Attachment 6F - Early Enrollment Benefit Booklet.doc

EARLY ENROLLMENT BENEFIT BOOKLET

FEDERAL LONG TERM CARE INSURANCE PROGRAM

P.O. Box 9170

Boston, Massachusetts 02117-9170

1-800-LTC-FEDS (1-800-582-3337)

TDD 1-800-843-3557

Group Policyholder: United States Office of Personnel Management (OPM) Insurer: John Hancock Life Insurance Company or Metropolitan Life Insurance Company

Program Administrator: Long Term Care Partners, LLC®

Group Policy Numbers: 900-001; 900-002

NOTICES: PLEASE READ CAREFULLY!

Important: Our decision to issue coverage was based upon your responses to the questions on your application. We have sent or will send a copy of your application to you. We may deny benefits or rescind your insurance coverage if your answers are incorrect or untrue for any reason. Please review the copy of your application. If any information you provided to us about your health or eligibility status has changed, you must notify us immediately. The best time to clear up any questions is now, before a claim arises! If for any reason, any of your answers is incorrect, please contact: Federal Long Term Care Insurance Program, P.O. Box 9170, Boston, Massachusetts 02117-9170. You may also call 1-800-LTC-FEDS (1-800-582-3337), TDD 1-800-843-3557.

The Group Policy, including this Benefit Booklet, is designed to be a qualified long term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended. Subject to specified dollar limits that vary depending on your age, you may be able to include your premium in your itemized deductions on your Federal income tax return, if your total medical expenses, including the allowable portion of your premium, exceed 7½% of adjusted gross income. The allowable dollar limits are reviewed each year by the U. S. Treasury and adjusted accordingly. We have designed the Group Policy so that benefits you receive under the Program should be tax-free. Please remember that tax laws can change and to consult your tax advisor if you have any questions or need further details.

The Program may not cover all of your long term care costs. Please review all coverage limitations and exclusions described in this Benefit Booklet and your Schedule of Benefits.

Within 30 days after you receive this Benefit Booklet, you may cancel your coverage and receive a refund of your premium if you are not satisfied with it. If you wish to do this, you must notify us within 30 days of receiving this Benefit Booklet. Then we will refund all of your premium within 30 days. It will be as if the coverage was never issued. You may cancel your coverage at any other time; however, we will only refund premium that covers a period after the effective date of your cancellation.

YOUR COVERAGE IS GUARANTEED RENEWABLE. This means we will not cancel your coverage as long as you pay your premium on time. Please see the Premiums section for information on when we may change your premium. Please see the Statements Made by You Relating to Insurability subsection of the General Provisions section, for information on when we may Contest the Validity of your coverage. We and OPM will determine whether to renew the Group Policy. Your consent or the consent of any other person who may have a beneficial interest under the Group Policy is not required. You will be notified in the event the Group Policy is ended. You may continue your coverage, even if the Group Policy ends, subject to the terms and conditions of the Continuation of Coverage section.

This Benefit Booklet together with your Schedule of Benefits is your evidence of coverage. If you did not receive your Schedule of Benefits, please call 1-800-LTC-FEDS (1-800-582-3337), TDD 1-800-843-3557.

TABLE OF CONTENTS

SECTION PAGE

NOTICES

i

TABLE OF CONTENTS

ii

INTRODUCTION

Defined Terms

EFFECTIVE DATE OF COVERAGE

If You Lost Your Eligibility Status Before Your Original Effective Date If Your Eligibility Status Changed Before Your Original Effective Date Actively at Work Requirement for Employees and Members of the Uniformed Services

CONDITIONS FOR PAYMENT OF BENEFITS

ELIGIBILITY FOR BENEFITS

How to Ask Us to Determine Whether You Are Eligible for Benefits Continuing Assessment of Your Eligibility for Benefits Notice and Review of Benefit Eligibility Decision

WAITING PERIOD

COVERED SERVICES

Nursing Home and Assisted Living Facility Hospice Care Bed Reservations Services Provided at an Adult Day Care Center Services Provided by a Formal Caregiver at Home Services Provided by an Informal Caregiver Respite Services Caregiver Training Alternate Plan of Care International Benefits

MAXIMUM BENEFIT WE WILL PAY

CARE COORDINATION SERVICES

EXCLUSIONS

WAR, ACTS OF WAR, & SERVICE IN THE ARMED FORCES OR AUXILIARY UNITS

CATASTROPHIC COVERAGE LIMITATION

COORDINATION OF BENEFITS

Government Programs

CLAIMS

Notice and Review of Claim Determination

APPEALS

PAYMENT OF BENEFITS

TABLE OF CONTENTS (Continued)

