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Edit by LM 4/5/22 Not Apprvd


Long-Term Care


Information about the long-term care plans and the range of health and social services provided.

The State of Alaska is pleased to offer this voluntary Long-Term Care (LTC) Plan for benefit recipients and their spouses. The options available under this LTC Plan provide a range of health and social services for people who suffer a severe cognitive impairment or, because of a chronic condition, need help with the basic activities of daily living. There are three options available. These benefits may change from time to time. You should ensure that you have the current booklet by contacting the Division.

This Plan may not cover all costs associated with long-term care you may incur. You should carefully review all policy limitations.

Tax Qualification

This Plan is intended to be a qualified long-term care plan under section 7702(B) of the Internal Revenue Code of 1986 as amended. All terms and conditions for this Plan are intended to and shall be interpreted consistent with all legal requirements of a qualified longterm care plan as that term is defined by that IRS code section.

The Division retains the right to change the terms and conditions of this Plan when necessary to maintain the Plan as a qualified long-term care plan under the IRS code. If changes are made to the Plan, written notice of any changes will be provided to members as soon as possible.

Benefit Recipients:

People receiving a benefit from the Public Employees’, Teachers’, Judicial, or Elected Public Officers’ Retirement Systems (excluding alternate payees under a Qualified Domestic Relations Order ).

Dependents:

You may elect to cover your spouse if you elect coverage for yourself. You may be legally separated but not divorced.

Spouses of benefit recipients who lose coverage because of death or divorce may elect coverage for themselves only. No coverage may be elected for a new spouse if you remarry.

You may be covered by only one State of Alaska LTC Plan at a time. If you are covered by your own LTC Plan, your spouse have LTC coverage for you under their retirement benefit. If you are covered under your spouse’s LTC Plan, notify the Division when you retire so the LTC coverage can be moved to your own retirement benefit or terminated if you elect a new option.

LONG-TERM CARE PREMIUMS:
Age at Enrollment Silver Option Gold Option Platinum
≤ 40 $26 $76 $148
41 $27 $77 $150
42 $28 $78 $153
43 $30 $79 $155
44 $31 $81 $158
45 $33 $82 $161
46 $35 $84 $164
47 $37 $85 $167
48 $39 $89 $170
49 $41 $92 $172
50 $44 $96 $175
51 $46 $100 $177
52 $26 $76 $148
53 $49 $103 $180
54 $56 $114 $188
55 $60 $120 $192
56 $63 $126 $195
57 $67 $131 $199
58 $75 $143 $212
59 $84 $156 $225
60 $92 $168 $237
61 $100 $181 $250
62 $108 $193 $263
63 $123 $212 $281
64 $137 $231 $300
65 $151 $250 $319
66 $166 $269 $338
67 $180 $288 $357
68 $201 $313 $381
69 $222 $339 $404
70 $244 $364 $428
71 $265 $389 $451
72 $286 $414 $475
73 $314 $444 $502
74 $343 $474 $529
75 $371 $503 $556
76 $399 $533 $584
77 $427 $563 $611
78 $471 $609 $654
79 $515 $654 $698
80 $559 $700 $741
81 $603 $746 $784
82 $646 $791 $828
83 $731 $887 $923
84 $815 $982 $1018
≥ 85 $900 $1078 $1113
Effective: Jan. 1 - Dec. 31,
Monthly Rates
May 1, 2000 Age Premium (in dollars)
< 5016.10
50-5421.45
55-5926.80
60-6448.25
65-6980.45
70-74128.70
75-79193.05
80-84294.95
≥ 85412.90

Payment

Premiums are based on you or your spouse’s age at the time coverage begins. You pay the premiums for this coverage through deductions from your monthly retirement check. If you select joint coverage, premiums will be deducted for you and your spouse.

Once the claims administrator begins to make benefit payments under this LTC Plan, you will not need to pay LTC premiums for that person during that benefit period. Premium payments will resume on the first of the month following the end of that benefit period.

