Long term care insurance Everything you need to apply for coverage for yourself and your family members What you need to know How it works This booklet provides all This includes information about why this coverage is important, detailed plan the information you need information, and what is not covered. Be sure to review this information to understand the long before enrolling. term care (LTC) insurance coverage your employer is How to enroll in the plan offering through Unum. This section includes rates for the plan(s) being offered, Benefit Election Please follow the tabs to Forms, Long Term Care Insurance Applications (medical questionnaire), make sure you complete replacement forms, and other forms that require a signature. each section. Please refer to the grid below to determine which forms to complete. Long Term Care Protection Authorization Benefit Application Against and Agreement Election (medical Unintentional for Automatic Personal Form questionnaire) Lapse Payments Worksheet Employee* * Spouse¥ Other family members † Retired employee and spouse † * Employees: Complete the Long Term Care Application (medical questionnaire) only if you are choosing coverage over the guarantee issue limit or if you are enrolling after your initial guarantee issue enrollment period. ¥ For definition of spouse, please refer to the Benefit Election Form. † This form is only required if you choose for your payment to be automatically deducted from your checking account. • Call 1-800-227-4165 if you have any question about the forms. State forms to review These are forms for your review only. There is nothing to fill out. The state where your employer is located requires that this information be included for all consumers. How to enroll Underwritten by: Unum Life Insurance Long term care insurance Company of America The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent or insurance company. Who controls your future? Be prepared with long term care insurance from Unum. Your life, your choice How does this coverage help? There are plenty of decisions Here are some examples of how you to make for retirement… may use a long term care benefit of $3,000 per month, based on the • Fishing or golf? national averages for care:4 • Motor home or long-awaited cruise? Home health: • A house at the beach — • Long term care annual benefit $36,000 or close to the grandchildren? • Home health aide ($18.50/hour) – $24,050/year* • Left over for out-of-pocket expenses = $11,950 Long term care insurance may help you avoid a Assisted living: far more difficult decision: whether to exhaust your savings or liquidate your assets to pay for a period of long • Long term care annual benefit $36,000 term care. This policy may help you be prepared for the • Assisted living ($2,825.25/month) – $33,903/year financial realities and help you maintain control of some • Left over for out-of-pocket expenses = $2,097 important decisions, such as: • Who would take care of me? Private nursing home: • Where can I choose to receive care? • Long term care annual benefit $36,000 • Would I be a burden on my children if my savings • Private nursing home ($203.31/day) – $74,208.15/year couldn’t cover my care? • The cost of care that you will pay = –$38,208.15 out of pocket What is long term care? *Based on receiving care five hours a day/five days a week at Whether it’s due to a motorcycle accident or a serious $18.50/hour. For illustrative purposes only. illness, it is the type of care you may need if you couldn’t independently perform the basic activities of daily living: bathing, dressing, using the toilet, transferring from one How to Your benefit enrollment is coming location to another, continence and eating, or if you soon. To learn more, watch for suffered severe cognitive impairment from a condition such apply ) information from your employer. as Alzheimer’s disease. Who’s at risk? Long term care insurance is not just for the elderly. • 40% of people currently receiving long term care are working-age adults 18 to 64 years old.1 • About 70% of individuals over age 65 will require some type of long term care services during their lifetime.2 • By 2020, 12 million people are projected to need long term care.3 EN-1168 (2-11) Get the coverage you need. Won’t my other insurance pay for long term care? Why buy coverage at work? Unfortunately, no. 1.You may get more affordable rates when you buy this • Medical insurance and Medicare are designed to pay for coverage through your employer and you may extend your specific care for acute conditions — not for long term help coverage to your parents and spouse. with daily living. 