SECTION PAGE

BENEFIT CHANGES

Automatic Compound Inflation Option Future Purchase Option Other Benefit Changes Benefit Changes May Affect Your Premium

PREMIUMS

How Benefit Changes Affect Your Premium

GRACE PERIOD

WAIVER OF PREMIUM

WHEN YOUR COVERAGE WILL END

PORTABILITY

CONTINUATION OF COVERAGE

EXTENSION OF BENEFITS

REINSTATEMENT OF COVERAGE

GENERAL PROVISIONS

Statements Made by You Relating to Insurability Age No Cash Surrender Value Insurers Right to Change Contract Provisions Interpretation of Terms, Conditions and Provisions Limits on Legal Actions Refund of Premiums Payments on Your Death

DEFINITIONS

Act.

Actively at Work or Active Work Activities of Daily Living Adult Day Care Center Annuitant Assisted Living Facility Benefit Amount Benefit Booklet Benefit Period Catastrophic Event Contest the Validity Covered Services Daily Benefit Employee Family Member Formal Caregiver Group Policy Home Care Agency Home Health Aide TABLE OF CONTENTS (Continued)

SECTION PAGE

Homemaker Hospice Hospice Care Hospital.

Informal Caregiver Licensed Health Care Practitioner Maintenance or Personal Care Material To Your Insurability Maximum Lifetime Benefit Medicare Member of the Uniformed Services Misrepresentation.

Nurse Nursing Care Nursing Home

OPM.

Original Effective Date Original Issue Age Physician Plan of Care Program.

Qualified Long Term Care Services Qualified Relative Retired Member of the Uniformed Services Schedule of Benefits Severe Cognitive Impairment Signed Social Worker Substantial Assistance.

Substantial Supervision Terminal Illness or Terminally Ill Therapist Therapy Services United States Workforce Written or Writing

INTRODUCTION

Thank you for selecting the Federal Long Term Care Insurance Program (Program) to help meet your long term care insurance needs.

Under this Program you have coverage for long term care services you receive while you are in a Nursing Home, Hospice facility or Assisted Living Facility, plus coverage for long term care services you receive at home or in an Adult Day Care Center.

Your Schedule of Benefits provided with this Benefit Booklet specifies the amounts of coverage that you selected.

Long Term Care Partners, LLC is the designated Program administrator. You may contact Long Term Care Partners at 1-800-LTC-FEDS (1-800-582-3337), TDD 1-800-843-3557. In consultation with OPM, we may change the Program administrator at any time without notice.

Defined Terms

Throughout this Benefit Booklet, “you” and “your” mean the person that is named as the enrollee in the Schedule of Benefits and “we”, “us” and “our” mean either John Hancock Life Insurance Company or Metropolitan Life Insurance Company. All other words that have special definitions in this Benefit Booklet begin with capital letters and are defined in the Definitions section.

EFFECTIVE DATE OF COVERAGE

Your coverage is scheduled to take effect on the Original Effective Date shown on your Schedule of Benefits. However, your coverage does not go into effect, or your Original Effective Date changes, in the situations described below.

If You Lost Your Eligibility Status Before Your Original Effective Date

Except as described below, if you lost your status as a Workforce member or a Qualified Relative before your Original Effective Date, coverage does not go into effect for you under the Program.

Your coverage goes into effect on your Original Effective Date if you are an Employee or Member of the Uniformed Services who was involuntarily separated, for reasons other than your gross misconduct, after your application date but before your Original Effective Date. If you were involuntarily separated because of your gross misconduct, coverage for you and your Qualified Relatives does not go into effect.

Your coverage goes into effect on your Original Effective Date if you lost your status as a Qualified Relative after your application date but before your Original Effective Date due to:

the death of the Workforce member who was the basis of your status as a Qualified Relative; or the involuntary separation (for reasons other than gross misconduct) of the Employee or Member of the Uniformed Services who was the basis of your status as a Qualified Relative.

If Your Eligibility Status Changed Before Your Original Effective Date

If your eligibility status changed between your application date and your Original Effective Date, coverage does not go into effect for you under the Program, unless you have already passed the same or additional underwriting requirements that apply to your new status. If your status change requires additional underwriting, you must submit a new application that we must approve in order for you to receive coverage under the Program. The following are two examples. If you apply as an Employee or a Member of the Uniformed Services, and retire before your Original Effective Date, you must submit a new application with the additional underwriting required for a retiree. If you apply as an Annuitant, and become employed as an Employee before your Original Effective Date, your coverage will go into effect as scheduled.

