LONG TERM CARE INSURANCE PLAN TABLE OF CONTENTS

Transcription

1 Long Term Care Insurance Plan January 1, 2016

2 LONG TERM CARE INSURANCE PLAN TABLE OF CONTENTS Long Term Care Insurance PLAN Highlights... 1 Introduction... 2 Who is Eligible?... 2 How do I Enroll?... 3 Who Pays For My Coverage?... 3 How Does the Long Term Care Insurance Plan Work?... 3 What Long Term Expenses are Covered?... 3 When Do Long Term Care Benefits End?... 4 What Expenses are not Covered?... 4 How Do I Apply For Benefits?... 5 How Do I AppEAL A DENIED CLAIM?... 5 Statute of Limitations/Lawsuits... 5 Administrative Information... 5 Your ERISA Rights... 6 Assistance With Your Questions... 7 Termination Of the Plan... 7 Interpretation of the Plan... 7 The information in this summary, together with any insurance policies, the Certificate of Insurance and the Outline of Coverage under which long term care benefits are provided, serves as Summary Plan Description for the Medtronic Long Term Care Insurance Plan. With respect to benefit levels and coverage under the Plan, the applicable insurance policy governs. In the event of any conflict between an insurance policy and any other document that constitutes part of the Plan, the insurance policy will be the final authority.

3 LONG TERM CARE INSURANCE PLAN HIGHLIGHTS Who pays for my coverage? When does my coverage begin? When am I eligible to receive benefits? You pay the cost of coverage. If you are an Eligible Employee, your coverage is effective on the first of the month after your application is received and approved by Genworth Life Insurance Company. Employees should enroll online at genworth.com/groupltc (Group ID: Medtronic; Code: groupltc). To be an Eligible Employee, you must be regularly scheduled to work at least 30 hours per week and be actively at work. You are eligible to receive benefits when you are Chronically Ill, in receipt of a current eligibility certification from a licensed health care professional and satisfy the 90 calendar day Elimination Period. Chronically ill is specially defined in the Outline of Coverage provided by Genworth Life Insurance Company ( Outline of Coverage ). Please refer to your Outline of Coverage for additional information. What benefits are paid by the Plan? How do I apply for benefits? Where do I get more information? The Plan pays for care and services during your or your covered family members confinement up to the Nursing Facility Maximum; home and community care up to the Nursing Facility Maximum, bed reservation, home assistance benefits up to 3 months of full Nursing Facility Benefits, hospice care benefits and other assistance. Genworth Life Insurance Company must be notified within 30 days of the date the care or services begins. Please refer to the Outline of Coverage and included at the end of this summary for the specifics of your long term care insurance coverage. 1

4 INTRODUCTION The company provides long term care insurance coverage under the Medtronic Long Term Care Insurance Plan (hereinafter referred to as the Plan ) to help protect employees and their family members from the high costs of long term care services, including care at home, in the community, in assisted living facilities (including Alzheimer s facilities) and in nursing homes. This summary provides general information about the Plan s long term care insurance coverage, such as who is eligible and how to enroll. Specific information about the long term care benefits provided by the Plan can be found in the Outline of Coverage and the Certificate of Insurance. Make sure you consult the Outline of Coverage for the details of your long term care insurance coverage. The capitalized terms in this summary are defined in the Outline of Coverage. The Outline of Coverage can be found at the end of this summary; you will receive the Certificate of Insurance from the insurance company after you enroll. WHO IS ELIGIBLE? You are eligible to participate in the Plan if you are a citizen or resident of the United States, employed by Medtronic, Inc. or a participating affiliate (hereinafter referred to as Medtronic ) and classified by Medtronic as a regular employee of Medtronic scheduled to work 30 hours or more per week and are actively at work. Employees regularly scheduled to work less than 30 hours per week are not eligible for the Plan. You are actively at work if you are performing the usual duties of your job at your usual place of work on a full-time basis at least 30 hours per week. You will be considered actively at work while on approved vacations, holidays and regularly scheduled days off, or during temporary business closures. You will not be considered actively at work if you are unable to perform your usual duties due to a sickness, accident or injury or if you are on a leave of absence, a sabbatical or retired. Employees covered under a collective bargaining agreement are eligible for coverage under the Plan only if coverage specifically is required pursuant to the terms of the applicable collective bargaining agreement. Plan benefits for employees eligible to participate in the Plan due to the terms of a collective bargaining agreement are governed by the terms of that agreement and, in the event of any conflict between the terms of this summary and the terms of the applicable collective bargaining agreement, the terms of the applicable collective bargaining agreement will govern. Individuals employed in Puerto Rico or who Medtronic designates as temporary employees (including employees on a temporary agency payroll), leased employees, casual workers, interns, contract workers, independent contractors or similar classifications performing services for Medtronic, are not considered regular employees whether or not they are paid W-2 wages by Medtronic. If you are eligible for Plan coverage, you can also enroll your eligible family members between the ages of 18 and 75. Eligible family members include: Your spouse. Your domestic partner and his or her adult children (if any), but only if your partner and the children were covered by the Plan on or before December 31, 2015 and the partner and the children remain continuously covered thereafter (these pre-2016 domestic partners are hereinafter referred to as grandfathered domestic partners ). If your domestic partner and his or her children (if any) were not covered by the Plan on or before December 31, 2015, you may not enroll your partner or your partner s children after that date, even if your partner was covered by the Plan in the past. Your adult child(ren), and the adult children of a grandfathered domestic partner. Your siblings / siblings-in-law. Your parents / parents-in-law. Your grandparents / grandparents in-law. All eligible persons must be at least 18 years of age, maintain a permanent United States residence, and have an active Social Security number or tax identification number issued by the United States government. When do I become eligible? If you are not covered by a collective bargaining agreement, you become eligible on the date you first satisfy the Plan s eligibility requirements (for example, on your date of hire if you are actively at work). If you are covered by a collective bargaining 2