2.Depending on your plan, you may be able to pay your • Medicaid only helps with long term care expenses after you premiums through convenient payroll deduction. have depleted virtually all of your assets. The exact amount 3.Your employer has selected coverage from Unum, the varies by state but usually leaves just a few thousand dollars leading provider of group LTC insurance for employees in in total assets. the U.S.6 Only long term care insurance may cover those costs and Additional help for caregivers allow you to maintain as much of your assets as possible. Even if you don’t need long term care in the immediate Do I need to be in a nursing home to use future, you may be a caregiver for someone you love. Your my LTC insurance? plan includes LTC Connect® service, which gives you access All Unum plans include a home health option. This allows you to counselors who can help you find long term care providers to use your benefit to pay for an aide to come to your home, in your area, a support group, or other assistance you so you can remain in your residence as long as possible. For an may need. This service also provides discounts for medical extra premium, some plans allow you to pay a family member equipment such as walkers, hearing aids, wheelchairs, and or friend to take care of you. other related needs. Why buy now? People often buy long term care insurance at an early age, because the younger you are, the more affordable the rates. In fact, 63% of the people who buy group LTC insurance are under age 55.5 1,2,3 U.S. Department of Health and Human Services, “National This information is not intended to be a complete description Clearinghouse for Long-Term Care Information,” updated of the insurance coverage available. The policy or its provisions October 2008. Available at: http://www.longtermcare.gov/ may vary or be unavailable in some states. The policy has LTC/Main_Site/Understanding_Long_Term_Care/Basics/Basics. exclusions and limitations which may affect any benefits aspx, cited November 17, 2009. payable. For complete details of coverage and availability, 4 Genworth Financial, “2009 Cost of Care Study,” April 2009. please refer to Policy Form GLTC04 or contact your Unum 5 American Association for Long Term Care Insurance, “2008 representative. LTCI Sourcebook,” February 2008. Underwritten by: Unum Life Insurance Company of America, 6 LIMRA, 2008 Group LTC Report, 2009. Based on inforce cases. Portland, Maine Excluding federal and California-specific Group LTC plans, Unum unum.com also ranks first in number of employees enrolled. © 2011 Unum Group. All rights reserved. Unum is a registered Nursing home care based on 24-hour care for one year. trademark and marketing brand of Unum Group and its insuring Assisted living based on 12 months care. Home care based on subsidiaries. five hours of care per day, five days per week for Non-Medicaid Certified home health aide services. EN-1168 (2-11) FOR EMPLOYEE INFORMATION JEFFERSON BANCSHARES, INC. SCHEDULE OF BENEFITS / PLAN HIGHLIGHTS Your Long Term Care (LTC) insurance plan is listed below. Elimination Period: Your plan’s elimination period of 90 days is the amount of time you must wait before benefits become payable. This time period can be accumulated over a period of 730 days and needs to be satisfied only once during the life of your plan. Newly Hired Employees: Once eligible for the plan, will have 31 days to sign up for Guarantee Issue coverage. Please check with your employer for your effective date. All Active Employees & Newly Hired Employees: Who enroll after the Guarantee Issue enrollment period or choose benefits over the Guarantee Issue limits will be required to fill out a medical questionnaire. Medical Underwriting Effective Date: The effective date for those applicants requiring medical underwriting is the later of the Plan Effective Date or the Medical Underwriting Approval Date. |Medical Underwriting means that you must answer all questions on a medical questionnaire. In some cases, an interview may also be necessary. Delayed Effective Date: If you are absent from work because you are injured, sick, temporarily laid off or on a leave of absence, your coverage will not begin on your otherwise expected effective date. Medical Underwriting for Employees and Family: Completion of the Benefit Election Form is required for enrollment. EMPLOYEES: Your employer funded basic plan, as well as additional benefit amounts of up to and including $6,000 and a Facility Benefit Duration of 3 or 6 years, is being offered on a Guarantee Issue basis. This does not require completion of the Long Term Care Insurance Application (medical questionnaire) if you apply during your initial eligibility period. The Long Term Care Insurance Application (medical questionnaire) is required if enrolling after your initial eligibility period or if you choose to buy $7,000, $8,000, $9,000 or the Lifetime Duration coverage. Spouses and all Family Members must complete the Benefit Election Form, the Long Term Care Insurance Application (medical questionnaire) and must be approved for coverage in order to enroll in the Long Term Care plan. All Medical Questionnaires must accompany a signed Authorization to Request Medical Information Form #6720-03 located in