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Upcoming important dates
Volunteer Recognition Lunch-
May 3, 2013
Year End Celebration-
May 20, 2013
Gail Baylor
Director of Human Resources
Office: Ogg Administration 202
Phone: 828.771.2048
Email: gbaylor@warren-wilson.edu
Contents
Summary of BenefitsTerms You Should Know
Benefits Information
Limitations and Exclusions
Rehabilitation and Alternative Care Plans
Claim Information
Termination of Coverage
General Information
Terms You Should Know
When You See These Words, This is What Unum Means:
"Active Employee" means an employee working for the Policyholder:
- on a full-time basis for earnings that are paid regularly;
- for a minimum of 20 hours per week; and
- at the Policyholder's usual place of business or at a location to which their job requires them to travel.
"Activities of Daily Living" (ADLs) are:
- BATHING - washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower with or without equipement or adaptive devices.
- DRESSING - putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.
- TOILETING - getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
- TRANSFERRING - moving into or out of a bed, chair, or wheelchair with or without equipment such as cands, quad canes, walkders, crutches, or grab bars or other supportive devices including mechanical or motorized devices.
- CONTINENCE - the ability to maintain control of bowel or bladder function; or, when unable to maintain control of bowel or bladder functions, the ability to perform personal hygience (including caring for catheter or colostomy bag).
- EATING - feeding oneself by getting food into the body from a receptacle (such as a plate, cup, or table) or by a feeding tube or intravenously.
"Adult Day Care" means a community-based program offering health, social, and related support services to impaired adults. Adult Day Care can be provided by:
- a Home Health Care Provider; or
- an Adult Day Care Facility.
"Adult Day Care Facility" means a facility that operates under applicable state licensing laws and any other laws that apply, or meets the following tests:
- operates a minimum of 5 days a week;
- remains open for at least 6 hours a day;
- is not an overnight facility;
- maintains a written record of care on each patient;
- includes a plan of care and record of services provided;
- has a staff that includes a full-time director and at least one registered nurse who are there during operating hours for at least 4 hours per day;
- has established procedures for obtaining appropriate aid in the event of a medical emergency; and
- provides a range of physical and social services to adults.
"Assisted Living Facility" means:
- an institution that is liscensed by the appropriate licensing agency (if licensing is required) to primarily engage in providing ongoing care and services to a minimum of 3 inpatients in one location and operates under state liscensing laws and any other laws that apply; or
- any other institution that meets all of the following tests:
- provides 24 hour a day care, custodial service and personal care assistance to support needs resulting from a Disability;
- has an employee on duty at all times who is awake, trained and ready to provide care;
- provides 3 meals a day, including spcial dietary requirements;
- operates under applicable state licensing laws and any other laws that apply;
- - has formal arrangements for the services of a Physician or nurse to furnish medical care in the event of an emergency;
- - is authorized to administer medication to patients on the order of Physician; and
- - is not, other than incidentally, a home for the mentally retarded, the mentally ill, the blind or deaf, a hotel or home for alcoholics or drug abusers; or
NOTE: These requirements are typically met by Assisted Living Facilities that are either free standing facilities or part of a life care community. In general, they are not met by individual residences, boarding homes, or independant living units. - a similar institution approved by Unum.
"Disability" and "Disabled" mean:
- you are unable to perform, without Substantial Assistance from another individual, at least two Activities of Daily Living; or
- you require Substantial Supervision by another individual to protect you from threats to health and safety due to Severe Cognitive Impairment.
"Elimination Period" means the number of consecutive days during which you must be Disabled and under the regular care of a Physician before benefits become payable:
If your plan includes Professional Home Care Services, each calender week that you receive at least one day of these services will be counted as seven days towards completing the Elimination Period. However, if you do not receive services for at least one day within a calender week, the Elimination Period will begin again.
If your plan does not include Professional Home Care Services, the entire Elimination Period must be completed while residing in a Long Term Care Facility or an Assisted Living Facility.
"Family Members" means:
- the married spouse of an Active or Retired Employee;
- the domestic partner of an Active or Retired Employee. A domestic partner is the person named in the Active or Retired Employee's declaration of domestic partnership. The Active or Retired Employee must execute and provide the plan administrator with such a declaration which states and gives proof that the domestic partner has had the same permanent residece as the Active or Retired Employee for a minimum of 12 consecutive months prior to the date insurance would become effective for that domestic partner. The Active or Retired Employee must not have signed a declaration of domestic partnership with anyone else withinthe last 12 months of signing the lastest declaration of domestic partnership. Also the domestic partner must be at least 18 years old, compentent to contract, not related by blood closer than would bar marriage, the sole named domestic partner, not married to anyne else, and the declaration of domestic partnership must be approved and recorded by the plan administrator.
