your Daily Benefit amount at any time. This election will go into effect on the first day of the month following the date on which the Insurance Company receives and approves your request. 

Increasing Your Benefit Amount
You can make a written election to increase your Daily Benefit amount, subject to the following conditions*: 

  • you are under age 85;
  • you provide evidence of insurability that is acceptable to the Insurance Company; and
  • you are not in the Elimination Period or eligible for benefit payments within the 6-month period prior to the proposed date of Daily Benefit increase. 

*other conditions and restrictions may also apply if you have Compound Inflation coverage, Shared Care coverage, or Nonforfeiture coverage. 

Your election to increase your Daily Benefit amount will go into effect on the first day of the month that is on or after the date that the Insurance Company approves the increase. 

You can contact the John Hancock Customer Service at 1-800-711-9407 (Monday through Friday from 8:30 a.m. to 6:30 p.m., Eastern Time) if you have a question about increasing or decreasing your Daily Benefit amount.