5 agreement, you become eligible on the 61st day after you first satisfy the Plan s eligibility requirements (for example, on the 61st day after your date of hire if you are actively at work). HOW DO I ENROLL? You must enroll for long term care insurance coverage by submitting an application to the insurance company. Employees may enroll online at genworth.com/groupltc (Group ID: Medtronic; Code: groupltc). Reduced medical underwriting is available if you are under age 66 and enroll within the first 31 days of the date you first become eligible. All other applicants (and all covered family members) are subject to full medical underwriting. Your coverage (and, if applicable, coverage for your family members) is effective on the first day of the month after your application is received and approved by the insurance company. If you wish to enroll a family member, contact the insurance company. See Administrative Information for contact information. WHO PAYS FOR MY COVERAGE? You pay the full cost of your coverage directly to the insurance company. Premium rates are included in your Information Kit. Your cost depends on your age and the options you select. See How Does the Long Term Care Insurance Plan Work? below. HOW DOES THE LONG TERM CARE INSURANCE PLAN WORK? The Plan is designed to provide benefits for long term care and services in the event you become Chronically Ill. The insurance provided under the Plan is intended to be federally tax-qualified long term care insurance within the meaning of Internal Revenue Code Section 7702B(b), as amended. The Plan reimburses certain expenses for Covered Care. Covered Care must: Constitute Qualified Long Term Care Services; and Be provided pursuant to a written Plan of Care prescribed by a Licensed Health Care Practitioner; and Occur while coverage is in force and prior to the exhaustion of any benefit limits and the Coverage Maximum. The Plan provides different options for the duration of benefits and for maximum coverage levels. Currently, the Plan provides: Three (3) options for the duration of benefits o o o 24 months 36 months 48 months Four (4) options for the Nursing Facility Maximum o o o o $1,500 per month $3,000 per month $4,500 per month $6,000 per month Nursing Facility Maximum is defined in the Outline of Coverage as the maximum amount that will be paid for confinement in a nursing facility, assisted living facility or hospice care facility. This amount is also used to determine other benefit maximums. See the Outline of Coverage for details. The Plan also includes (3) inflation protection options and an optional non-forfeiture benefit rider. You may change your coverage options at any time. You may need to provide proof of good health to increase your coverage and any optional coverage is subject to approval by the insurance company. See your Outline of Coverage for more information and/or contact the insurance company. See Administrative Information for contact information. WHAT LONG TERM EXPENSES ARE COVERED? Once you or a covered family member has satisfied the 90 calendar day Elimination Period, long term care benefits are payable for expenses incurred for: Care and services during confinement in a nursing facility or assisted living facility, up to the Nursing Facility Maximum based on the option selected. Home and Community Care up to 100% of the Nursing Facility Maximum. Bed Reservation for temporary absences of up to 60 days per calendar year when room charges are covered in the facility. 3