A benefit period begins on the first day of a Covered Program of Care and ends 90 days after the Covered Program of Care is no longer necessary. A Covered Program of Care is no longer necessary when the covered member no longer meets the benefit eligibility. It does not include any day prior to the effective date of coverage under this Plan.

You must first meet the deductible period of 90 days of covered long-term care. Only one deductible period applies during any one benefit period. At the end of any benefit period, any subsequent Covered Program of Care will be subject to the deductible period before any benefits are paid.

After you meet the deductible period, the Plan pays 100% of the charges for covered long-term care services up to the daily and lifetime maximums.

Lifetime Maximum Benefit

The maximum lifetime benefit for each person for all covered long-term care expenses is:

Silver Option Gold Option Platinum Option
$400,000 $300,000 $300,000
5% annual increase simple inflation protection 5% annual increase compound inflation protection

You must apply for this coverage before appointment to your first benefit from any retirement system.

To meet this deadline, your Retiree Health Benefits Enrollment/Waiver form must be postmarked or received by the deadline. If you do not apply for coverage at this time, you waive your right to apply for this coverage at a later date.

You can send in the form seperately, but most often this form is completed as part of the retirement packet.

Benefit Recipients

You may elect to cover your spouse if you elect coverage for yourself. You may be legally separated but not divorced.

Spouses of benefit recipients who lose coverage because of death or divorce may elect coverage for themselves only. No coverage may be elected for a new spouse if you remarry.

You may be covered by only one State of Alaska LTC Plan at a time. If you are covered by your own LTC Plan, your spouse have LTC coverage for you under their retirement benefit. If you are covered under your spouse’s LTC Plan, notify the Division when you retire so the LTC coverage can be moved to your own retirement benefit or terminated if you elect a new option.

This information is only intended to be a summary of coverages provided. Please refer to the Long-Term Plan Care Booklet for additional information or exclusions.

LONG-TERM CARE BENEFITS SUMMARY:
Silver Option Gold Option Platinum
Deductible 90 days of covered long-term care 90 days of covered long-term care 90 days of covered long-term care
Benefit Eligibility Inability to perform 2 of 6 activities of daily living or cognitive impairment Inability to perform 2 of 6 activities of daily living or cognitive impairment Inability to perform 2 of 6 activities of daily living or cognitive impairment
Lifetime Maximum Benefit $400,000 all services $300,000 all services $300,000 all services
Nursing Home Daily Benefit $200 in and out of Alaska $200 in and out of Alaska $200 in and out of Alaska
Assisted Living Facility Daily Benefit $150 in and out of Alaska $150 in and out of Alaska $150 in and out of Alaska
Home Health Care Daily Benefit $125 in and out of Alaska $125 in and out of Alaska $125 in and out of Alaska
Hospice Daily Benefit $125 in and out of Alaska $125 in and out of Alaska $125 in and out of Alaska
Respite Care Daily Benefit Amount Up to $200 in and out of Alaska, maximum of 14 days Up to $200 in and out of Alaska, maximum of 14 days Up to $200 in and out of Alaska, maximum of 14 days
Inflation Protection None 5% annual increase simple inflation protection 5% annual increase simple inflation protection
Effective: Jan. 1 - Dec. 31,

Coordination with Medicare

If a covered member incurs charges for which benefits are payable under Medicare (including benefits that would be payable except for application of Medicare’s deductible or coinsurance features), the benefits payable under this Plan for these charges will be reduced by the benefits payable under Medicare.

Coordination of Benefits

Daily benefits are payable only for that portion of an expense which is not payable under:

  • Any federal, state, or other governmental health care plan of law, except Medicaid.
  • Any other plan which any employer contributes to or sponsors.
  • Any occupational disease law.
  • Any motor vehicle no-fault law

Benefits will be reduced by the dollar amount paid by any of the above, to the extent that the combination of this Plan’s benefit and the above exceeds 100% of the actual covered expenses.

Guaranteed Renewable

This Plan is guaranteed renewable. This means that you have the right to continue this coverage as long as you pay your premiums on time. Premiums may change on a class basis. Your coverage may not be cancelled or terminated on the grounds of your age or the deterioration of your mental or physical health.