Actively at Work Requirement for Employees and Members of the Uniformed Services

If you are an Employee or a Member of the Uniformed Services, you must be Actively at Work on the Original Effective Date shown on your Schedule of Benefits. If your Original Effective Date falls on a weekend or holiday, you must be Actively at Work on the last work-day before your Original Effective Date. For employees working an alternative work schedule, an “AWS” day counts as a day you are Actively at Work. If you are not Actively at Work as required above, your coverage does not go into effect until the first day of the month on or after the day you return to Active Work. That date will then be your Original Effective Date. You must notify us of the date you return to Active Work. Your Original Effective Date does not change under this Actively at Work requirement if you were involuntarily separated (for reasons other than your gross misconduct) after your application date and before your Original Effective Date.

CONDITIONS FOR PAYMENT OF BENEFITS

We will pay benefits for long term care services if:

you receive them after your coverage becomes effective (please see the Original Effective Date shown on your Schedule of Benefits and the Effective Date of Coverage section); and you are eligible for benefits (please see the Eligibility for Benefits section); and you receive them after satisfying any required waiting period (please see the Waiting Period section); and they are Covered Services (please see the Covered Services section); and you have not exhausted your Maximum Lifetime Benefit (please see the When Your Coverage Will End section).

Payment of benefits is also subject to the maximums and limitations shown on your Schedule of Benefits and the exclusions and limitations contained in the following sections: Maximum Benefit We Will Pay, Exclusions, Catastrophic Coverage Limitation, Coordination of Benefits and When Your Coverage Will End.

ELIGIBILITY FOR BENEFITS

You are eligible for benefits if, after your coverage becomes effective:

a Licensed Health Care Practitioner has certified within the last 12 months that:

you are unable to perform, without Substantial Assistance from another person, at least 2 Activities of Daily Living for an expected period of at least 90 days due to a loss of functional capacity; or you require Substantial Supervision due to your Severe Cognitive Impairment; and we agree with that certification; and we approve a Written Plan of Care established for you by a Licensed Health Care Practitioner or our care coordinator.

How to Ask Us to Determine Whether You Are Eligible for Benefits

If you believe you may be eligible for benefits, you or your representative must call 1-800-LTC-FEDS (1-800-582-3337), TDD 1-800-843-3557.

If we need more information to make our determination:

we may contact you, your Physician or other persons familiar with your condition; and/or we may access your medical records to get information about your condition (we cannot determine that you are eligible for benefits if we are not given access to your medical records); and/or we may request, at our expense, to have you examined by a licensed health care professional and/or to conduct an on-site assessment.

Continuing Assessment of Your Eligibility for Benefits

We will reassess whether you continue to be eligible for benefits at least once every 12 months, but no more frequently than every 30 days.

Notice and Review of Benefit Eligibility Decision

We will send you Written notice of our decision on whether you are eligible for benefits no later than 10 business days after we have received all the information we need. If we determine that you are eligible for benefits, the notice will state the date as of which you are eligible for benefits and will include claim forms.

If we determine that you are not eligible for benefits, the notice will provide the reason(s) for the denial. You or your representative may request a review of a denial by sending a Written request to us within 60 days of the date of the denial. Within 60 days after the date we receive your request, we will send you Written notice of our decision. If, on review, we determine that you are eligible for benefits, the notice will state the date as of which you are eligible for benefits and will include claim forms. If, on review, we uphold the initial denial, you may request an appeal. Please see the Appeals section.

WAITING PERIOD

The waiting period is the number of days during which you must be eligible for benefits and receiving Covered Services before we will pay benefits. You only have to satisfy the waiting period once in your lifetime. Days applied toward satisfying the waiting period need not be consecutive, nor associated with the same episode of care. The days will be added together until the waiting period is satisfied. The length of your waiting period is shown on your Schedule of Benefits. We do not pay benefits during your waiting period.

The waiting period does not apply to Hospice Care, respite services and caregiver training. Because we do not apply the waiting period to Hospice Care, respite services and caregiver training, these Covered Services do not count toward meeting your waiting period.

COVERED SERVICES

The Program provides reimbursement up to the Benefit Amount shown in your Schedule of Benefits for the following Covered Services if they are part of the Written Plan of Care approved by us 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 Program.

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.

Hospice Care

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.

We will also pay for Hospice Care provided to you at home.

Bed Reservations

If you are in a Nursing Home, Hospice facility, or Assisted Living Facility, and you leave that facility, we will pay for actual charges you incur to hold a space to enable you to return to that facility. We will not pay more than the benefit that we would pay if you had been in the facility on those days. Benefits for bed reservations are limited to 30 days per calendar year.

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.

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.

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 does not normally live in your home at the time you become eligible for benefits.

Benefits for Informal Caregivers who are Family Members are limited to 365 days in your lifetime.

