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.

Important Documents:

• Bronze Option Booklet
• Silver, Gold, and Platinum Options Booklet
• Long-Term Care Plans Presentation

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.

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:

You must apply for this coverage before appointment to your first benefit from any retirement system. If you do not apply at this time, you waive your right to apply for this coverage at a later date.

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.

Important Documents:

• Retiree Health Dependent Change
• Long-Term Care Health Questionnaire

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.

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:

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