Free Choice of Provider

You may select any provider who meets the definitions as outlined in this Plan.

The payments made under this Plan for services rendered by a provider are not construed as regulating in any way the fees that the provider charges.

Under this Plan, payments may be made, at the discretion of the claims administrator, to the provider, or other person or organization furnishing the service or making the payment, or to the retiree, or to such person or organization and the retiree jointly.

The providers that furnish care and services or other benefits to members do so as independent contractors. The Plan is not liable for any claim or demand from damages arising from or in any way connected with any injuries that members suffer while receiving care in any facility or services from any provider.

Coverage Starts:

New benefit recipients who are approved will be covered under this Plan on the date of their appointment to receive retirement, disability, or survivor benefits.

Coverage Ends:

Coverage under the LTC Plan ends at the earliest time one of the following occurs:

  1. Failure to Pay Premium

    Coverage ends on the last day of the calendar month in which you pay the required monthly premium. If at any time your benefit check is insufficient to pay the monthly premium, you may pay the premium directly to the claims administrator. Contact the Division for more information.

    A person who pays premiums for this coverage directly to the claims administrator will lose coverage if:

    • A premium payment is delinquent by more than 60 days; or
    • Premium payments are delinquent twice in any one calendar year by more than 31 days.

    If your coverage ends due to failure to pay the premium, coverage may be reinstated back to the date it ended without requiring proof of good health; however, within 5 months of the date coverage ended you or your representative must:

    • Provide proof acceptable to the Plan that you suffered a severe cognitive impairment or loss of functional capacity at the time your contribution was due; and
    • Must pay all past due premiums.
  2. Termination of Retirement Benefits

    Coverage ends on the last day of the calendar month in which you cease to be eligible for a benefit from any of the retirement systems. A retiree whose benefit terminates because they return to employment may pay LTC premiums directly to the claims administrator and will remain covered. When re-retired, you may have LTC coverage only if you have continued the premium payments for you and your spouse during your period of re-employment.

  3. Cancellation of Coverage

    You may cancel your participation in the Plan at any time by submitting a signed, written request to the Division. Your premium deductions will be stopped the first of the month following receipt of your request. Your coverage will nd on the last day of the month in which the last premium is deducted. You may not cancel your coverage and retain coverage for your spouse. If you cancel participation, you forfeit all rights to future coverage and you are not eligible to re-enroll.

  4. Spouse Coverage

    Your spouse’s coverage will end on the same day your coverage ends, unless you divorce. Coverage for your spouse ends on the date the divorce is final, unless your spouse continues coverage as described below. You must notify the Division of your divorce. Premiums for your spouse will stop only after the Division receives your written notification.

    If you have selected coverage for your spouse and you divorce or die (and your spouse is not eligible for a continuing benefit), your spouse may continue coverage by paying the premiums directly to the claims administrator. To continue coverage, your spouse must apply for coverage within 60 days following your death or divorce and pay premiums retroactive to the date coverage ended. Contact the Division for more information.

Changing Your Spouse's Coverage

You may terminate coverage for your spouse at any time. To terminate your spouse’s coverage, submit a written request to the Division.

Your termination of spouse coverage will be effective on the first of the month following receipt of your written request by the Division. Once you terminate your spouse’s coverage, you cannot reinstate it except as described below.

If you choose coverage for yourself only because you are not married when you retire or if you remarry following divorce or the death of your spouse, you may request to cover your new spouse. Your request must be postmarked or received by the Division within 120 days after your marriage. Your new spouse will be required to provide information on his or her health and will be subject to approval or denial by the claims administrator. If your spouse’s coverage is approved, he or she will be covered on the first of the month following the approval assuming the premium is paid.

Decrease Your Level of Coverage

You may decrease the coverage option for yourself or your spouse at any time before you begin a Covered Program of Care by notifying the Division in writing. For example, you may decrease from the Platinum Option to the Gold Option. Changes in your option are effective on the first of the month following receipt of your written request.