Respite Services

Respite services provide your primary caregiver with temporary relief from his/her caregiving responsibilities. We will pay for respite services provided in a facility or by a Formal or Informal Caregiver at home. Benefits for respite services are limited to an amount equal to 30 times your Daily Benefit Amount per calendar year.

Caregiver Training

We will pay for the training of a caregiver (except a Formal Caregiver) to perform Maintenance or Personal Care services for you at home. This includes the training of an Informal Caregiver or a caregiver whose services are not covered under the Program (such as your spouse or another Family Member who normally lives with you). Benefits for caregiver training are limited to an amount equal to 7 times your Daily Benefit Amount in your lifetime.

Alternate Plan of Care

Under the circumstances described below, our care coordinator can authorize benefits for services that are not specifically defined as Covered Services (for example, making your home wheelchair-accessible). Benefits for 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:

it effectively meets your long term care service needs; and it is not provided by a person who normally lives in your home at the time you become eligible for benefits; and it is cost-effective.

International Benefits We will pay benefits for Covered Services you receive outside the United States (see 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. 80% of your Maximum Lifetime Benefit can be used for Covered Services you receive outside the United States; the other 20% would be available for Covered Services you receive in the United States.

For example: Let’s assume that your Daily Benefit Amount is $150 and your Benefit Period is 5 years. For purposes of determining international benefits, your Daily Benefit Amount is $120 ($150 x 80%) instead of $150. We would pay up to $90 ($120 x 75%) for services provided to you by a Formal or Informal Caregiver at home. 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 other 20% ($54,750) of your Maximum Lifetime Benefit would be available for those services.

The Coordination of Benefits section does not apply to international benefits.

MAXIMUM BENEFIT WE WILL PAY

If you receive more than one Covered Service on the same day, the most we will pay is the highest Benefit Amount shown on your Schedule of Benefits for one of those services. For example, if you receive Hospice Care and Informal Caregiver services on the same day, the most we will pay for both of those services is the Benefit Amount for Hospice Care (since Hospice Care has a higher Benefit Amount than Informal Caregiver services). As with any other payment, our payment is limited by your Maximum Lifetime Benefit.

CARE COORDINATION SERVICES

Our care coordinators are Licensed Health Care Practitioners who provide the following services at no additional charge to you:

1.

provide general information about long term care services; and

2.

assess and approve your need for long term care services; and

3.

develop a plan for your receipt of long term care services; and

4. monitor and reassess long term care services from time to time; and

5.

access discounts for services, when available.

Our care coordinators will provide the services described above for your Qualified Relatives, regardless of whether they are enrolled in the Program, as long as you are enrolled. The services listed under items 2, 3 and 4 will be available for your Qualified Relatives at an additional charge to you. Our care coordinators can provide you with information on the cost of these services.

You do not have to be eligible for benefits or satisfy the waiting period in order to receive care coordination services.

EXCLUSIONS

This section describes those services and supplies that are not covered under the Program.

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

1.

illness, treatment or medical condition arising out of:

your participation in a felony, riot or insurrection; or your attempted suicide, while sane or insane; or injuries you intentionally inflict on yourself; or

2. care or treatment for alcoholism or drug addiction; or

3.

care or treatment provided in a government facility, including a Department of Defense or Department of Veterans Affairs facility, unless otherwise required by law; or 4.

care you receive while in a Hospital, except in a unit specifically designated as a Nursing Home or Hospice facility; or

5.

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); or

6. services or supplies for which you are not obligated to pay in the absence of insurance; or

7.

services provided by any person who normally lives in your home at the time you become eligible for benefits.

WAR, ACTS OF WAR, & SERVICE IN THE ARMED FORCES OR AUXILIARY UNITS

Unlike most long term care insurance policies available today, your coverage does not contain a war exclusion. Your coverage may be reduced if a war or act of war (declared or undeclared) is determined to be a Catastrophic Event under the Catastrophic Coverage Limitation section. As a result, whether you are a civilian or Member of the Uniformed Services, benefits may be payable under the Program for conditions due to war or acts of war, declared or undeclared, or service in the armed forces or auxiliary units.

CATASTROPHIC COVERAGE LIMITATION

Benefits described in this Benefit Booklet are subject to this Catastrophic Coverage Limitation. 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 Program. Although it is unlikely, it is possible that such an event could occur. This provision would apply to any claims related to a Catastrophic Event. If you are affected by a Catastrophic Event, your Daily Benefit Amount would remain the same but your Benefit Period (as shown in your Schedule of Benefits) would be shortened. For example, if you chose a Daily Benefit Amount of $100 and a Benefit Period of 5 years, you would still be entitled to receive up to $100 per day, but your Benefit Period would be reduced to fewer than 5 years.

