Long-Term Care Plan Frequently Asked Questions

This information is intended to supplement but not replace the information in the Long Term Care booklets. Should there be a difference between this and the booklet, the booklet will prevail.


I pay a monthly Long-Term Care premium, but my spouse did not show up on my monthly bill.

When loading the Long Term Care (LTC) spouse plans for 208 spouses, a critical process failed, excluding the LTC spouse plan from January Retiree Direct Billing statements distributed by PayFlex on December 11, 2013. PayFlex is updating their records to include the LTC Spouse Plan. The new statement will contain only the LTC Spouse plan. However, the current due total amount will be the total of the premiums due for January. The statement will include the following notice:

  • This is a corrected statement for the month of January that reflects the LTC Spouse plan that was incorrectly left off of the statement previously sent by PayFlex Systems. Please use this statement to pay January premiums to PayFlex. The current due amount is the total due for all premiums for January.

The PayFlex Call Center was notified of this issue yesterday afternoon, December 16, 2013. Retirees missing a LTC spouse plan on their statement should expect to receive a new January statement in the mail in the next several days.

Are there exclusions for pre-existing conditions?

Long Term Care required due to a pre-existing condition is excluded.

  • A pre-existing condition is any that was diagnosed or treated during the 3 months before coverage started.
  • If you need care in the first 12 months of coverage due to a pre-existing condition, no benefits will be paid for that period of care.
  • If you need care in the first 12 months of coverage due to something other than a pre-existing condition, benefits are paid as normal.
  • If you need care after 12 months of coverage is covered, regardless of the cause.

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What do I need to do to qualify for benefits?

To qualify for benefits, the Bronze plan requires that you are incapable of performing two of the following five Activities of Daily Living (ADLs):

  • Eating – your ability to feed yourself
  • Dressing – your ability to put on or take of your clothes, fasten buttons or zippers
  • Toileting – your ability to get safely to and from the toilet and perform basic personal hygiene
  • Transferring – your ability to move in and out of a bed or chair
  • Walking – your ability to walk without someone’s assistance

The Silver, Gold and Platinum plans require that you be incapable of performing two of the following six ADL’s:

  • Eating – your ability to feed yourself
  • Dressing – your ability to put on or take of your clothes, fasten buttons or zippers
  • Toileting – your ability to get safely to and from the toilet and perform basic personal hygiene
  • Transferring – your ability to move in and out of a bed or chair
  • Continence – your ability to maintain control of bowel and bladder functions or if unable, the ability to perform associated personal hygiene (ie caring for a catheter or colostomy bag)
  • Bathing - your ability to wash yourself in a tub, shower or by sponge bath

Cognitive Impairment such as Alzheimer which requires that you be supervised in order to perform the ADLS is a trigger. Certification of medical necessity from a physician is required under all plans. Prior inpatient care is not required.

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What types of facilities will be covered?

The plans cover licensed nursing care facilities, in home care provided by a licensed home health care agency, and adult day care. Silver, Gold and Platinum also cover assisted living facilities and respite care. Care provided by family members or, outside of the United States, is not covered.

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When do benefits begin?

The deductible period is 90 days under all plans. You must receive 90 days of covered care before benefits are paid. You may be in any level of care or multiple levels of care to satisfy the 90 days. For example, you may be in home health care for 60 days and in a nursing home for another 30 days to meet the deductible period.

You do not need to receive care every day during the 90 day period. If you receive care only certain days of the week, you still receive credit for the full week of care toward the 90 day deductible.

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What are the benefit eligibility triggers?

The current plan requires that you be incapable of performing 2 out of 5 activities of daily living (ADLs) to qualify for benefits. The new plans will require that you be incapable of performing 2 out of the following 6 ADLs: bathing (new), dressing, eating, toileting, transferring, and walking. Cognitive impairment will also be a trigger. Certification of medical necessity from a physician is required under all plans. Prior inpatient care is not required.

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What is excluded under the Long Term Care plan?

The plans do not cover Long Term Care required due to:

  • Alcohol or drug addiction
  • Acts of war, declared or undeclared
  • Suicide, attempted suicide or intentionally self-inflicted injuries
  • Mental or nervous disorders without demonstrative organic disease
  • Confinement in a government institution unless required to pay
  • Services provided when you are hospitalized
  • Services provided by someone who lives with you, is a member of your family or who does not normally charge for services
  • Services covered by the retiree medical plan, Medicare or any law or government program, except Medicaid.
  • Services provided outside the United States
  • Services because of past or present service in a government armed forces

Note that Alzheimers and other forms of dementia are covered.

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Will inflation protection be automatic or may it be elected at periodic intervals?

The Bronze and Silver plans have no inflation protection. The Gold plan has 5% simple inflation protection and the Platinum plan has 5% compound inflation protection. Inflation protection is automatic and associated benefit maximums (both daily and lifetime) will be adjusted annually on the date of your enrollment.

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When does inflation protection stop?

Inflation protection stops at age 85. The lifetime and daily benefit amounts reached by that date are locked in for the life of the policy.

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What will be required for proof of good health to buy up or elect LTC for the first time?

A simple health questionnaire asking for information about current health status will be required initially. Based on the questionnaire, you will either be approved or asked to provide more information in writing or in person or have a medical examination.

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Will premiums increase as I age?

No. Premiums are based on your age at retirement and while all premiums may increase, your premium will always be based on your age on the date you retired. If you elect coverage for your spouse or qualified same sex partner, you pay a separate premium based on their age at your retirement.

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How often do the premiums increase?

Premiums are subject to review annually and may increase at any time the fund is insufficient to pay the expected claim costs. Premiums have not changed since the inception of the plan.

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Who insures the Long Term Care Plan?

The plans are insured by the retirement systems and claims are paid by a third party administrator.

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Can I use Medicare to cover Long Term Care expenses?

Medicare covers some costs but the coverage is limited and approved only for short term periods. Neither Medicare nor the retiree medical plan cover lengthy nursing home stays or home care services for personal care needs.

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Can I use Medicaid to cover Long Term Care expenses?

Yes but you must meet their financial eligible criteria which require you to spend down your assets. Under Medicaid, your choice of where you receive care may also be limited.

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Can I change my LTC coverage?

You may decrease your coverage, from Platinum to Gold for example, or drop coverage for your spouse at any time. You may never increase your level of coverage. You may apply for coverage for a new spouse within 120 days of the date of marriage.

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Is the LTC Plan tax qualified?

Yes. The plan is tax qualified which means any benefits paid by the plan are not taxable and you may be able to deduct the premiums from your income taxes.

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