Long-Term Care Plan

Exclusions and Limitations 

Your Long-Term Care (LTC) Insurance Plan covers a wide range of services. However, there are certain services, expenses, and conditions that the plan does not cover. 

Note: You should refer to the LTC Plan’s Insurance Certificate for additional information concerning the exclusions and limitations described in this section. You can obtain this document by contacting Human Resources. 

Limitations on Benefits
The LTC Plan has the following limitations on benefits: 

  • No care, service or expense will be covered unless it is included in your Plan of Care. The Plan of Care may be amended from time to time.
  • All benefits, except the Stay at Home Benefit, are subject to the Certificate Limit for the option selected and shown on the enrollment material.
  • To receive reimbursement under the Nursing Home Benefit, care must be provided in a facility or a distinctly separate part of a facility, that meets one of the following standards:
    • it is licensed in the jurisdiction in which it operates to provide Nursing Care (skilled or intermediate); or
    • it is approved by Medicare as a skilled nursing facility; or
    • it meets Federal certification requirements as a Hospice facility or is licensed, certified or registered under the law of its jurisdiction to provide Hospice Care.

   Care and services delivered in the Nursing Home but not part of the facility’s bill are not eligible for reimbursement
   u
nless the outside provider is part of your Hospice Care program as defined in your Plan of Care.
 

  • To receive reimbursement under the Alternate Care Facility Benefit, care must be provided in a facility or a distinctly separate part of a facility that is engaged primarily in providing 24-hour Custodial Care and that:

a.  is licensed by the appropriate licensing agency, if any, to provide primarily Custodial Care; or
b.  if licensing is not required in the jurisdiction, it is engaged primarily in providing 24-hour Custodial Care to at least 5 unrelated inpatients; and

      • provides 3 full meals daily, accommodating patients’ special dietary needs; and
      • has an awake employee, who is trained to provide Custodial Care, on duty at all times; and
      • provides care as a part of a Plan of Care; and
      • has appropriate methods and procedures for medication management; and
      • has a formal arrangement for obtaining appropriate aid in the event of a medical emergency.

   This benefit does not apply unless you are a resident in the facility. 

  • Community-Based Professional Services are not provided in residential facilities like Nursing Homes or Alternate Care Facilities. They must be provided by someone who is not Immediate Family (except as described under Exclusions below).
  • Informal Care Benefits are subject to the following limits:
    • Benefits payable for charges incurred on any day will not exceed the lesser of: the Informal Care Daily Benefit shown in the enrollment material for the option selected; and the charges incurred on that day.
    • No benefits will be payable for charges for Informal Care incurred during a calendar year after benefits totaling the Calendar Year Limit for Informal Care have become payable for those charges incurred during one year. The Calendar Year Limit is shown in the enrollment material for the option selected.
    • No benefit is payable under this coverage for any charge to the extent that a benefit is payable for that charge under the Community Based Professional Care Benefit.
    • The total of benefits payable for all charges incurred on any day under this coverage and under the Community Based Professional Care Benefit will not exceed your Daily Benefit.

    Informal Care must be provided in your Home. The person providing the care must be 18 years or older; or employed 
    through a Home Health Agency; or certified to provide such care in the jurisdiction where the care is provided. 

  • The policy contains a Coordination of Benefits provision that may reduce or eliminate the benefits otherwise payable under the policy with respect to benefits payable under another Plan. 

Exclusions

  • Conditions resulting from the following are not eligible for coverage.
    • Your intentionally self-inflicted injury.
    • War, whether declared or not, or any act of war; or service in any armed forces or auxiliary units.
    • Your commission or attempt to commit a felony; your engaging in an illegal occupation; or participating in an insurrection or riot.
  • The LTC Plan does not cover:

a.  care, services or treatment specifically provided for detoxification or rehabilitation for alcohol or drug
     addiction; or
b.  charges normally not made in the absence of insurance; or
c.  except under the Informal Care Benefit, care, treatment or charges provided by a member of Your Immediate
     Family, unless

      • the family member is one of the following professionals – a duly licensed registered nurse, licensed vocational nurse, licensed practical nurse, physical therapist, occupational therapist, speech therapist, respiratory therapist, licensed social worker, or registered dietitian; and
      • the family member is a regular employee of a Nursing Home, Alternate Care Facility, Adult Day Center or Home Health Care Agency that is providing the services; and
      • the organization receives the payment for the services; and
      • the family member receives no compensation other than the normal compensation for employees in his or her job category.

d.  care, services, or supplies furnished by or covered as a benefit under a program of any government or its
     subdivisions or agencies, except as required by law and except:

      • a program established by the Federal government for its civilian employees;
      • Medicare; and
      • Medicaid (This means any state medical assistance program under Title XIX of the Social Security Act as amended from time to time).

e.  any service or supply to the extent that charges for it are payable under Medicare, or would be payable but for
     the application of a deductible or coinsurance or co–payment amount under Medicare. This exclusion will not
     apply in those instances where Medicare is determined to be secondary payor under applicable law.

  • No benefit is payable under the Policy for care received outside the United States, except as described in International Coverage. 

Pre-Existing Condition Exclusion
If, within the six (6) months after your Initial Coverage Effective Date, you need: 

  • Substantial Assistance to perform at least two of the Activities of Daily Living; or
  • Substantial Supervision to protect yourself from threats to health and safety due to the presence of a Severe Cognitive Impairment; 

that is caused or contributed to by a Pre-Existing Condition, the LTC Plan will not reimburse expenses for care, services or treatment while such Substantial Assistance or Substantial Supervision continues; or, if you recover, later becomes needed due to the same Pre-Existing Condition. 

If you were required to apply for coverage by completing a Long-Term Care Insurance Application with medical history questions, the Pre-Existing Condition provision will not apply to you. 

Pre-Existing Condition means any condition (illness, disease, injury or symptom) that, during the six (6) months just prior to your Initial Coverage Effective Date, causes you to: 

  • consult a Health Care Professional; or
  • seek diagnosis or medical advice or receive medical care or treatment; or
  • undergo hospital admission or a Health Care Professional’s visit for testing or for diagnostic study; or
  • obtain services, supplies, prescription drugs or medicines. 

NOT AN ERISA PLAN
It is important for you to understand that your Long-Term Care Plan is not considered to be a “covered employee benefit plan” under the terms of the Employee Retirement Income Security Act of 1974 (ERISA), and is therefore not subject to ERISA’s reporting, disclosure, and other requirements. 

The Administrative Information section of the Summary Plan Description (SPD) website is incorporated into this section by reference. The Administrative Information section contains additional important information about your Long-Term Care Insurance Plan benefits.