The following types of events, among others, could be considered a Catastrophic Event:

natural disaster (e.g., flood, earthquake, other severe change to the environment); or

· epidemic, or other widespread health crisis; or

· act of terrorism; or

· war (declared or undeclared) or any act of war; or

· any other occurrence that reaches the significance of a Catastrophic Event.

We will determine, in consultation with OPM, whether a Catastrophic Event has occurred by estimating the number of claims expected to arise from the event or series of events. We will also assess whether the expected claims attributable to the event(s) could undermine the financial stability of the Program.

It is also important to note that this provision will apply only if we determine that a Catastrophic Event has occurred; it will apply only to enrollees affected by the Catastrophic Event and to claims related to that Catastrophic Event. For example, if a natural disaster triggers this provision, the Benefit Period for those whose claims are unrelated to that natural disaster would not be affected.

If we establish that a Catastrophic Event has occurred, we will consult with OPM to determine the new, shorter Benefit Period for affected enrollees. The amount of the Benefit Period reduction will depend on the number of claims attributable to the Catastrophic Event. Once the reduction is determined, there will be no further reductions related to that Catastrophic Event. If we find that claims are less severe than was estimated at the time we determined the reduction, then we will partially or fully restore your Benefit Period.

COORDINATION OF BENEFITS

Some enrollees may be eligible for benefits for long term care services under another plan or through other programs that are not listed in the Exclusions section. For this reason, the Program includes this Coordination of Benefits (COB) provision. This COB provision follows the guidelines set by the National Association of Insurance Commissioners (NAIC).

In determining the amount of benefits we will pay, this COB provision allows us to look at other plans that might pay benefits for long term care services that you receive. The other plans we look at include government programs, 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. This COB provision does not apply to international benefits.

If the 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 this case, we will require you to submit the explanation of benefits you received from the other plan or program when you submit a claim subject to this COB provision. We may also request a copy of the other plan or program booklet or terms of coverage. We will pay no more than the difference between what your other coverage(s) would pay and your actual expenses.

In those instances where this COB provision applies, the rules for determining which plan or program is primary (pays first) are as follows. These rules are subject to the special rules for government programs explained below.

1. The plan or program that covers the enrollee as a member, an employee, or a Workforce member is considered primary over that covering the enrollee as a dependent or a Qualified Relative.

2. The plan or program covering the enrollee as a member, an employee, or a Member of the Uniformed Services is considered primary over that covering the enrollee as a laid-off or retired employee, an Annuitant, or a Retired Member of the Uniformed Services.

3.

The plan or program covering the enrollee as a dependent or a Qualified Relative of: a member, an employee, or a Member of the Uniformed Services, is considered primary over that covering the enrollee as a dependent or a Qualified Relative of: a laid-off or retired employee, an Annuitant or a Retired Member of the Uniformed Services.

If none of these rules determine the order, then the plan or program that has covered the enrollee for the longest period of time will be primary.

Government Programs

Unless otherwise required by law, any benefits for long term care services that you receive under other plans or programs established by a government are primary (pay first) to the Program. Please see the Exclusions section, which excludes payment of benefits for care provided in a government facility.

CLAIMS

You or your representative must submit Written proof of your claim to us no later than April 1st of the year after the year you incurred charges for Covered Services. If you or your representative do not submit proof of claim within this time limit, we may deny benefits unless you can show that it was not reasonably possible for you to submit proof of claim within the time limit, and you or your representative submitted proof of claim as soon as reasonably possible.

We must receive adequate Written proof (such as bills for services) that you have incurred charges for Covered Services. To assist us in determining whether you have incurred charges for Covered Services:

we may contact you, your Physician or other persons familiar with the services provided to you; and/or we may access your medical records to get information about your condition or the services provided to you (we cannot approve a claim if we are not given access to your medical records); and/or we may request to have you examined, at our expense, by a health care provider and to conduct an on-site assessment; and/or we may require you to submit Medicare explanations of benefits or documentation from any other source from whom you may have received or are eligible to receive reimbursement for the Covered Service for which you have submitted a claim.

Notice and Review of Claim Determination

We will send you Written notice of our claim determination no later than 10 business days after we receive all the information we need.

If we deny your claim, in whole or in part, the notice will provide the reason(s) for the denial. You or your representative may request a review of a denial by sending a Written request to us within 60 days of the date of the denial. Within 60 days of the date we receive your request, we will send you Written notice of our decision. If the initial denial is upheld on review, you may request an appeal. Please see the Appeals section.

APPEALS

If you choose to appeal our benefit eligibility or claim decision, you must send a Written request to us within 60 days after the date of our review decision. We will send all the relevant information we have received to an independent third-party mutually agreed to by OPM and us. The independent third-party will provide you with a Written notice of its final determination within 60 days after we receive your Written request for appeal. The decision of the independent third party is final and binding on us.

