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Exclusions and Limitations

Exclusions

The Federal Program does not pay benefits for any of the following:

• illness, treatment or medical condition arising out of:
  • your participation in a felony, riot or insurrection;
  • your attempted suicide, while sane or insane; or
  • injuries you intentionally inflict on yourself;
• care or treatment for alcoholism or drug addiction;
• care or treatment provided in a government facility, including a Department of Defense or Department of Veterans Affairs facility, unless otherwise required by law;
• care you receive while in a hospital, except in a unit specifically designated as a nursing home or hospice facility;
• any service or supply to the extent the expense for it is reimbursable under Medicare, or would be so reimbursable except for the application of a deductible, coinsurance or copayment amount. (This exclusion will not apply in those instances where Medicare is determined to be the secondary payor under applicable law);
• services or supplies for which you are not obligated to pay in the absence of insurance; or
• services provided by any person who normally lived in your home at the time you became eligible for benefits.  

Limitations

Benefits payable for covered services are subject to maximums and limitations. See the section titled Benefits Provided by the Federal Program (Benefit Amounts and Maximum Lifetime Benefit subsections).  

Coordination of Benefits

The Federal Program includes a Coordination of Benefits (COB) provision that follows the guidelines set by the National Association of Insurance Commissioners (NAIC). In determining the amount of benefits we will pay under the Federal Program, the COB provision allows us to look at other plans that might pay benefits for long term care services you receive. The other plans we look at include government programs (other than Medicaid), group medical benefits, and other employer-sponsored long term care insurance. We do not look at Medicaid, individual insurance policies or association group insurance policies. The COB provision does not apply to international benefits.

If the Federal Program is primary (this means it pays first), we will pay benefits without coordinating with other plans. That means that we will pay benefits to the maximum extent permitted by your coverage. If another plan or program is primary, then it will pay first. In that case, we will pay no more than the difference between the amount payable by your other coverage(s) and your actual expenses up to the Daily Benefit Amount or Weekly Benefit Amount you select.  

Catastrophic Coverage Limitation (No War Exclusion)

Unlike most long term care insurance policies available today, coverage under the Federal Program does not have a war exclusion. As a result, whether you are a civilian or member of the uniformed services, benefits may be payable under the Federal Program for conditions due to war or acts of war, declared or undeclared, or service in the armed forces or auxiliary units. Your coverage may be reduced, however, if a war or act of war (declared or undeclared) is determined to be a Catastrophic Event as described below.

If there was a Catastrophic Event, the length of time during which you could receive benefits could be shortened.We will consult with OPM when determining if a Catastrophic Event has occurred. A Catastrophic Event is an event or series of events affecting such a significant number of enrollees that it threatens to undermine the financial stability of the Federal Program. This is less likely as Federal Program reserves grow.

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

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