the enrollment kit. Benefit Duration 3 Years 6 Years Lifetime Employee Facility Benefit Amount $2,000 $2,000 $2,000 In Increments of $1,000 to $9,000 to $9,000 to $9,000 Spouse/Family Facility Benefit Amount $1,000 $1,000 $1,000 In Increments of $1,000 to $9,000 to $9,000 to $9,000 Assisted Living Facility Percent 100% 100% 100% Non Forfeiture 3 Yr Shortened 3 Yr Shortened 3 Yr Shortened Benefit Period Benefit Period Benefit Period Professional Home & Community Care 50% 50% 50% Total Choice Home Care - Option 50% 50% 50% Inflation Protection * - Option Compound Compound Compound * If you selected an inflation option, and you terminate that inflation option at a future date, you can purchase the inflated coverage amount at your original age. Lifetime Maximum: The Lifetime Maximum is the maximum benefit dollar amount Unum will pay over the life of your coverage. This dollar amount is based on the Facility Benefit Amount and Benefit Duration. For Example: If you choose $3,000 Facility Monthly Benefit Amount & 3 Year Duration, your Lifetime Maximum is calculated as follows, $3,000 per Month X 12 Months X 3 Years = $108,000 Lifetime Maximum. Insurance Age: Final cost of coverage will be based on your Insurance Age. If you enroll for coverage on or before the group policy effective date, Insurance Age is your age on the group policy effective date. If you enroll for coverage after the group policy effective date, Insurance Age is your age on the date you sign the enrollment form. Questions: Please call 1-800-227-4165 with questions regarding your Long Term Care Insurance. Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 (207) 575-2211 QUALIFIED LONG TERM CARE INSURANCE OUTLINE OF COVERAGE FOR THE EMPLOYEES OF JEFFERSON BANCSHARES, INC. - #136358 Group Master Policy/Certificate Form Number GLTC04/CLTC04 Caution: If you must complete an Application for Long Term Care Insurance which includes evidence of insurability, the issuance of a long term care insurance certificate will be based on your responses to the questions on your application. You retained a copy of your Application for Long Term Care Insurance when you applied. If your answers are incorrect or untrue, the company may have the right to deny benefits or rescind your coverage. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact Unum at this address: Unum Life Insurance Company, 2211 Congress Street, Portland, Maine 04122. NOTICE TO BUYER: This plan may not cover all of the costs associated with long term care which you may incur during the period of coverage. You are advised to review carefully all coverage limitations. 1. The policy is a group policy which is issued in the state of Arkansas. 2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of the important features of the policy. You should compare this outline of coverage to outlines of coverage for other policies available to you. This is not an insurance contract, but only a summary of coverage. Only the group policy contains governing contractual provisions. This means that the group policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR CERTIFICATE CAREFULLY! 3. FEDERAL TAX CONSEQUENCES. The policy is intended to be a federally tax-qualified long term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended. 4. TERMS UNDER WHICH THE CERTIFICATE MAY BE CONTINUED IN FORCE OR DISCONTINUED a. RENEWABILITY - THE CERTIFICATE IS GUARANTEED RENEWABLE. This means you have the right, subject to the terms of the policy to continue your coverage as long as premium for your coverage is paid on time. Unum cannot change any of the terms of the policy on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY. b. CONTINUATION OF COVERAGE. If your group long term care coverage ends for reasons other than non-payment of premium or your choice to have premium payments stopped for your coverage, you may elect continuation of coverage. This means that the same coverage you had under this plan can continue on a direct billed basis. If you are already direct billed, your coverage will automatically transfer to continued coverage. Election for continued coverage must be made within 60 days of the date your group coverage would otherwise end. Any premium that applies must be paid directly to Unum by you for any coverage to be continued. c. WAIVER OF PREMIUM. We will waive payment of premium for your coverage during any period of time that you are receiving benefits under the policy. However, premium payments will not be waived if you are only receiving Respite Care or Additional Care Benefits. 71-04 1 Arkansas (04/06) 5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS. WE HAVE A LIMITED RIGHT TO CHANGE PREMIUMS. We reserve the right to change any and all premiums. Any change in premium must apply to all similar policies issued on this policy form and in the state in which the policy is or certificates are sitused. Premiums cannot be increased because of any change in the age or health of the persons covered under the policy. We cannot discontinue the policy except where required by law or as a result of non-payment of premium. 