PAYMENT OF BENEFITS

All benefits will be paid in United States currency. All benefits will be paid directly to you unless you have completed an assignment of benefits. You may not assign benefits to any provider of Covered Services outside the United States. We will determine, in our sole discretion, whether to honor assignments to Informal Caregivers. You may not assign benefits prior to a claim.

BENEFIT CHANGES

Automatic Compound Inflation Option

(Applies only if your Schedule of Benefits indicates “Yes” for this option)

On each anniversary of your Original Effective Date (or of the date you switch to this option), your Daily Benefit Amount and the remaining portion of your Maximum Lifetime Benefit will automatically increase at a rate of 5% compounded annually. In addition, the remaining portions of: (1) your lifetime maximum for caregiver training; and (2) your calendar year maximum for respite services, will increase at the same rate as your Daily Benefit Amount. Increases under this option are made even if you are eligible for benefits, without regard to your age, claim status, claim history or the length of time your coverage has been in effect, and will not cause your premium to increase.

Future Purchase Option

(Applies only if your Schedule of Benefits indicates “Yes” for this option)

Every two years we will increase your Daily Benefit Amount and the remaining portion of your Maximum Lifetime Benefit, except as described below. We will send you notice of the first increase in the fall of 2003 for the increase that will apply on January 1, 2004. Increases will occur every other January 1st thereafter. The increase will be based on the change in the Department of Labor’s Consumer Price Index for Medical Care or another index mutually agreed upon by OPM and us. We will include the amount of the increase in the notice. Please see the Premiums section, How Benefit Changes Affect Your Premium subsection for information on how increases under this option affect your premium.

An increase under this provision will also increase the remaining portions of: (1) your lifetime maximum for caregiver training; and (2) your calendar year maximum for respite services, at the same rate as your Daily Benefit Amount.

If you do not want the increase, you must send us a Written rejection before the date the increase will take effect. If you want the increase, you do not have to take any action other than paying the additional premium. The increase will automatically take effect. Increases under this option will be made regardless of your age, but we will not increase your benefits under this option if you are eligible for benefits or if you declined a total of 3 prior increases.

Increases under this option do not require you to provide evidence of your good health, except as noted below. Each time we send you notice of an increase under this option, we will also offer you the opportunity to receive future benefit increases under the automatic compound inflation option instead of this option. If you elect to switch to the automatic compound inflation option, you will not receive the current increase under the future purchase option.

If you declined a total of 3 increases under this option and you later wish to resume receiving increases, you must provide, at your expense, evidence of your good health that is satisfactory to us.

Other Benefit Changes

At any time, you may request an increase or decrease in your coverage by Writing to us or calling us at 1-800-LTC-FEDS (1-800-582-3337), TDD 1-800-843-3557. In order to receive approval of a request for an increase, you must provide, at your expense, evidence of your good health that is satisfactory to us. The amount of an increase or decrease is subject to Program options available at the time of your request.

Benefit Changes May Affect Your Premium

For information on how benefit changes affect your premium, please see the Premiums section.

PREMIUMS

Your premium payment is due and payable on the first day of the month in which it is due. It must be paid in United States currency.

The amount of your premium when coverage first goes into effect is based upon your Original Issue Age. Your premium will not change because you get older or your health changes or for any other reason related solely to you. We may only change your premium if you are among a group of enrollees whose premium is determined to be inadequate. While the Group Policy is in effect, OPM must approve the change.

How Benefit Changes Affect Your Premium

If you selected the automatic compound inflation option, your premium is designed to include all future inflation increases you will receive each year while you are insured. Your premium will not increase due to inflation increases under this option.

If you selected the future purchase option, your premium will increase for each inflation increase under this option; the additional premium for each increase will be based on your age and the premium rates in effect at the time the increase takes effect. If you accept an offer to switch from the future purchase option to the automatic compound inflation option, your premium will increase based on your age and the premium rates in effect at the time that switch goes into effect. However, once you have switched, your premium will not increase for any subsequent inflation increase.

If you request and we approve a Daily Benefit Amount increase other than an inflation increase, your additional premium will also be based on your age and the premium rates in effect at the time the increase takes effect. Other coverage increases you request and we approve will cause your entire premium to be based on your age and the premium rates in effect at the time the increase takes effect. If you request a decrease in benefits consistent with available Program options, your premium will decrease.

Please see the Benefit Changes section for information on these benefit change provisions.