6 Home Assistance Benefit up to a lifetime limit equal to 3 months of full Nursing Facility Benefits. Hospice Care Benefit if a person is both Chronically Ill and Terminally Ill; benefits are payable up to the Nursing Facility Maximum for care received in a covered facility and up to the limit for the Home and Community Care Benefit for care received while the insured person is living at home. Informal care for maintenance or personal care services provided in the insured s home, by someone who does not normally reside there; this benefit is subject to a calendar year limit of 30 days with a daily maximum of either: (1) 25% of the Nursing Facility Maximum per day (when daily benefits apply) or (2) 1% of the Nursing Facility Maximum (when benefits are payable on a calendar month basis). Respite Care Benefit for up to 30 days per calendar year. Alternate Care Benefits may, subject to approval by the insurance company and mutual agreement, pay for covered expenses incurred for services, devices or treatments that are Qualified Long Term Care Services not specifically covered under another benefit. Care coordination services. International Nursing Facility Benefit up to 75% of the Nursing Facility Maximum for confinement in an out-of-country nursing facility. This benefit terminates four years after the date for which it first makes payment. Premiums will be waived for each coverage month an while the insured is receiving benefits for Nursing Facility, Assisted Living Facility, Bed Reservation, Home and Community Care or Hospice Care. WHEN DO LONG TERM CARE BENEFITS END? Coverage ends on earliest of the following dates: Your date of death; The date you cancel coverage; The date the policy lifetime maximum is exhausted; or The end of the grace period for payment of the premium. WHAT EXPENSES ARE NOT COVERED? The Plan does not cover any expenses for Covered Care: For which no charge is normally made in the absence of insurance; or Provided outside the US unless covered under the International Nursing Facility Benefit; Provided by an immediate family member; or Provided by or in a Veteran s Administration or Federal government facility; If the care or confinement is a result of a Pre- Existing Condition begins with twelve (12) months following the effective date of coverage; Resulting from illness, treatment or medical condition arising out of any of the following: War or act of war; Attempted suicide or an intentionally selfinflicted injury; Participation in a felony, riot or insurrection; Service in the armed forces or units auxiliary thereto; or Alcoholism or addiction to drugs or narcotics (except for an addiction to a prescription medication when administered in accordance with the advice of a physician). Benefits will be paid only for Covered Care expenses that are in excess of the amount paid or payable under: Medicare (including amounts that would be reimbursable but for the application of a deductible or coinsurance amount); Any State or Federal workers compensation, employer s liability or occupational disease law; and Any other federal, state or other governmental health or long term care program or law, except Medicaid. See your Outline of Coverage for more information, including details on coordination of benefits and any state variations in coverage options and exclusions. 4

7 HOW DO I APPLY FOR BENEFITS? You should notify the insurance company within 30 days of the date care or services begin or as soon as reasonably possible thereafter. See Administrative Information for contact information. Upon receipt of a notice of claim, the insurance company will provide you or the insured person with claim forms needed to file proof of loss. If the claim forms are not received within 15 days, proof of loss can be filed without them with a letter describing the nature and extent of the loss and the covered expense for which the claim is made. If the claim is for a continuing loss, written proof of loss must be given to the insurance company within 90 days after the end of each monthly period for which benefits may be payable. For any other loss, written proof must be provided to the insurance company within 90 days after the date of such loss. Unless the insured is not legally capable, the required proof must always be given to the insurance company no later than 1 year from the time specified. Also, the insurance company must receive updates to the insured s Plan of Care on an ongoing basis. Once the Elimination Period of 90 days is satisfied, benefit payments will be made on a monthly basis after receipt of claim as long as the insured remains eligible to receive benefits. When a claim is paid, a notice showing the total amount of benefits that have been paid to date will be sent. See your Certificate of Insurance for more information and/or contact the insurance company. See Administrative Information for contact information. HOW DO I APPEAL A DENIED CLAIM? If a claim under the Plan is denied in whole or in part, the insurance company will provide you or the insured person with a written notice. This notice will include the reasons for the denial, with reference to the specific provisions of the Plan on which the denial was based, a description of any additional information needed to process the claim, and an explanation of the claims review procedure. Within 180 days after receipt of the written notice denying the claim, the insured may appeal by submitting a written request for reconsideration of the claim. Documents or records in support of the appeal should accompany any such request. The insured may review pertinent documents and submit issues and comments in writing. The insurance company will review the claim and provide, within 30 days, a written response to the appeal. In the written response, the insurance company will explain the reason for the decision, with specific reference to the provisions of the Plan on which the decision is based. See your Certificate of Insurance for more information and/or contact the insurance company. See Administrative Information for contact information. STATUTE OF LIMITATIONS/LAWSUITS No claimant may begin any legal action to recover Plan benefits or to enforce or clarify rights under the Plan, under ERISA or under any other provision of law, whether or not statutory, until the claims procedures described in the Certificate of Insurance have been exhausted in their entirety. Legal action relating to benefit claim denials must be commenced in the proper forum by the time period specified in the Certificate of Insurance. For other claims, legal action must be commenced in the proper forum before the earlier of 30 months after the claimant knew or reasonably should have known of the principal facts on which the claim is based, or 12 months after the claimant has exhausted the claims procedure under the Plan. Knowledge of all facts that you or your dependents knew or reasonably should have known will be imputed to every claimant who is or claims to be entitled to benefits or rights by reference to you or your dependents for the purpose of applying the time periods. In any legal action brought relating to the Plan all explicit and implicit determinations by the insurance company, Medtronic and any other fiduciary (including determinations as to whether the claim, or a request for a review of a denied claim, was timely filed) will be given the maximum deference permitted by law. Any review of a final decision or action of the persons reviewing a claim will be based only on the evidence presented to or considered by those persons at the time they made the decision that is the subject of review. ADMINISTRATIVE INFORMATION Official Plan Name Medtronic Long Term Care Insurance Plan, also commonly referred to in this summary as the Plan. 5