Benefits are available for covered expenses. Covered expenses are those expenses incurred for care received in connection with a Covered Program of Care

Benefit Eligibility

You are eligible to receive benefits if one or more licensed healthcare practitioners certifies that you are chronically ill. Chronically ill means that:

  • You are unable to perform, without substantial assistance from another individual, at least two activities of daily living for at least 90 days due to a loss of functional capacity; or
  • You require substantial supervision to protect you from threats to health and safety due to a severe cognitive impairment.

Long-term care benefits are available for qualified long-term care services which, as determined by the claims administrator, are needed by a chronically ill individual. Care can include:

  • Skilled or intermediate nursing care;
  • Home health care;
  • Occupational therapy services;
  • Physical therapy services; or
  • Speech therapy services.

Qualified long-term care services are those which are appropriate and essential for the diagnosis, treatment, rehabilitation, mitigating, curing, or maintenance of disease or injury or for personal assistance with the activities of daily living listed below that are necessary as a result of a physical incapacity resulting from a covered disease or injury or the effects of aging. Essential personal assistance means the covered individual requires substantial human assistance (i.e., handson or standby assistance) in at least two of the following activities of daily living:

  • Bathing
  • Continence
  • Dressing
  • Eating
  • Toileting
  • Transferring

Essential personal assistance may also mean the covered individual requires substantial human assistance due to severe cognitive impairment.

Severe Cognitive Impairment

Severe cognitive impairment means the covered member has been certified by one or more licensed healthcare practitioners as requiring substantial supervision or verbal cueing by another person in order to protect the covered member and others from serious threats to health and safety

Severe cognitive impairment means a deterioration or loss in the covered member’s intellectual capacity that is measured by clinical evidence and standardized tests which reliably measure impairment in short or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.

The claims administrator will make the determination of the loss of functional capacity. In making the determination, they will take into account, as appropriate, evidence furnished by the covered member and written documentation furnished by the covered member’s attending physician and other licensed healthcare practitioners. A covered member who otherwise meets either of the requirements described above, will not be determined to have suffered a loss of functional capacity unless, within the preceding 12–month period, a licensed healthcare practitioner has certified the covered member meets the requirements.

The Plan provides coverage for covered expenses for custodial care when it is received in connection with a Covered Program of Care. The benefit amount is based on where services are received.

The patient’s licensed healthcare practitioner must order the needed care. The care received must not be at the insistence of, or for the convenience of, the patient or the patient’s family.

Pre-existing Conditions Limitation

The Plan does not cover a Covered Program of Care which is provided or begun before the person’s effective date or during the first 12 months of coverage and is caused by a pre-existing condition. Any condition that was diagnosed or treated within the three consecutive months before the individual’s effective date is considered a pre-existing condition.

Limitations and Exclusions

The following services are not covered and no benefits are payable for:

  • A loss caused by declared or undeclared war or any such act.
  • A loss caused by a suicide attempt or an intentionally selfinflicted injury.
  • A confinement in a government institution, unless the covered individual is legally obligated to pay a charge.
  • Services received or expenses incurred on any day the covered individual is confined to a hospital.
  • Services or expenses that are covered by the State of Alaska retiree group medical plan.
  • Services received or expenses incurred outside the United States.
  • Services provided by a person who usually resides in the covered individual’s home or is a member of the covered individual’s family, or when the person performing the service normally does not charge for the service.
  • Services received for which the covered individual is not legally obligated to pay.
  • Services received which are covered under Medicare.
  • Services provided or required because of the past or present service of any person in the armed forces of a government.
  • Services provided or required under any law or governmental program except Medicaid.

Intial Claim

To start the claim process, you or your representative should call the claims administrator’s toll-free number. You should be prepared to provide information on your condition and care needs and proof you are chronically ill. If the claims administrator requires additional information, they may contact you, your representative, your physician or another person familiar with your condition. You may be required to provide access to your medical records. The claims administrator has the right to have you examined, at the Plan’s expense, by a health care provider and to conduct an on-site assessment.

The claims administrator has the right to review your continuing eligibility to receive benefits. In order to remain eligible for benefits, a licensed healthcare practitioner (see page 13) must recertify you as chronically ill at least every twelve months.

