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Covered Services
Your Schedule of Benefits shows the benefit options and amounts you selected.
The Federal Long Term Care Insurance Program (FLTCIP) provides reimbursement for actual charges you incur up to the Benefit Amount shown in your Schedule of Benefits for the following Covered Services if you are eligible for benefits (see the Eligibility for Benefits section) and you have satisfied the applicable waiting period. Please see the Exclusions section for information on those services and supplies that are not covered under the FLTCIP.
Nursing Home and Assisted Living Facility
On any day you are in a Nursing Home or Assisted Living Facility, including those specializing in the care of persons with Alzheimer's disease, we will pay for:
- room and board accommodations; and
- Nursing Care, Maintenance or Personal Care, and Therapy Services provided to you by a Formal Caregiver; and
- drugs, incontinence supplies, dietary supplements, personal medical equipment and laundry services.
On any day you are in a Hospice facility, we will pay for:
- room and board accommodations; and
- Hospice Care; and
- drugs, incontinence supplies, dietary supplements, personal medical equipment and laundry services.
The waiting period does not apply to care in a Hospice facility.
Services Provided by a Formal Caregiver at Home
We will pay for the following services provided to you by a Formal Caregiver at Home: Nursing Care, Maintenance or Personal Care and Therapy Services. A Formal Caregiver may include Family Members provided:
- the Family Member is one of the following professionals — a Nurse, Therapist, Social Worker or registered dietician; and
- the Family Member is a regular employee of a Nursing Home, Assisted Living Facility, Adult Day Care Center or Home Care Agency; and
- the organization receives the payment for the services; and
- the Family Member receives no compensation other than the normal compensation for employees in his or her job category; and
- the Family Member did not normally live in your Home at the time you became eligible for benefits.
Services Provided by an Informal Caregiver
We will pay for services provided by an Informal Caregiver if the services are:
- provided to you at Home or at a location other than a Nursing Home, Hospice facility or Assisted Living Facility (such as the home of a friend or relative); and
- approved by our care coordinator as part of your Written Plan of Care; and
- provided by a person who did not normally live in your Home at the time you became eligible for benefits. (Note: We will pay for Informal Caregiver services provided by a person who began living in your Home after you became eligible for benefits.)
Benefits for Informal Caregivers who are Family Members are limited to 500 days in your lifetime and will be reduced by any days you received Informal Caregiver services from a Family Member under any prior FLTCIP Benefit Booklet.
We will pay for Hospice Care provided to you at Home.
The waiting period does not apply to Hospice Care at Home.
Services Provided at an Adult Day Care Center
We will pay for services provided to you under an adult day care program at an Adult Day Care Center.
We will pay actual charges you incur for Stay-At-Home Services up to the Stay-At-Home Lifetime Benefit Amount shown in your Schedule of Benefits. The waiting period does not apply to the Stay-At-Home Benefit. Except for Care Planning Visits, you must be living at Home in order to be eligible for the Stay-At-Home Benefit. Stay-At-Home Services consist of expenses for:
- Care Planning Visits; and
- Home Modifications; and
- Emergency Medical Response Systems; and
- Durable Medical Equipment; and
- Caregiver Training; and
- Home Safety Checks.
We reserve the right to limit the amount payable for Home Modifications to an amount appropriate for similar work in your geographic area. We will consider a county or such greater area as is needed to establish a representative cross section of providers who regularly furnish the type of Home Modification for which the charge is made.
The maximum amount payable in your lifetime for Caregiver Training will be 7 times your Daily Benefit Amount.
The Stay-At-Home Lifetime Benefit Amount is shown in your Schedule of Benefits. You may use any unused portion of this benefit amount for future Stay-At-Home Services and new episodes of care. Benefits paid under the Stay-At-Home Benefit will not reduce your Maximum Lifetime Benefit. You may receive the services of a Formal Caregiver or an Informal Caregiver, or Hospice Care at Home while receiving benefits under the Stay-At-Home Benefit.
The Stay-At-Home Benefit will not be available to you beginning on the earliest of the following dates:
- the date you no longer are eligible for payment of benefits; or
- the date you no longer reside at Home; or
- the date you exhaust your Stay-At-Home Lifetime Benefit Amount; or
- the date your coverage ends.