GRACE PERIOD

There is a 30-day grace period for payment of your premium. This means that we must receive your premium payment by the 30th day after the date it is due. If we do not receive your premium by the end of this grace period, we will send you Written notice of termination of your coverage by first class United States mail. You will have 35 days from the date of the termination letter to pay your premium, otherwise your coverage will end (please see the When Your Coverage Will End section for more information).

To help protect you from unintended lapse of your coverage, you should designate a person (if you have not already done so) to whom we will also send any notice of termination that we send to you. The person that you designate will not be responsible for your premium payment. You must notify us of any change in your designation.

WAIVER OF PREMIUM

You will not have to pay your premium if you are eligible for benefits and have satisfied the waiting period. We will also waive your premium if you are eligible for benefits and receiving Hospice Care. If you satisfy the requirements for waiver of premium on the first day of a month, the waiver will take effect on that date. Otherwise, the waiver will take effect on the first day of the following month.

If, at a later date, you are no longer eligible for benefits (e.g., you recover) and wish to maintain your coverage, you will have to resume paying your premium on the first day of the month following the month in which you are no longer eligible for benefits.

WHEN YOUR COVERAGE WILL END

Your coverage will end on the earliest of the following:

the date you specify to us that you wish your coverage to end; or the date of your death; or the end of the period covered by your last premium payment if you do not pay the required premium when due; or the date the Group Policy ends, subject to the Continuation of Coverage section below; or the date that you have exhausted your Maximum Lifetime Benefit (in this event care coordination services will continue).

PORTABILITY

Your long term care insurance coverage under the Program is portable. This means that you can keep your coverage if you are no longer a Workforce member or Qualified Relative provided you continue to pay your premium, and have not exhausted your Maximum Lifetime Benefit.

CONTINUATION OF COVERAGE

If the Group Policy ends, OPM has stated that it intends to continue your insurance coverage by replacing the Group Policy with another one that will:

be effective on the day after the Group Policy ends; and provide coverage that is substantially the same as that provided by the Group Policy; and calculate your premium based on the same issue age(s) as under the Group Policy.

In the unlikely event that the Group Policy ends and there is no replacement policy as described above, we will continue your coverage as described in the Portability section.

EXTENSION OF BENEFITS

If, as of the date your coverage ends, you are eligible for benefits and are in a Nursing Home, Hospice facility or Assisted Living Facility, we will extend payment of benefits under the Program for Covered Services you receive while you are in any of these facilities as long as you remain eligible for benefits. Payment of benefits will be subject to all other requirements stated in this Benefit Booklet. This extension of benefits will end on the earliest of the following:

the date you are no longer eligible for benefits; or the date your confinement ends; or the date you exhaust your Maximum Lifetime Benefit.

REINSTATEMENT OF COVERAGE

If your coverage ends because you did not pay your premium when due, your coverage will be reinstated as of the date it ended if, within 6 months of the date your coverage ended, you or your representative:

submit evidence satisfactory to us that you suffered a cognitive impairment or loss of functional capacity before the expiration of the 30-day grace period for payment of your premium (the standard of proof we will require will be no more restrictive than the requirements to establish eligibility for benefits); and submit all past due premiums to us.

If your coverage ends because you canceled it or did not pay your premium when due, your coverage will be reinstated as of the date it ended, if within 12 months of the date coverage ended you:

request reinstatement; and submit, at your expense, evidence of your good health that is satisfactory to us; and submit all past due premiums to us.

If your coverage is reinstated, your premium will be based on your age as if your coverage had continued without interruption.

GENERAL PROVISIONS

Statements Made by You Relating to Insurability

No statement made by you which relates to insurability will be used by us to Contest the Validity of your coverage or to deny an otherwise valid claim, unless the statement was contained in a Written form that you signed and we provided you with a copy of such form.

If your coverage has been in force for less than 6 months, we may Contest the Validity of your coverage or deny an otherwise valid claim upon a showing of Misrepresentation by you.

If your coverage has been in force for at least 6 months but less than 2 years, we may Contest The Validity of your coverage or deny an otherwise valid claim upon a showing of Misrepresentation that is relevant to the condition (such as your Severe Cognitive Impairment or inability to perform 2 Activities of Daily Living due to a stroke) for which benefits are sought.

If your coverage has been in force for 2 years or more, we may Contest the Validity of your coverage or deny an otherwise valid claim only upon a showing that you knowingly and intentionally, by statement or omission, provided inaccurate information Material To Your Insurability.

Age

If your date of birth is not correct as shown on your application, a retroactive adjustment in premium and/or benefits may be made, as deemed appropriate by us, based on the correct information.

No Cash Surrender Value

Your coverage has no cash surrender value or other monetary value that can be paid, assigned, borrowed, or pledged as collateral for a loan.