6. TERMS UNDER WHICH THE CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED. a. You may cancel your coverage for any reason within 30 days after it is delivered to you or your representative. Simply return your certificate, within 30 days of its receipt, to us. If this is done, your certificate will be canceled from the beginning and all premiums paid for your coverage will be refunded. b. If you die while insured under the policy, we will refund any pro rata portion of any premium paid covering the period after your death. We will make the refund within 30 days after we receive written notice of your death. Payment will be made to your estate. 7. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the insurance company. Neither Unum nor its agents represent Medicare, the federal government or any state government. 8. LONG TERM CARE COVERAGE. Policies of this category are designed to provide coverage for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital, such as in a nursing home, in the community or in the home. The policy provides coverage in the form of a fixed dollar indemnity benefit if you are Chronically Ill and you are receiving care while confined in a Long Term Care Facility. If the policy includes coverage for Professional Home and Community Care or Total Choice Home Care and you elect such coverage, we will pay you a benefit if you choose to receive care at home or in the community. Coverage is subject to the policy limitations, benefit maximums and elimination period requirements. 9. BENEFITS PROVIDED BY THE POLICY. Refer to the attached SUMMARY OF BENEFITS for the benefits available under the Policyholder’s plan. Eligibility for Benefits You will be eligible for a benefit if, on or after the effective date of your coverage and while your coverage is in effect, you become Chronically Ill. Conditions for Payment of Benefits To receive benefits under the policy, the following conditions must be met: x you must satisfy the Elimination Period, if applicable; x you must be receiving Qualified Long Term Care Services; x the treatment for your Chronic Illness must be provided pursuant to a written Plan of Care; and x we must approve your claim. You must also provide us with a Licensed Health Care Practitioner’s Certification that you are unable to perform (without Substantial Assistance from another individual) two or more Activities of Daily Living for a period of at least 90 days, or that you require Substantial Supervision by another individual to protect you from threats to your health or safety due to Severe Cognitive Impairment. You will be required to submit a Licensed Health Care Practitioner’s Certification every 12 months. 71-04 2 Arkansas (04/06) Limitations on Payment of Benefits We will not pay benefits in excess of any coverage amounts you choose or for coverages that you have not elected. Benefits paid will reduce your Lifetime Maximum Benefit and will no longer be available once your Lifetime Maximum has been reached. We will not pay benefits for Qualified Long Term Care Services you receive during the Elimination Period, except as described in the Respite Care Benefit and the Additional Care Benefit provisions. The policy only pays benefits if you are receiving Qualified Long Term Care services. LTC Facility Benefit Payment You must give us proof that you are receiving Qualified Long Term Care Services in a LTC Facility before a LTC Facility Monthly Benefit is paid. If you are eligible for benefits for a period th of less than one month, we will pay you 1/30 of the monthly benefit for each day that you are Chronically Ill and receiving Qualified Long Term Care Services in a LTC Facility. (Refer to the OPTIONAL BENEFITS PROVIDED BY THE POLICY section of this Outline of Coverage for information on benefit payments for home care). Additional Care Benefit: Once you are eligible for a benefit payment, you will have access to Additional Care designed to assist you in living at home or in other residential housing. You do not need to complete your Elimination Period for an Additional Care Benefit payment to begin. The Additional Care must be: x appropriate for your Chronic Illness and conform with generally accepted medical standards; x provided pursuant to a written Plan of Care; x recommended by a Licensed Health Care Practitioner; and x approved by us prior to receipt of Additional Care. Bed Reservation Benefit If you are receiving a LTC Facility Monthly Benefit and your stay in the facility is interrupted due to a stay in an acute care facility, or due to a temporary absence and a charge is made to reserve your LTC Facility accommodations, you will be eligible for a Bed Reservation Benefit. th We will pay you 1/30 of the LTC Facility Monthly Benefit for each day you are absent from the LTC Facility: x up to 90 days per calendar year if your absence is due to a stay in an acute care facility; or x up to 30 days per calendar year for a temporary absence not related to a stay in an acute care facility. In no event will the maximum number of Bed Reservation days exceed 90 days per calendar year. Bed Reservation Benefit payments will reduce your Lifetime Maximum Benefit and will no longer be available once your Lifetime Maximum Benefit has been reached. If your stay in a LTC Facility is interrupted while you are satisfying your Elimination Period, such days will be used to help satisfy your Elimination Period. Respite Care Benefit If you are Chronically Ill and receiving Respite Care but you are not receiving a LTC Facility Monthly Benefit (or a Home Care Monthly Benefit if your coverage includes a home care benefit) you will be eligible to receive a Respite Care Benefit. The Respite Care Benefit you will th receive is equal to 1/30 of your LTC Facility Monthly Benefit for each day you have Respite Care for up to 21 days each calendar year. You do not need to complete your Elimination Period for Respite Care payments to begin and the days you are receiving Respite Care will count toward satisfying your Elimination Period. Words That Have A Special Meaning Activities of Daily Living (ADLs) are bathing, dressing, toileting, transferring, continence and eating. 71-04 3 Arkansas (04/06) Additional Care means special services; equipment or caregiver training designed to assist you in living at home or in other residential housing. Additional Care may include: x assistance in locating long term care providers and caregivers in your area (this service is also available even if you are not eligible for benefits); x a visit from a Licensed Health Care Practitioner who will develop your Plan of Care; x a visit from a home safety expert who will assess your residence and offer suggestions for increased personal safety; x purchase or rental of a medical alert service; x purchase or rental of durable medical equipment; x home modifications for your support; or x caregiver training. Chronic Illness and Chronically Ill means you are unable to perform, without Substantial Assistance from another individual, two or more Activities of Daily Living; or you require Substantial Supervision by another individual to protect you from threats to your health and safety due to Severe Cognitive Impairment. Elimination Period means the number of days during which you are Chronically Ill and you are receiving services appropriate for your Chronic Illness, but no benefit is payable. Lifetime Maximum Benefit means the total dollar amount of benefits that will be paid under the policy, excluding any Additional Care Benefit. Long Term Care (LTC) Facility means a facility (such as a nursing facility, an assisted living facility, a hospice facility, a rehabilitation facility, an Alzheimer’s facility or a residential care facility) that is licensed by the appropriate federal or state agency to engage primarily in providing care and services sufficient to support your needs resulting from Chronic Illness. Plan of Care means a written plan prescribed by a Licensed Health Care Practitioner, based upon an assessment that evaluates your level of functional capacity. Qualified Long Term Care Services means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitative services and maintenance or personal care services that are required by you. Respite Care means short-term or periodic Qualified Long Term Care Services which are required to maintain your health or safety and to give temporary relief to your primary caregiver from his or her caregiving duties. Severe Cognitive Impairment means a severe deterioration or loss in your short or long term memory; your orientation as to person, place, or time; or your deductive or abstract reasoning as reliably measured by clinical evidence and standardized tests. Such loss can result from a sickness, injury, advanced age, Alzheimer’s disease or similar form of dementia. Substantial Assistance means stand-by or hands-on assistance without which you would not be able to safely and completely perform the ADL. Stand-by assistance means the presence of another person within arm’s reach of you while you are performing the ADL. Hands-on assistance means physical assistance (minimal, moderate or maximal) without which you would not be able to perform the ADL. Substantial Supervision means continual supervision (which may include cueing by verbal prompting, gestures or other demonstrations) by another individual for the purpose of protecting you from threats to your health or safety. OPTIONAL BENEFITS PROVIDED BY THE POLICY -- EACH OF THE FOLLOWING OPTIONAL BENEFITS IS AVAILABLE UNDER THE POLICYHOLDER’S PLAN. OPTIONAL BENEFITS MAY BE AVAILABLE AT AN ADDITIONAL COST TO YOU. YOU MAY ALSO REFER TO THE ATTACHED SUMMARY OF BENEFITS TO DETERMINE AVAILABLE OPTIONAL BENEFITS. 71-04 4 Arkansas (04/06)