Additional Covered Services and Benefits
We will pay for actual charges you incur for Bed Reservations. We will not pay more than the benefit that we would pay if you had been in the Nursing Home, Assisted Living Facility or Hospice facility on those days. Benefits for Bed Reservations are limited to 60 days per calendar year and will be reduced by any days you received Bed Reservation Benefits under any prior FLTCIP Benefit Booklet.
We will pay for Respite Services:
- provided in a Nursing Home, Assisted Living Facility or Hospice Facility; or
- provided by a Formal or Informal Caregiver at home; or
- provided at an Adult Day Care Center.
Benefits for Respite Services are limited to an amount equal to 30 times your Daily Benefit Amount per calendar year and will be reduced by any benefits you received for Respite Services under any prior FLTCIP Benefit Booklet.
The waiting period does not apply to Respite Services.
We may approve alternatives to your Written Plan of Care that we deem to be both appropriate for you and cost effective for the FLTCIP.
An Alternate Plan of Care is one that:
- is designed specifically for you; and
- is primarily being made to improve your ability to perform one or more Activities of Daily Living; and
- is mutually agreed upon by you, a Licensed Health Care Practitioner and us; and
- contains recommendations for alternate services or supplies for you that are not otherwise covered under your Benefit Booklet; and
- may be modified as appropriate.
We will base our review of a request for an Alternate Plan of Care on the following:
- your medical status; and
- current and future care plans; and
- long-term cost projections for current and future care plans and the Alternate Plan of Care; and
- the suitability and effectiveness of the Alternate Plan of Care.
You may choose not to accept the final terms of the Alternate Plan of Care.
The Alternate Plan of Care may not be used:
- to pay for any charges for services or supplies described in the Exclusions section; or
- to supplement the maximum amount for any benefit under your Benefit Booklet; or
- to pay for expenses covered under the Stay-at-Home Benefit.
Benefits payable for charges incurred for services and supplies provided under the Alternate Plan of Care will not exceed the lesser of: the actual charges; or the appropriate charges for such services or supplies.
We will deem a charge appropriate only if it does not exceed the general level of charges being made by others in your area when furnishing like or similar services or supplies. In determining appropriateness, we will consider a county or such greater area as is needed to establish a representative cross section of providers who regularly furnish the type of service or supply for which the charge is made.
Your receipt of services for your care under an Alternate Plan of Care will be subject to the Waiting Period section. The benefits we will pay for such services will be subject to the Maximum Benefit We Will Pay section.
We will pay benefits for Covered Services you receive outside the United States (see the Definitions section for the definition of United States). When you receive such services, we will pay benefits up to 80% of the Benefit Amounts shown on your Schedule of Benefits.
If your Schedule of Benefits shows that you have a 2, 3 or 5 year Benefit Period, 80% of your Maximum Lifetime Benefit can be used for Covered Services you receive outside the United States; the remaining 20% will be available for Covered Services you receive in the United States.
If your Schedule of Benefits shows that you have an unlimited Benefit Period, your Benefit Period will be limited to 10 years for Covered Services you receive outside the United States. For such services, your Maximum Lifetime Benefit will be equal to 3,650 days (10 years) x 80% of your Daily Benefit Amount. Your Maximum Lifetime Benefit for Covered Services you receive in the United States will remain unlimited.
Example 1: Let's assume that you selected a Daily Benefit Amount of $150 and that you have a 5 year Benefit Period. For purposes of determining international benefits, your Daily Benefit Amount is $120 ($150 x 80%) instead of $150. We would pay up to $120 per day for Covered Services. Out of your Maximum Lifetime Benefit of $273,750, you could use up to 80% ($219,000) for all Covered Services you receive outside the United States. If you return to the United States and receive Covered Services, the remaining 20% ($54,750) of your Maximum Lifetime Benefit will be available for those services.
Example 2: Let's assume that you selected a Daily Benefit Amount of $150 and that you have an unlimited Benefit Period. For purposes of determining international benefits, your Daily Benefit Amount is $120 ($150 x 80%) instead of $150. We would pay up to $120 per day for Covered Services. Your Maximum Lifetime Benefit for Covered Services you receive outside the United States would be limited to $438,000 (3,650 x $120). If you return to the United States and receive Covered Services, your Maximum Lifetime Benefit would remain unlimited for those services.
The Coordination of Benefits section does not apply to international benefits.