8 Plan Type The Plan is a group long-term care insurance plan. Plan Number The Plan is a component plan of the Medtronic Group Insurance Plan which is plan number 540. Plan Sponsor and Plan Administrator Medtronic, Inc. 710 Medtronic Parkway, LC 245 Minneapolis, MN Plan s Sponsor s Employer Identification Number Plan Year The Plan operates on a calendar year basis, beginning on January 1 and ending on December 31. Plan Funding The insurance coverage under the Plan is fully insured under a group insurance contract. The insurance premiums are paid solely by participants; Medtronic does not pay any portion of the insurance premiums. Agent for Service of Legal Process Vice President, Chief Litigation Counsel Medtronic 710 Medtronic Parkway Minneapolis, MN Legal process also may be served on the Plan Sponsor and Plan Administrator at the address above. Insurance Company Genworth Life Insurance Company Group Processing Center Medtronic P.O. Box St. Paul, MN For Appealing a Benefit Claim Denial Contact the insurance company in writing. The Certificate of Insurance describes how to make and appeal a claim for benefits. To Apply for Benefits or If you Have Questions, Contact: Genworth Life Insurance Company Group Processing Center Medtronic P.O. Box St. Paul, MN YOUR ERISA RIGHTS As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to the following. Receive Information About Your Plan and Benefits Examine (without charge) at the Plan Administrator s office and at other specified locations such as work sites and union halls all documents governing the Plan, including insurance contracts and collective bargaining agreements and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series), and updated Summary Plan Descriptions. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the Plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. 6

9 No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. Know Your Rights If your claim for a benefit is denied or ignored in whole or in part you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time frames. Under ERISA, there are steps you can take to enforce your ERISA rights. For instance: If you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored in whole or in part you may file suit in a state or Federal court provided you have exhausted the administrative procedures under the Plan. If it should happen that Plan fiduciaries misuse the Plan s money, or if you re discriminated against for asserting your ERISA rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. If you file suit against the Plan, the court will decide who should pay court costs and legal fees. If you re successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees for example, if it finds your claim is frivolous. You may have additional rights under ERISA. However, applicable law and the Plan s provision require you to pursue all claim and appeal rights on a timely basis before seeking other legal recourse regarding claims for benefits. ASSISTANCE WITH YOUR QUESTIONS If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration (EBSA), U.S. Department of Labor, listed in your telephone directory; or the Division of Technical Assistance and Inquiries, Employee Benefit Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, DC You may also obtain certain publications about your rights and responsibilities under ERISA by: Calling the Employee Benefits Security Administration Brochure Request Line (also called the Publications Hotline ) at ; Logging on to the Internet at or Contacting the EBSA field office nearest you. TERMINATION OF THE PLAN Medtronic reserves the right to amend or terminate the Plan at any time. If Medtronic terminates the Plan, you have the right to continue the coverage by paying the premiums to the insurance company. You will be sent a notice giving you the option to continue to maintain your coverage. INTERPRETATION OF THE PLAN The Plan Administrator has full and complete discretion to interpret and administer the Plan, and has delegated this authority to the Senior Vice President, Chief Human Resources Officer, the Vice President of Global Rewards and the Senior Benefits Director (hereinafter the Authorized Individuals). Pursuant to this delegation, the Authorized Individuals have full and complete discretion to interpret and administer the Plan including, without limitation, discretionary authority to interpret the Plan, make rules, determine eligibility for benefits, determine coverage and benefit amounts, resolve all claims and disputes regarding the Plan and further delegate any or all of such discretionary authority as they deem appropriate. The decisions of the Authorized Individuals are final and binding on all persons and can be overturned on review only if they are arbitrary, capricious or otherwise constitute an abuse of discretion. The Authorized Individuals have delegated the responsibility for handling benefit claims and appeals under the Plan to an insurance company (the insurance company is listed in this summary). 7

