Aetna Recovery Care Choice

Every benefit below is transcribed from the Aetna Recovery Care Choice outline of coverage CLIRE08515NV (Nevada edition), for policy form CLIRECC025NV, and from the Aetna Recovery Care Choice brochure CLIRE08671, the Aetna Senior Supplemental Insurance company profile CGFMP08395, which states the A.M. Best rating and its date. Benefits, amounts and riders vary by state; the policy issued to you governs.

• What triggers a claim: two of six activities, or cognitive impairment Included

  The daily nursing facility and assisted living benefit is payable once the carrier receives documentation establishing that the insured cannot perform two or more of the activities of daily living, or has a cognitive impairment.

  Acceptable documentation may include a Comprehensive Minimum Data Set assessment within the first fourteen days of a confinement, or another written assessment where the facility is not Medicare or Medicaid certified. The carrier may re-assess, generally not more than once in any ninety day period.

• The daily benefit, and what you choose Included

  Pays a daily amount for nursing facility or assisted living confinement, up to a maximum of $700 a day, with a choice of 90, 180, 270 or 360 covered days and a choice of a 0, 20 or 100 day elimination period. Memory care is included. The lifetime maximum is equal to twice the number of covered days.

  The elimination period has to be met before benefits are paid and is satisfied only once in the lifetime of the policy — not once per claim.

• It pays for custodial care, and the facility need not be Medicare approved Included

  The daily nursing facility coverage pays for all levels of nursing facility care — skilled, intermediate and custodial — and for services in an assisted living facility. The facility does not have to be approved by Medicare.

  This is the gap the policy exists for. Medicare pays for the first 20 days of skilled care only, and only after an inpatient admission of at least three days; it pays nothing for intermediate or custodial care, and nothing for an assisted living facility.

• Bed reservation Included

  Pays to reserve the insured's bed during a covered nursing facility or assisted living confinement when the insured is admitted to hospital as an inpatient.

  It is not payable unless, on discharge from hospital, the insured returns immediately to the facility they were in before.

• Prescription drugs Included

  Pays toward prescription medication needed to treat a covered illness or injury while the policy is in force: $10 per generic prescription and $25 per brand name prescription, to a $300 annual maximum.

  This is the one benefit the pre-existing condition limitation does not apply to.

• A Medicare Part B excess charge benefit, inside a short-term care policy Included

  Pays 100% of the difference between what Medicare pays and the amount charged by the provider, which shall be no greater than the actual charge or the limiting charge allowed by Medicare, whichever is less. The claim must be for Medicare Part B.

  This is a Medigap-shaped benefit in a policy that is not a Medicare Supplement and is not a substitute for one. It is unusual and it is worth asking about, but do not let it stand in for a Medigap policy — it covers excess charges and nothing else Medicare leaves you.

• Optional rider: home care, and family can be paid for it Optional rider

  Pays a weekly benefit when the insured receives at least three home care service visits per week, of at least one hour each, in their home from a home care provider. Up to $2,100 a week, with a choice of 13, 26, 39 or 52 weeks, a 0 or 20 day elimination period, and a lifetime maximum equal to twice the number of covered weeks.

  Family and friends can receive 25% of the weekly home care benefit if they provide the home care services, and the agency does not have to be approved by Medicare. Without this rider, home health care is excluded from the policy entirely.

• Optional rider: daily hospital confinement Optional rider

  Pays a daily amount for hospital confinement including observation stays, up to $700 a day, with a choice of 3 to 10 or 20 days per period of care and a lifetime maximum of 365 days. An observation stay of less than 24 hours pays 50% of the daily hospital confinement benefit, once per period of care.

• Optional rider: adult day care Optional rider

  $50, $100 or $150 a day for health-related services, social engagement and physical activities at an adult day care centre, up to 30 visits a year. The same two-of-six activities or cognitive impairment test applies.

• Optional rider: inflation protection Optional rider

  Increases the daily nursing facility benefit on each policy anniversary, starting one year after the rider's effective date, by a choice of 3% or 5%, on a simple or compound basis. The increases continue whether or not you are claiming.

  It applies to the daily nursing facility benefit only, not to the other riders, unless a rider says otherwise. During a period of care the amount payable is the amount in force when the loss was incurred.

• Optional riders: the rest of them Optional rider

  Home modification, $2,500 lifetime maximum, payable while you are receiving the nursing facility or home care benefit. Mental health visits with a licensed professional, in office or by telehealth, at $25, $50, $75 or $100 per visit, 20 visits a year. Outpatient rehabilitation at $50, $100 or $150 a day, 15 or 30 visits a year. Ambulance transportation at $200, $400 or $600 per ride, 4 uses a year. Pet boarding at $50, $75 or $100 a day, 30 days per period of care, while you are confined to a nursing home.

  Mental health visits are covered by that rider even though mental and nervous disorders are excluded from confinement benefits. Preventive care visits are not covered under it.

• What the policy will not pay for Not covered

  Confinement for experimental or investigational procedures and clinical trials, mental or nervous disorders and substance use disorders, obesity and weight reduction including bariatric surgery and its complications, tobacco cessation, and learning disorders, developmental delays or sleep disorders. Outpatient treatment, services or supplies of any type, except those payable under the prescription drug benefit, the Medicare Part B excess charge benefit and the outpatient rehabilitation, ambulance and mental health riders. Confinement in a hospice care facility. Home health care, unless the home care rider is attached. A stay in a community living center or a place that primarily provides domiciliary, retirement or educational care. War, riot or international armed conflict. A lawful conviction following a crime or felony, or an illegal act, or time imprisoned — excluding acts related to domestic violence. Suicide or intentionally self-inflicted injury, sane or insane. Skydiving, scuba diving, hang or ultra-light gliding, ballooning, bungee jumping, parakiting, riding an all-terrain vehicle, racing, sports for pay or profit and rodeo contests. Injury sustained while driving over the legal blood alcohol limit. Confinement outside the United States.

Issue ages

40 to 89, age at signature date.

Renewability

Guaranteed renewable for your life provided premiums are paid when due, subject to the policy termination provisions.

Pre-existing conditions

Pre-existing conditions are not covered by the policy or any attached rider, whether disclosed in the application or not, for the first 6 months from the date you become insured. A pre-existing condition is a sickness or injury for which medical care, treatment, diagnosis or advice was received or recommended in the 6 months before the effective date, or a condition that manifested itself in those 6 months in a way that would cause an ordinarily prudent person to seek medical advice. The prescription drug benefit is not subject to this limitation.

Financial strength

Rated “A” (Excellent) by A.M. Best as of 13 March 2024 — the third highest of sixteen ratings, which is the part the letter on its own does not tell you. It is a view of the insurer’s ability to pay claims, not a comment on this policy, and it can be changed at any time.

Policy form

CLIRECC025NV. Form numbers and benefits vary by state.