- the natural, adoptive, or step-parents/grandparents of an Active or Retired Employee and their spouse or domestic partner.
- the natural, adoptive, foster, or step-siblings of an Active or Retired Employee and their spouse or domestic partner.
- the natural, adoptive, foster, or step-children of an Active or Retired Employee and their spouse or domestic partner. Family Members who are eligible for coverage as an Active or Retired Employee are only eligible for coverage as an employee.
- To be eligible for coverage, Family Members must be between the ages of 18 and 80.
"Grace Period" means the 45 days immediately following any premium due date during which premium payment must be made.
"Home Health Care Provider" means:
- an organization which is licensed or certified by the appropriate licensing agency of the state where Professional Home Care Services will be provided;
- it is certified as a home health care organization as defined under Medicare;
- it is any other organization that meets all of the following tests:
- primarily provides skilled nursing care and other theraputic services;
- has standards, policies and ruls established by a professional group which is associated with the organization;
- includes at least one Physician and one registered nurse;
- maintains a written record of care on each patient; and
- includes a plan of care and record of services provided; or
- a similar organization approved by Unum.
"Hospice Care" means a formal program of care for terminally ill patients whose life expectancy is less than 6 months, provided on an inpatient basis and directed by a Physician in a Hospice Care Facility that is licensed, certified or registered in accordance with state law.
"Licensed Health Care Practitioner" means any Physician, and any registered professional nurse, licensed social worker, or any other individual who meets such requirements as may be prescribed by the Secretary of the Treasury.
"Lifetime Maximum Amount" means the maximum Umum will pay you all long term care benefits. You have your own Lifetime Maximum Amount.
"Long Term Care Facility" means:
- an institution, or a distinctly seperate part of a hospital, that is licensed or certified as a nursing home (if licensing or certification is required) or operates under the law as a nursing home to provide skilled, intermediate or custodial care and operates under and complies ith North Carolina facility licensing requirements and any other laws that apply; or
- any other institution that meets all of the following tests:
- is operated as a health care facility under applicable state licensing laws and any other laws;
- primarily provides nursing care under the orders of a Physician;
- provides patient care under the supervision of a registered nurse or licensed practical nurse;
- regularly provides room and board and continuous 24 hour a day nursing care of sick and injured persons;
- maintains a daily medical record of each patient who must be under the care of a Physician;
- is authorized to administer medication to patients on the order of a Physician; and
- is not, other than incidentally:
- a home for the mentally retarded, the mentally ill, the blind or the deaf, alcoholics or drug abusers, or
- a hotel or residence; or
- a similar instituion approved by Unum.
"Physician" means a person who is operating within the scope of his/her license, and is either:
- licensed to practice medicine and surgery and prescribe and administer drugs; or
- legally qualified as a medical practitioner and required to be recognized, under this plan for insurance purposes, according to the insurance laws of the governing jurisdiction. Unum will consider a person to be a Physician only when the person is performing tasks that are within the limits of the person's medical license. Unum will not recognize the following as Physicians for claims that you make to Unum for long term care insurance:
- you, or
- your spouse, daughter, son, parent, sister, brother, grandparent, or grandchild.
"Professional Home Care Services" means:
- visits to your residences by a Home Health Care Provider to provide skilled nursing care; physical, respiratory, occupational, dietary, or speech therapy; and homemaker services. Each one hour or more day of a Home Health Care Provider's services will be considered one visit;
- Adult Day Care; or
- Hospice Care.
- The treatment and services you receive must be provided pursuant to a written plan of care developed by a Licensed Health Care Practitioner.
Professional Home Care Services do not include services performed by your spouse, daughter, son, parent, sister, brother, grandparents, or grandchild through a Home Health Care Provider or an Adult Day Care Facility.
"Respite Care" means care provided to you for a short period of time to allow your informal caregiver a break from their caregiving responsibilities.
"Retired Employee" means an employee who has retired from active employment with the Policyholder.
- A Retired Employee under the age of 81 is eligible for the plan.
"Severe Cognitive Impairment" means a severe deterioration or loss in intellectual capacity, as reliability measured by clinical evidence and standardized tests in:
- short or long term memory;
- orientation to people, places or time; and
- deductive or abstract reasoning. Such deterioration or loss requires Substantial Supervision by another individual for the purpose of protecting you from harming yourself or others. The loss can result from a Disability, Alzheimer's disease, or similar forms of dementia.
"Substantial Assistance" means stand-by assistance by another person without which you would not be able to safely and completely perform the ADL.
"Substantial Supervision" means the presence of another individual for the purpose of protecting you from harming yourself or others.