10 Pursuant to this delegation, the insurance company has full and complete discretion to interpret and administer the provisions of the Plan and to determine benefits payable under the Plan. Benefits will be paid only if you have met the Plan's eligibility and participation requirements and the insurance company determines that you are entitled to benefits according to the terms of the Plan. If the insurance company issues an adverse benefit determination, you (or your authorized representative) may appeal that decision under the appeal procedures described in the Certificate of Insurance. Keep in mind that the Plan's appeal procedures are mandatory you (or your authorized representative) may not begin any legal action regarding a claim until the appeals process is complete. The decisions of the insurance company are final and binding on both you and Medtronic. 8

11 Genworth Life Insurance Company Administrative Office P.0 Box St Paul MN Long Term Care Insurance Outline of Coverage from Genworth Lif e Insurance Company Page 1 of 8 Group Policy Form No.: Series 7053 Certificate Form No.: 7053CRT Group Policyholder: Medtronic NOTICE TO BUYER This Group Policy may not cover all of the costs associated with long term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all Group Policy limitations. CAUTION The issuance of this long term care insurance Certificate is based upon Your responses to the questions on any Application You submit. A copy of Your Application(s), if any, will be provided to You. If Your answers are incorrect or untrue, Genworth Life Insurance Company (called We, Us and Our in this Outline of Coverage) has 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 Us at this address: the Administrative Office address shown above. 1. POLICY DESIGNATION The Policy is a Group Policy issued in the state of MINNESOTA. 2. PURPOSE OF THE OUTLINE OF COVERAGE This Outline Of Coverage provides a very brief description of the important features of the Group 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 individual or group policy, and not the Outline Of Coverage, contains governing contractual provisions. This means that the individual or group policy sets forth in detail the rights and obligations of both You and Us. Therefore, if You purchase this Coverage, or any other coverage, it is important that You READ YOUR POLICY OR CERTIFICATE CAREFULLY! 3. FEDERAL TAX CONSEQUENCES THE GROUP 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 POLICY OR 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 Group Policy, to continue the Certificate until Benefits are exhausted, by paying Your Premium on time. We cannot change any of the terms of the Certificate on Our own, except that, in the future, WE MAY INCREASE THE PREMIUM YOU PAY. (b) CONTINUATION COVERAGE: Your Coverage will be continued in accordance with the terms of Your Certificate even if the Policyholder ceases to sponsor the Group Policy or discontinues coverage for the group of eligible persons to which You belong. You must pay Us all Premium required for the continuation of Your Coverage. (c) WAIVER OF PREMIUM: Premium will be waived for each coverage month while You are receiving Nursing Facility Assisted Living Facility, Bed Reservation, Home and Community Care or Hospice Care Benefits. 5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUM WE HAVE THE RIGHT TO CHANGE PREMIUM BECOMING DUE IN THE FUTURE. We can change Premium either on a Group Policy or class basis; but only if We change Premium for all similar Certificates issued 7053-OL MN _4/1/13

12 under the Group Policy in the same State. Premium will not change due to a change in Your age, health, or use of Benefits. A change in Premium may occur only once in any 12 month period. We will give You at least 60 days written notice before We change Premium. The rates used to determine Your Premium are guaranteed until 7/1/ TERMS UNDER WHICH THE CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED 30-Day Free Look Period: You have 30 days from the day You receive the Certificate to review and return it to Us at Our Administrative Office if You are not satisfied with it for any reason. All Premium paid will be refunded within 10 days after: (a) return of the Certificate during this Free Look Period; or (b) Our denial of Your Application. Unearned Premium Refunds: Unearned Premium will be refunded if Your Coverage ends due to death, surrender or cancellation. 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 Us. Neither We nor Our agents or producers 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. This Coverage reimburses You for covered long term care expenses You incur. It is subject to an Elimination Period, limitations, exclusions, and other provisions and conditions of the Group Policy. 9. BENEFITS PROVIDED (a) Covered Services: Payment of institutional and non-institutional Benefits described below is subject to the provisions, conditions, limitations and exclusions of the Group Policy as restated in the issued Certificate. Once the Elimination Period has been satisfied, Benefits are available up to daily or monthly and annual maximums until the applicable Benefit limits are exhausted. Benefits are paid up to the applicable limits for 100% of Your Covered Expenses. You will be responsible for the payment of any expenses not reimbursed by Your Coverage. The limits and features for Your Coverage are based on Your plan choices. (b) Institutional Benefits: These pay for Covered Expenses incurred while confined in a Nursing Facility, Assisted Living Facility, or Hospice Care Facility. This includes room charges in a Nursing Facility or Hospice Care Facility. The Assisted Living Facility Benefit includes room charges and pays up to 100% of the Nursing Facility Maximum. Bed Reservation Benefits are available for temporary absences of up to 60 days per calendar year when room charges are covered in the facility. (c) Non-Institutional Benefits: These include the following: Outline of Coverage Page 2 of 8 Privileged Care Coordination Services are offered to assist in identifying care needs and community resources available to deliver care while You are Chronically Ill. When You choose to use these services they will be furnished by a Privileged Care Coordination team provided by Us at no cost to You. The Home and Community Care Benefit covers services received at home and in the community for: Adult Day Care. Nurse and Therapist Services. Home Health or Personal Care Services from Formal Providers (licensed or certified individuals and Home Health Agencies) and Incidental Homemaker and Chore Care received during the same visit and by the same person who provided You with those Home Health or Personal Care Services. The Home and Community Care Benefit pays up to 100% of the Nursing Facility Maximum. The Home Assistance Benefit covers: home modifications; assistive devices; supportive equipment; emergency medical response systems; and caregiver training. It pays up to a lifetime limit equal to 90 days/3 months of full Nursing Facility Benefits OL MN _4/1/13

