How to Submit Long Term Care Claims

What Is Covered

• Nursing Facility Care including room and board
• Home Health Care
• Adult Day Care as part of an approved plan of care
• Hospice Care, excluding drugs, supplies, equipment or doctor visits
• Respite Care
• Assisted Living

What Is Not Covered - Group Plan

We do not reimburse expenses for the following:

• Services received outside the United States or its territories or possessions.
• Any costs incurred if you already have a Functional Incapacity or Severe Cognitive Impairment on the effective date of this policy.
• Any costs incurred while you are not covered by this policy, except as specifically described in “Extension of Benefits” in Section 5.
• Services provided to you by a member of your Immediate Family, except as specifically described in “Respite Care Benefit” in Section 6.
• Services provided to you by any person other than an employee of a licensed provider of Long Term Care services, or a provider specifically approved by us, except as specifically described in “Respite Care Benefit” in Section 6.
• Any costs incurred by your dependent child or any dependent other than your covered spouse.
• Services or items furnished or paid for by a governmental entity, facility, or program other than Medicaid unless we are required to do so by specific law.
• Services or items furnished free of charge or for which you are not legally obligated to pay in the absence of insurance.
• Any personal care items. Personal care items are those articles or supplies that are used for the personal care, grooming, hygiene, entertainment, enjoyment, refreshment, or convenience of an individual and that are not necessary, as determined by us, to assist or enable the individual to successfully perform the Activities of Daily Living.
• Costs of mechanical assistance, machinery, or devices, including installation.
• Care for a condition that arises from, or originates during, services in the armed forces.
• Care for a condition resulting from participation in a felony or illegal occupation.
• Prescription and over-the-counter drugs and medications, supplies and equipment (e.g., needles, oxygen, gloves, etc), and physician visits.
• Transportation, including ambulance transfer.
• Services that fall outside the established plan of care that we have approved.

What Is Not Covered - Individual LTC Plan

We do not reimburse expenses for the following:

• Care resulting, directly or indirectly, from attempted suicide or an intentionally self-inflicted injury while sane or insane.
• Care resulting from your alcoholism or addiction to drugs or narcotics. This does not include addiction that results from drugs or narcotics taken as prescribed by a physician.
• Care for a condition that results from war or an act of war, whether declared or undeclared.
• Care for a condition resulting from participation in a felony or illegal occupation.
• Services received outside the United States or its territories or possessions.
• Services provided to you by a member of your Immediate Family, except as specifically described in “Respite Care Benefit” in Section 5.
• Services provided to you by any person other than an employee of a licensed provider of Long Term Care services, or a provider specifically approved by us, except as specifically described in “Respite Care Benefit” in Section 5.
• Services or items furnished by or in a Veteran’s Administration or federal government facility, unless otherwise required by law.
• Services or items furnished free of charge or for which you are not legally obligated to pay in the absence of insurance.
• Services that fall outside the established Plan of Care that we have approved.
• Any personal care items. Personal care items are those articles or supplies that are used for the personal care, grooming, hygiene, entertainment, enjoyment, refreshment, or convenience of an individual and that are not necessary, as determined by us, to assist or enable the individual to successfully perform the Activities of Daily Living.
• Costs of mechanical assistance, machinery, or devices, including installation.
• Transportation, including ambulance transfer.
• Prescription and over-the-counter drugs and medications and physician visits.
• Services received while your coverage is not in force except as provided under “Extension of Benefits” in Section 4.