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Site Map Glossary Employee Book of Benefits OneCall: 1-877-861-2255 |
Home > Long Term Care > How the Plan Works
EligibilityYou and your spouse are eligible to apply for long term care insurance at any time by completing an application and a statement of health form and submitting it to MetLife.You do not have to be enrolled in the plan in order for your spouse to participate. This plan is also available to surviving spouses of retirees. EnrollmentYou must complete a statement of health. Eligible family members must also complete a statement of health.To obtain an enrollment package for yourself or an eligible family member, call MetLife at 1-800-GET-MET8. The enrollment package will include the statement of health and a premium chart. If you complete a statement of health and your request for enrollment is denied by the insurance company, the notice of denial will include instructions on how to appeal the decision. When Coverage BeginsWhen you enroll with a statement of health, your coverage will begin the first of the month following the date the insurance company accepts your request for enrollment.If you enroll with a statement of health and you are accepted into the plan, once you are authorized for benefits and have completed the waiting period, benefit payments will begin even if you have a pre-existing condition. Premium PaymentsYou pay the full cost of your coverage. The cost of your coverage depends on the daily benefit and lifetime benefit you chose, and your age as of the time your coverage began.You will pay the insurance company directly. You may be billed quarterly, semiannually or annually, or you may have monthly deductions taken directly from your checking account. You will have a 31-day grace period. If you do not pay within that grace period, your coverage will be canceled as of the last day of the month in which you paid your last contributions. ...Changes in Premiums When you enroll, your premiums will be based on your age as of the time your coverage becomes effective. Except for changes in premium rates for all enrollees, which may occur from time to time, your premiums remain the same as you get older. If you increase your coverage, your contributions for the additional coverage will be based on your age at the time the change is effective. ...No Premiums While Benefits are Paid You will not be required to pay premiums during any period in which you are receiving benefits. Premiums are waived as of the first day of the month on or after the date you begin receiving benefits. Your premiums will resume as of the first of the month on or after the date your eligibility for benefits ceases. If you die while covered by the plan, all or a portion of your premiums may be returned to your estate. If you die before age 65, your estate will receive the contributions you paid up until the date of your death, less any benefits you had received. If you die after age 65, your estate will receive the contributions you paid up to age 65, less any benefits you had received. This amount will be reduced by approximately 20% each year after age 65. There will be no return of premium if death occurs after age 70. Note: Due to state insurance regulations this feature is not available to residents of Arkansas, Pennsylvania, and Washington. Residents of these states will have an enhanced respite services benefit instead of this feature. ...If You Stop Paying Premiums If you stop paying premiums, your coverage will terminate if you have paid premiums for less than 3 years. If you pay premiums for 3 years or more and then stop, you will still have some coverage. The non-forfeiture feature allows you to maintain some coverage even if you choose to cancel your coverage. The feature provides the full daily benefit with a total lifetime benefit based on the greater of the total paid contributions amount or 30 times the daily benefit in effect immediately prior to the non-forfeiture date. When Benefits are PaidOnce enrolled in the plan, if you think you need benefits, you or your designated representative may call MetLife at 1-800-GET-MET8 to initiate the benefit authorization process. A nurse at the insurance company will review your situation with you, your doctor or other care provider to determine the extent to which you are unable to perform, without substantial assistance from another individual, the following activities of daily living:
The insurance company will notify you as to your authorization for benefits within ten working days after receiving the necessary information. If you are not authorized for benefits, the insurance company will explain the reasons for the denial and instruct you how to appeal the decision. Waiting PeriodBecause this is long term care insurance, payments begin after you have established a need for extended care. You must satisfy a waiting period of 90 days. Any day paid by your group medical plan or by Medicare will count as a waiting period day. During this waiting period, you will pay for services covered by the plan. Once the waiting period is over, you will then begin to receive benefit payments for covered services. You will not have to fulfill another waiting period unless you have gone for more than 180 days without being eligible for benefits.What the Plan PaysAfter you satisfy the waiting period, the plan pays benefits up to a daily benefit amount. The daily benefit is the maximum amount of reimbursement that you can receive for each day you are eligible for benefits. There is a daily benefit for nursing home care and respite care services and another daily benefit for home care services and assisted living facilities. The total lifetime benefit is the maximum amount of benefits you can receive from the plan.You choose one of three nursing home daily benefit amounts. The nursing home daily benefit amount you choose will determine your home care daily benefit amount and your total lifetime benefit.
When the total amount of benefits you have received equals your total lifetime maximum amount, your coverage ends. Coordination of BenefitsYour benefits will be reduced by the dollar amount payable by any of the following, to the extent that the combination of your benefit and amounts payable or which would be payable by any of the following exceed 100% of the actual charge for the covered expenses:
Last updated: Thursday April 21 2005 | ||||||||||||||
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