13 Outline of Coverage Page 3 of 8 The Hospice Care Benefit covers services designed to provide palliative care and alleviate Your discomforts when You are both Chronically Ill and Terminally Ill. Benefits are payable up to: the Nursing Facility Maximum for care received in a covered facility; and the limit for the Home and Community Care Benefit when care is received while You are living at home. The Respite Care Benefit provides short-term coverage to relieve the person who normally and primarily provides You with care in Your home on a regular, unpaid basis. It pays for up to 30 days per calendar year. The Alternate Care Benefit may, subject to Our approval and mutual agreement, pay for Covered Expenses incurred for services, devices or treatments that are Qualified Long Term Care Services not specifically covered under another Benefit. The Contingent Nonforfeiture Benefit gives You the right to reduce coverage or convert to limited paid-up Benefits in the event of a cumulative Premium increase that is considered to be substantial as stated in the Certificate. (d) Eligibility For The Payment Of Benefits: For You to be eligible for the payment of Benefits: You must be Chronically Ill; We must receive a Current Eligibility Certification for You; and We must receive ongoing proof which verifies that the Covered Care You receive is needed due to You continually being Chronically Ill. Conditions: Benefits will only be paid as reimbursement for expenses paid on Your behalf only if all of the following conditions have been satisfied: You must meet the above Eligibility For The Payment Of Benefits requirements. The expenses must qualify as Covered Expenses. The Covered Care and related Covered Expenses must be consistent with and received pursuant to Your Plan of Care as prescribed by a Licensed Health Care Practitioner. Your Coverage must not have ended before the date(s) the Covered Care is received. Any applicable Elimination Period must be satisfied. You must not have exhausted the Coverage Maximum or any daily, monthly, annual or lifetime limits applicable to the specific Benefits being Claimed. You must meet the requirements for payment in accordance with all the provisions of Your Certificate. The care, service, cost or item for which Benefits are payable must meet the definition of Qualified Long Term Care Services. Meaning Of Terms: The following definitions are being provided to assist You in understanding certain terms used in this Outline Of Coverage. The Certificate contains additional definitions not provided for in this Outline Of Coverage. The definition of any capitalized term in this Outline Of Coverage is provided for in the General Definitions section of the Certificate. Activities of Daily Living means the following self-care functions: bathing (washing oneself); continence (control of bowel and bladder functions); dressing (putting on and taking off clothes and assistive devices); eating (taking nourishment); toileting (including performing associated personal hygiene tasks); and transferring (moving in and out of a bed, chair or wheelchair). Chronically Ill or Chronically Ill Individual refers to a person who has been certified by a Licensed Health Care Practitioner as: Being unable to perform, without Substantial Assistance from another individual, at least two (2) Activities of Daily Living due to a Loss of Functional Capacity. In addition, this Loss of Functional Capacity must be expected to exist for a period of at least 90 days; or Requiring Substantial Supervision to protect the person from threats to health and safety due to a Severe Cognitive Impairment. Loss of Functional Capacity means requiring the Substantial Assistance of another person to perform the prescribed Activities of Daily Living. Severe Cognitive Impairment is a loss or deterioration in intellectual capacity that: is comparable to (and includes) Alzheimer s disease and similar forms of irreversible dementia; and is measured by clinical evidence and standardized tests that reliably measure impairment in the person s: short-term or long term memory; orientation as to people, places or time; deductive or abstract reasoning; and judgment as it relates to safety awareness. Substantial Assistance is either: Hands-on Assistance which is the physical assistance (minimal, moderate or maximal) of another person without which You would be unable to perform the Activity of Daily Living; or Standby Assistance which is the presence of another person within arm s reach of You that is necessary to prevent, by physical intervention, injury to Yourself while You are performing the Activity of Daily Living OL MN _4/1/13