Insurers

Your coverage is underwritten by John Hancock Life Insurance Company or Metropolitan Life Insurance Company. Each insurance company has issued an identical group policy to OPM. Each person enrolled for coverage under the Program will be insured by only one policy and one insurer as designated by Long Term Care Partners, LLC. Long Term Care Partners will administer all aspects of the Program on a uniform basis.

Right to Change Contract Provisions

We reserve the right to make changes in this Benefit Booklet, the Group Policy, or the administration of the Program in order to comply with applicable laws or regulations. Any such change will be made in consultation with OPM and will apply to all enrollees who have received affected Benefit Booklets. We will give you Written notice of any change to this Benefit Booklet as soon as is reasonably possible.

Interpretation of Terms, Conditions and Provisions

The Group Policy and this Benefit Booklet determine the governing contractual provisions. They will be applied in accordance with the Act and Program regulations. We have discretion to interpret the terms, conditions and provisions of the Group Policy and this Benefit Booklet. OPM may consult with us about our interpretation.

Limits on Legal Actions

No legal action or suit under the Program may be started against us:

before you have exhausted the appeals process described in the Appeals section; or more than 2 years from the date of the notice of final benefit or claim denial on appeal.

No legal action or suit to recover benefits under the Program may be started against OPM.

In any action at law or in equity that relates to the Program, the amount of recovery shall be limited to the benefit that would be payable under the Program. No extra-contract, punitive, compensatory, or consequential damages shall be recoverable under the Program.

The Program shall supersede and preempt any state or local law, regulation, or requirement as permitted by the Act or any Program regulations.

Refund of Premiums

We will refund any premium that you paid to cover any period after the date of your death or after the effective date of your cancellation of coverage.

Payments on Your Death

If, at the time of your death, any portion of benefits is payable or any premium is to be refunded as described under the Refund of Premiums subsection, we will pay such amount to your estate or to an alternative payee. The alternative payee must be a person who is deemed, in our sole discretion, to be justly entitled to the payment. Neither the program administrator nor we will be liable as a result of any payment made in good faith under this provision.

DEFINITIONS

Act means the Long Term Care Security Act, 5 U.S.C. §§ 9001-9009.

Actively at Work or Active Work means:

for an Employee, that you meet all of the following conditions:

you are reporting for work at your usual place of employment or other location to which government business requires you to travel; and you are able to perform all the usual and customary duties of your employment on your regular work-schedule; and you are not absent from work due to sickness, injury, annual leave, sick leave or any other leave (for employees working an alternative work schedule, an “AWS” day counts as a day you are Actively at Work);

for a Member of the Uniformed Services, that you are on active duty and are physically able to perform the duties of your position.

Activities of Daily Living means:

bathing: washing your hair or washing yourself by sponge bath, or in either a tub or shower, including the task of getting into or out of the tub or shower;

dressing: putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs;

transferring: moving into or out of a bed, chair or wheelchair;

toileting: getting to and from the toilet, 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); and/or eating: feeding yourself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously.

Adult Day Care Center means any facility operated, licensed and/or certified as an Adult Day Care Center under the laws of the jurisdiction in which it is located, or other facility that satisfies all of the following:

provides a program of adult day care; and maintains a Written record of services provided to each client; and has established procedures to get emergency medical care; and is not a place that predominantly provides services for recreation or social activities; and maintains a client-to-staff ratio of 8 (or less) to 1 including a full-time director, 1 or more Nurses in attendance during operating hours at least 4 hours a day, and at least 2 staff members in attendance whenever clients are present.

Annuitant means a person as defined by the Act at 5 U.S.C. § 9001(2). The term includes Federal annuitants, surviving spouses of deceased Federal or Postal employees who are receiving a Federal survivor annuity, and individuals receiving compensation from the Department of Labor who are separated from Federal service. The term does not include retired employees of the District of Columbia government or their survivors.

Assisted Living Facility means a facility that satisfies all of the following:

maintains all appropriate licensing required under the laws of the jurisdiction in which it is located to provide Maintenance or Personal Care; and provides care and services 24 hours a day sufficient to assist residents with needs which result from the inability to perform Activities of Daily Living or Severe Cognitive Impairment; and has a minimum of 6 residents; and uses aides trained or certified to provide Maintenance or Personal Care in accordance with any laws applicable to the provision of such care; and provides 24 hour supervision of residents by a trained and awake staff; and has formal arrangements for emergency medical care; and maintains Written records of services provided to each resident; and provides residents with 3 meals a day; and has appropriate methods and procedures to assist in administering prescribed drugs where allowed by law.

The term includes any such facility that specializes in the care of persons with Alzheimer’s disease and other dementias. The term does not include:

any facility used primarily to provide residential services and not Maintenance or Personal Care, such as congregate…