Filing Deadline

You must submit your claim in writing to the claims administrator and you must give proof of the nature and extent of the loss.

Be sure to report claims promptly. The deadline for filing a claim for benefits is 90 days after the start of a Covered Program of Care. If, through no fault of your own, you are unable to meet the deadline for filing a claim, your claim will be accepted if you file as soon as reasonably possible, but not later than one year after the deadline unless you are legally incapacitated. Otherwise, late claims will not be covered.

If A Claim is Denied

  1. Claims Administrator Appeals

    If you feel that the claim or certification should be covered under the terms of this Plan, you or your provider should make a written appeal to the claims administrator. You should include any documents, Long-Term Care – Silver, Gold, and Platinum Options 27 records, or other information which you would like to have reviewed in connection with your appeal. Your appeal must be received within 60 days of the date the denial is issued. Your appeal will be reviewed and the claims administrator will send you a written response.

  2. Plan Administrator Appeals

    Claim denials can be appealed to the Plan administrator if:

    • Benefits covered by the Plan have been denied; or
    • The reimbursement is lower than the Plan provides.

    Claim denials cannot be appealed if a claim is denied because it is not covered by the Plan.

    If, after exhausting your appeal rights to the claims administrator, you feel that the services should be covered under the terms of the Long-Term Care Plan, you may send a written appeal to the Division. Your appeal should include copies of the claim documents, benefit explanations, and all correspondence between you and the claims administrator. Your appeal must be postmarked or received within 45 days of the claims administrator’s final decision.

    The Division will review your appeal to determine if it should be covered under the terms of the Long-Term Care Plan or will refer your appeal to an independent medical review group. Once the review is complete, the Division will issue a written decision.

  3. Emergency Procedures

    If a member’s life or health is threatened by delays inherent in the formal appeals process, you may request an emergency review. In making an emergency determination, we will generally rely on the opinion of your treating physician.

  4. Individual Case Management

    If you have an illness or accident that may extend for some time, the Long-Term Care Plan provides for alternate means of care through Individual Case Management (ICM).

    When reviewing claims for the ICM program, the claims administrator always works with you, your family, and your physician so you receive close, personal attention. The claims administrator identifies and evaluates potential claims for ICM, always keeping in mind that alternative care must result in savings without detracting from the quality of care.

    Through ICM, the claims administrator can consider recommendations involving expenses usually not covered for reimbursement. This includes suggestions to use alternative medical management techniques or procedures or suggestions for cost-effective use of existing Plan provisions.

    If you have questions regarding ICM and its possible application to you, call the claims administrator. All parties must approve alternate care before it is provided.

Page Last Modified: 05/16/22 13:33:02

© State of Alaska || || drb.alaska.gov

Long-Term FAQs

Who do I contact to open a claim?

CHCS Services, Inc. is the claims administrator. You may contact them at (888) 287-7116 to initiate a claim.

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Where do I submit expenses for processing?

Your receipts for expenses may be submitted to:

CHCS Services, Inc.
P.O. Box 13431
Pensacola, FL 32591-3431

Fax: (866) 383-5821

Learn More
Is there a web site that I can find information about the plan and my claims?

Yes, CHCS has made a portal available where members may view which plan they are in enrolled in, review plan documents, and obtain a claim submission packet. Members can also use the portal to view claims and receive messages from their case manager.

Learn More
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.

Learn More
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 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
  • Continence – your ability to maintain control of bowel and bladder functions or if unable, the ability to perform associated personal hygiene (i.e., caring for a catheter or colostomy bag)
  • Bathing – your ability to wash yourself in a tub, shower or by sponge bath

The Silver, Gold, and Platinum plans also provide benefits for cognitive impairment (such as Alzheimer’s), which requires that you be supervised in order to perform the ADLs. 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. The Silver, Gold and Platinum plans 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 is excluded under the LTC 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 Alzheimer’s 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.

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, 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 LTC plan?

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

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Can I use Medicare to cover LTC 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 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.

Learn More
Retiree FAQs