14 Substantial Supervision is continual supervision (which may include cueing by verbal prompting, gestures, or other demonstrations) by another nearby person that is necessary to protect the severely cognitively impaired person from threats to his or her health or safety (such as may result from wandering). Coverage means the Benefits You have under the Group Policy or Continuation Coverage as evidenced by Your Certificate. Coverage Maximum means the maximum amount of Benefits under Your Coverage. The Coverage Maximum will change as described below and when You elect changes. Your Coverage Maximum is $. Your Coverage Maximum and amounts based on the Nursing Facility Maximum are: (a) reduced as payments are made for Covered Expenses; (b) increased when Benefit Increases apply; and (c) exhausted when they are reduced to zero. Covered Care means those Qualified Long Term Care Services for which Your Coverage pays Benefits or would pay Benefits in the absence of an Elimination Period or payment limits. Covered Expenses means costs You incur for Covered Care. Each Benefit defines the Covered Expenses under that Benefit. An expense is considered to be incurred on the day on which the care, service or other item forming the basis for it is received by You. A Current Eligibility Certification is a written certification by a Licensed Health Care Practitioner, who is not a member of Your Immediate Family, that You meet the above requirements for being Chronically Ill. The certification must be renewed and submitted to Us every 12 months. Elimination Period means the length of time, beginning with the first day on which You incur a Covered Expense, before You are entitled to Benefits. Days used to satisfy the Elimination Period do not need to be consecutive; and can be accumulated over time. Once satisfied, You will never have to satisfy a new Elimination Period for Your Coverage. Your Elimination Period is 90 days of Calendar Days. Nursing Facility Maximum means the maximum amount We will pay when You are Confined in a Nursing Facility. This may be a daily maximum or a monthly maximum, based on Your plan choice. This amount is also used to determine other Benefit maximums. The Nursing Facility Maximum is the maximum total amount payable for all Covered Expenses incurred (a) on a day when it is a daily maximum; or (b) in a calendar month when it is a monthly maximum. This limitation does not apply to Benefits that are not subject to a daily or monthly maximum. Your Nursing Facility Maximum is $ per month. Qualified Long Term Care Services means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating, and rehabilitative services and maintenance or personal care services which: (1) are required by a Chronically Ill Individual; and (2) are provided pursuant to a Plan of Care prescribed by a Licensed Health Care Practitioner. OTHER FEATURES AND OPTIONS (Optional items available for added Premium) Automatically Included International Nursing Facility Benefit: This Benefit will pay for Covered Expenses You receive while You are outside the United States. Subject to the Coverage Maximum, it pays up to 75% of the Nursing Facility Maximum for confinement in an Out-of-Country Nursing Facility. This Benefit terminates four years after the date for which it first makes payment. Optional Nonforfeiture Benefit: This Benefit provides a continuation if Your Coverage ends due to non-payment of Premium after it has been in force for at least three years. Any Benefit Increases will cease; and the Coverage Maximum will be reduced to the greater of: (a) the sum of all Premium paid (and not waived under the Waiver of Premium Benefit) for Your Coverage; or (b) the amount equal to one month (30 days) of Benefits under the Nursing Facility Benefit in effect at the time Your Coverage ends. In no event will this amount exceed the unused Coverage Maximum at the time Your Coverage ends. Automatically Included Informal Care Benefit: This Benefit provides for the payment of Covered Expenses incurred for health and personal care assistance another person provides to You in Your Home in accordance with Your Plan of Care. That person can be a member of Your Immediate Family or someone else provided he or she: (a) did not reside with You in Your Home at the time Your first satisfied the Eligibility For The Payment Of Benefits provisions; and (b) is not compensated, as an employee, by any organization that is paid to provide such assistance. Payment is subject to a calendar year total of 30 days with a daily maximum of: 25% of the Nursing Facility Maximum per day when daily Benefits apply; or 1% of the Nursing Facility Maximum per day when Benefits are payable on a calendar month basis. This Benefit will not be paid for any day for which payment is made under the Home and Community Care Benefit. Payment of this Benefit is subject to the Elimination Period OL MN Outline of Coverage Page 4 of _4/1/13

