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Benefits Provided by the Federal Program

Alternate Plan of Care

Under the circumstances described below, our Care Coordinator can authorize benefits for services for your care that are not specifically defined as covered services. For example, under an Alternate Plan of Care, we will consider a facility that is not otherwise covered under the Federal Program (such as a residential care facility licensed in California). If you select the Comprehensive Option, our Care Coordinator can also authorize benefits for supplemental items that enable you to remain at home, such as modification to your home to make it wheelchair accessible, durable medical equipment, and emergency response systems.

Services for your care and supplemental items for which benefits are authorized by us under this section are called an Alternate Plan of Care and, as such, will be considered covered services. Benefits under an Alternate Plan of Care will only be authorized if we determine, in our sole discretion, that the Alternate Plan of Care meets the following criteria:

• it is part of your written plan of care approved by us; and
• it effectively meets your long term care service needs; and
• it does not include services provided by a person who normally lived in your home at the time you became eligible for benefits; and
• it is cost-effective for the Federal Program; and
• for the Facilities-Only Option, it does not include services that are provided outside a facility.

Your reimbursement for services for your care will be subject to the Waiting Period subsection. Supplemental items you pay for under an Alternate Plan of Care will not count toward satisfying your Waiting Period. However, after you satisfy your Waiting Period and if you remain eligible for benefits, we will reimburse you retroactively for any expenses you incurred for approved supplemental items you received during your Waiting Period.

For example, if you pay for modifications to your home to make it wheelchair accessible during the Waiting Period and you remain eligible for benefits, once your Waiting Period has been satisfied, we will reimburse you for the cost you incurred to modify your home.

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Call: 1-800-LTC-FEDS (1-800-582-3337) (TTY: 1-800-843-3557)

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