Long Term Care FAQs

We have answers for using your Long Term Care plan.

What is long term care?

Long term care is assistance provided to you if you are chronically ill and unable to perform specified activities of daily living (ADLs). This assistance can include:

• Skilled nursing care
• Intermediate nursing care
• Home health care
• Alternate care facility (such as a residential care facility)
• Your own home
• Hospice facility
• Adult day care facility

If my employer does not offer group long term care (LTC) coverage, can I purchase individual LTC coverage?

Individual LTC coverage is offered through WEA Trust Member Benefits. This plan pays 100% of your actual daily covered charges up to the maximum daily benefit you choose. It includes several inflation protection options, which automatically increase your benefit limits annually.

For more information, or to request the WEA Trust Member Benefits Individual LTC application packet, please call us at 800.279.4010.

I purchased an individual long term care (LTC) plan through another company. How will this affect my WEA Trust Group LTC Plan?

We will calculate and pay LTC benefits without considering the benefits available through your individual plan. You may continue both policies if you choose. Therefore, you may be allowed to submit any charges that we do not cover to your individual plan to review for payment. Please contact the insurer for your individual LTC plan for information regarding how your individual policy interacts with your WEA Trust Group LTC plan.

What services are covered under the WEA Trust Group Long Term Care (LTC) Plan?

You may receive benefits for 6 types of services that are covered:

• Nursing home facility
• Alternate care facility
• Home health care
• Hospice care
• Adult day care
• Respite care

We will pay for only one type of service per day except in the case of respite care as noted below. If you access any of these benefits, you will be required to pay a 25% copayment plus any charges that exceed the daily maximum benefit allowed under the policy.

If you receive regular care from someone who lives with you and who is not paid for providing this care, you may be eligible for respite care benefits. This benefit pays a specified amount for no more than 14 days per benefit period to someone who replaces your usual caregiver while your regular caregiver takes a rest or vacation from providing care. This benefit is the only one that can be paid to a nonlicensed provider or a family member. The respite care benefit can also be paid in addition to home health care or adult day care benefits for the same day.

How do I qualify for long term care (LTC) benefits?

You must have a severe cognitive impairment, such as Alzheimer’s disease, or the inability to perform, without substantial assistance from another person, at least 3 of 6 activities of daily living (ADLs) as defined by your LTC policy. These ADLs include bathing, continence, dressing, eating, toileting, and transferring. Your physician must complete a certification form verifying that you are severely cognitively impaired or incapable of preforming 3 of the aforementioned ADLs and that this incapacity is expected to last at least 90 consecutive days. In addition, your physician must provide a care plan identifying the types of long term care services you require. You must also satisfy an elimination period before benefits are payable.

How do I file a claim for long term care (LTC) benefits?

You may obtain LTC claim forms by calling us. The forms require statements from you and your treating physician. You should file a claim as soon as possible, but you must file within 90 days of becoming functionally incapacitated.

If you have specific questions about completing the LTC claim forms or about your LTC policy, please contact us during normal business hours at 800.279.4000.

Why do you need medical records?

To verify your eligibility for benefits, we need medical records documenting your medical condition and substantiating your severe cognitive impairment or your inability to perform three of the six defined activities of daily living.

Why do I have to pay for medical records?

Under the terms of your long term care (LTC) policy, it is your responsibility to provide medical documentation to us and to pay any fees associated with the release of this information.

How are long term care (LTC) benefits paid?

Generally, your WEA Trust policy pays 75% of the actual covered charges incurred up to the maximum daily benefit indicated on your benefit summary. You will be required to pay 25% of the charges plus any charges that exceed the daily maximum benefit. However, before paying any benefits, we must verify what, if any, of your expenses may be eligible for payment through other sources, such as Medicare, group health insurance, workers compensation, etc. To the extent that your expenses are compensable by another source, we will not pay LTC benefits. If you r expenses are only partially covered through other sources, we pay an amount remaining up to the amount we would have paid in the absence of other reimbursement.

Are long term care (LTC) benefits taxable?

No. Your WEA Trust Group Long Term Care (LTC) Plan is a tax-qualified plan. Therefore, benefits are not considered taxable income.

Both my spouse and I have coverage under the WEA Trust Group Long Term Care (LTC) Plan as employees and dependents. How does this affect what benefits are payable?

Under the terms of your LTC policy, if both you and your spouse are / were employees of a school district that provides WEA Trust group LTC coverage and you each elected to be covered as a dependent under your spouse's  LTC plan, you are eligible for enhanced LTC benefits as follows:

• Your maximum daily benefit will be either the sum of the applicable maximum daily benefits payable under both policies, or 100% of the actual daily charges incurred, whichever is less.
• Your maximum lifetime benefit will be the sum of the maximum lifetime benefit amounts payable under both policies.

How long will I receive long term care (LTC) benefits?

In general, if all policy requirements are met, your LTC benefits are paid while you experience covered expenses and you are functionally  incapacitated until you have exhausted the lifetime maximum benefit amount, whichever occurs first. Please refer to your specific insurance benefit description for the lifetime maximum benefit amount.