15 Outline of Coverage Page 5 of EXCLUSIONS AND LIMITATIONS Pre-Existing Conditions Limitation: We will not pay for Covered Expenses incurred for any care or confinement that is a result of a Pre-Existing Condition when the care or Confinement begins within twelve (12) months following Your initial Certificate Effective Date. A Pre-Existing Condition means a condition (illness, disease, injury or symptom) for which medical advice or treatment was recommended by, or received from, a Health Care Professional within six (6) months prior to Your initial Certificate Effective Date. A Health Care Professional includes anyone who is: a Physician; a Nurse; a physician assistant; a physical, occupational, speech or respiratory therapist; a chiropractor; an acupuncturist; a homeopathic doctor; or a Licensed Health Care Practitioner. Non-eligible Facilities/Providers: A Nursing Facility, Assisted Living Facility or Hospice Care Facility must meet the applicable definition stated in Your Certificate in order to qualify for Coverage. Non-eligible Levels of Care: Coverage is not based on the specific level of care; but is for care furnished for a specific covered reason, by or through the covered facilities and providers. Care from Immediate Family members is covered only when specifically indicated. Exclusions/Exceptions and Limitations: We will not pay Benefits for any Covered Care: for which no charge is normally made in the absence of insurance; provided outside the fifty (50) United States, the District of Columbia, and any territory of the United States of America; unless specifically provided for by a Benefit; provided by Your Immediate Family, unless: specifically covered by a Benefit; or he or she is paid as a regular employee of the organization that provides the services to You; provided by, or in, a Veteran s Administration or Federal government facility, unless otherwise required by law, or a valid charge is made to You or Your estate; resulting from illness, treatment or medical condition arising out of any of the following: war or any act of war; attempted suicide or an intentionally self-inflicted injury; participation in a felony, riot, or insurrection; service in the armed forces or units auxiliary thereto; for alcoholism or addiction to drugs or narcotics (except for an addiction to a prescription medication when administered in accordance with the advice of a physician). Non-Duplication: Benefits will be paid only for Covered Expenses that are in excess of the amount paid or payable under: Medicare (including amounts that would be reimbursable but for the application of a deductible or coinsurance amount); and Any State or Federal workers compensation, employer s liability or occupational disease law; Any other Federal, state or other government health or long term care program, (including the Community Living Assistance Services and Supports Act - CLASS Act ), or law except Medicaid. This Non-Duplication provision will not disqualify a Covered Expense from being used to satisfy any Elimination Period requirement. Coordination with Other Coverage: We will reduce the amount of Benefits We will pay for Covered Expenses when the total amount payable under this and all Other Long Term Care coverage is greater than the actual Covered Expense You incur for Covered Care. THE POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG TERM CARE NEEDS. 11. RELATIONSHIP OF COST OF CARE AND BENEFITS Because the costs of long term care services will likely increase over time, You should consider whether and how the Benefits of Your Coverage may be adjusted. Benefit levels will not increase over time unless the plan You purchase provides Benefit Increases. Unless otherwise described, these increases: will be automatic; will not require proof of good health; will be made without a corresponding increase in Premium; and will continue without regard to Your age, claim status or claim history, or length of time You have been insured. Benefit Increases cease when: (a) the applicable maximum has been exhausted; (b) they are terminated by You; (c) Your Coverage ends; or (d) Your Coverage is continued under any Nonforfeiture Benefit, if applicable. If You do not purchase a Benefit Increases option at initial issue, You may need to provide proof of good health to later increase coverage. Available increase options are described below. They are followed by a graphic comparison of the 7053-OL MN _4/1/13

16 Benefit levels of coverage that increase Benefits over time with coverage that does not increase Benefits. A similar graphic comparison illustrates Premium for those coverages at a given issue age. AVAILABLE BENEFIT INCREASE OPTIONS Outline of Coverage Page 6 of 8 5% Future Purchase Options will apply if no other Option is selected. 3% Compound Benefit Increases: On each anniversary of Your Certificate Effective Date Your then current Nursing Facility Maximum and the current amounts of other dollar maximums will each increase by 3%. 5% Compound Benefit Increases: On each anniversary of Your Certificate Effective Date Your then current Nursing Facility Maximum and the current amounts of other dollar maximums will each increase by 5%. 5% Future Purchase Options: These provide a way to increase Your Benefit maximums as of every 3rd anniversary of the Group Policy Effective Date. Increases will not be available or effective, and may be revoked or rescinded, if You are Chronically Ill or otherwise eligible for Benefits on the date the offer is accepted. You will be given the option to purchase additional coverage equal to 5% compounded annually for the 3 year period (an approximate increase of 15.8%). The increases will apply to Your then current Nursing Facility Maximum and the current amounts of other dollar maximums. The additional Premium for an increase will be based on: (1) the amount of the increase; and (2) Your age and the Premium in effect for the Group Policy on the date the increase takes effect. Offers and Benefit Increases cease when: (a) You have refused/declined two consecutive options to increase Benefit maximums; (b) the applicable maximum has been exhausted; (c) they are terminated by You; (d) Your Coverage ends; or (e) Your Coverage is continued under any Nonforfeiture Benefit, if applicable OL MN _4/1/13