Frequently Asked Questions

Benefits

Eligibility for Benefits

1. When are enrollees eligible for benefits?
    
2. What are Activities of Daily Living (ADL)?
    
3. What is Severe Cognitive Impairment?
    
4. What if I disagree with the insurance company's decision on being eligible for benefits and/or its decision on my claim?
    
5. Do I have any recourse if I exhaust the appeals process and still do not agree with the decision?

1. When are enrollees eligible for benefits?

You are eligible for benefits after you are enrolled in the program and you meet the following conditions. Benefits are payable after you meet these conditions and you satisfy any required waiting period.

• A licensed health care health practitioner certifies that:
   
  • You are unable to perform 2 of 6 activities of daily living (ADLs) AND your condition is expected to last at least 90 days,
    OR
  • You need substantial supervision due to a severe cognitive impairment.
     
• Long Term Care Partners agrees with the certification,
   
• A licensed health care professional develops a plan of care for you and Long Term Care Partners approves that plan of care.

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2. What are the Activities of Daily Living (ADL)?

The activities of daily living are listed below. If you need substantial assistance from another person to complete any one of these activities, you are considered dependent for that activity.

• Bathing:
  • getting into a tub or shower; and
  • getting out of a tub or shower; and
  • washing your body in a tub, shower or by sponge bath; and
  • washing your hair in a tub, shower or sink
     
• Dressing:
  • putting on any necessary item of clothing (including undergarments) and any necessary braces, fasteners or artificial limbs; and
  • taking off any necessary item of clothing (including undergarments) and any necessary braces, fasteners or artificial limbs.
     
• Transferring:
  • getting into a bed, chair or wheelchair; and
  • getting out of a bed, chair or wheelchair.
     
• Toileting:
  • getting to and from the toilet; and
  • getting on and off the toilet; and
  • performing associated personal hygiene.
     
• Continence:
  • maintaining control of bowel and bladder function; or
  • when unable to maintain control of bowel or bladder function, performing associated personal hygiene (including caring for catheter or colostomy bag).
     
• Eating:
  • feeding yourself by getting food into your mouth from a container (such as a plate or cup), including use of utensils when appropriate (such as a spoon or fork); or
  • when unable to feed yourself from a container, feeding yourself by a feeding tube or intravenously.

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3. What is Severe Cognitive Impairment?

Go to the full definition of Severe Cognitive Impairment.

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4. What if I disagree with the insurance company's decision on being eligible for benefits and/or its decision on my claim?

All denials are reviewed internally before they are issued. If you receive a denial, the denial letter will let you know how to request a review of the denial. If that denial is upheld, you may request an appeal. The letter upholding the denial will explain this process to you.

All appeals are reviewed by an appeals committee composed of: one or more representatives of John Hancock Life Insurance Company, one or more representatives of Metropolitan Life Insurance Company, and other person(s) as mutually agreed upon by OPM and Long Term Care Partners.

If the appeals committee upholds the denial, you may have the right to request a review by an independent third party. The letter upholding the denial will give you the details on requesting a review by an independent third party.

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5. Do I have any recourse if I exhaust the appeals process and still do not agree with the decision?

Yes. Once you have exhausted the appeals process, you may seek judicial review.

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