Attachment_6F_-_Alternative_Insurance_Plan_-_The_FLTCIP_Benefit_Booklet.pdf

The Federal Long Term Care Insurance Program Benefit Booklet

Alternative Insurance Plan

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BENEFIT BOOKLET

FLTCIP AIP

FEDERAL LONG TERM CARE INSURANCE PROGRAM

P.O. Box 797

Greenland, New Hampshire 03840-0797

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

TTY 1-800-843-3557

Group Policyholder: United States Office of Personnel Management (“OPM”) Insurer: John Hancock Life & Health Insurance Company (“John Hancock”)

Federal Program Administrator: Long Term Care Partners, LLC

Group Policy Numbers: 900-003

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NOTICES: PLEASE READ CAREFULLY!

Important: Our decision to issue coverage was based upon your responses to the questions on your Application, a copy of which has been or will be sent to you. We may deny benefits or rescind your insurance coverage if your answers are incorrect or untrue. If any information you provided to us about your health or eligibility status changed before the Original Effective Date shown on your Schedule, 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 797, Greenland, New Hampshire 03840-0797. You may also call 1-800-LTC-FEDS

(1-800-582-3337), TTY 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 Federal 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 Federal 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.

Please refer to the Definitions section for a definition of New Enrollee and Existing Enrollee.

New Enrollees Under the Federal Program. If you are a New Enrollee, within 30 days after you receive this Benefit Booklet, you may cancel your coverage if you are not satisfied with it and receive a refund of any premium you paid. 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 paid for coverage under this Benefit Booklet within 30 days. 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.

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Existing Enrollees Under the Federal Program. If you are an Existing Enrollee, coverage under your prior Benefit Booklet terminates as of the Effective Date of the Schedule of Benefits that accompanied this Benefit Booklet. If you are not satisfied with this Benefit Booklet and wish to cancel it, you must notify us within 30 days of receiving this Benefit Booklet. Then, we will cancel your coverage as of the Effective Date of the Schedule of Benefits that accompanied this Benefit Booklet, and refund any premium you paid for coverage after that date. Your cancellation of this Benefit Booklet will also cancel the prior Benefit Booklet on the same date.

YOUR COVERAGE IS GUARANTEED RENEWABLE. This means we will not cancel your coverage as long as you pay your premium on time. However, this does not mean that premiums are guaranteed to remain unchanged. Please see section When We May Increase Your Premium below and 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 Void 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.

WHEN WE MAY INCREASE YOUR PREMIUM. We reserve the right to increase your premium in the future. However, it is important to note that we cannot single you out and raise your premium because of your advancing age, declin-ing health, claim status or for any other reason related solely to you. We may only increase 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 increase in premium. As a reminder, your premium may also increase if you voluntarily elect to increase your benefits. Please see the subsection How Benefit Changes Affect Your Premium.

This Benefit Booklet together with your Schedule of Benefits is your evidence of coverage.

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TABLE OF CONTENTS

SECTION PAGE

NOTICES: PLEASE READ CAREFULLY!

New Enrollees Under the Federal Program Existing Enrollees Under the Federal Program

YOUR COVERAGE IS GUARANTEED RENEWABLE

WHEN WE MAY INCREASE YOUR PREMIUM

TABLE OF CONTENTS

INTRODUCTION

Defined Terms

EFFECTIVE DATE OF COVERAGE — NEW ENROLLEES

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

EFFECTIVE DATE OF COVERAGE— EXISTING ENROLLEES

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 Bed Reservations Caregiver Training Respite Services International Benefits

MAXIMUM BENEFIT WE WILL PAY

Exception for Caregiver Training

CARE COORDINATION SERVICES

EXCLUSIONS

Your Coverage Does Not Have a War Exclusion

COORDINATION OF BENEFITS

Government Programs

CLAIMS

Notice and Review of Claim Determination

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SECTION PAGE

APPEALS

Appeals Committee Independent Third Party Exhaustion of the Appeals Process

PAYMENT OF BENEFITS

BENEFIT CHANGES

Automatic Weekly Benefit Amount Increase Future Purchase Option (For Inflation Protection)

PREMIUMS

How Benefit Changes Affect Your Premium Contingent Benefit Upon Lapse

GRACE PERIOD

Protection Against Unintended Lapse (“PAUL”)

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 Insurer Right to Change Contract Provisions Interpretation of Terms, Conditions and Provisions Limits on Legal Actions Refund of Premiums Payments on Your Death

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TABLE OF CONTENTS (continued)

SECTION PAGE

DEFINITIONS

Act Actively at Work or Active Work Activities of Daily Living Alternative Insurance Plan Application Bed Reservations Benefit Amount Benefit Booklet Benefit Period Caregiver Training Covered Services Employee Existing Enrollee Federal Program Formal Caregiver Group Policy Hospital Licensed Health Care Practitioner Maintenance or Personal Care Material To Your Insurability Maximum Lifetime Benefit Medicare Member of the Uniformed Services Misrepresentation New Enrollee Nurse Nursing Care Nursing Home

OPM

Original Effective Date Physician Plan of Care Qualified Long Term Care Services Qualified Relative Respite Services Schedule of Benefits Severe Cognitive Impairment Signed Social Worker Spouse Substantial Assistance Substantial Supervision Therapist

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SECTION PAGE

Therapy Services United States Void or Voided Week Weekly Benefit Amount Written or Writing

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INTRODUCTION

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

Under the Federal Program’s Alternative Insurance Plan, you have coverage for long term care services you receive while in a Nursing Home. This Benefit Booklet describes your coverage. Your Schedule of Benefits provided with this Benefit Booklet shows the amounts of coverage that you have.

Long Term Care Partners, LLC, is the Federal Program administrator. You may contact Long Term Care Partners at 1-800-LTC-FEDS (1-800-582-3337), TTY 1-800-843-3557. In consultation with OPM, we may change the Federal 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 John Hancock Life & Health Insurance Company. All other words that have special definitions in this Benefit Booklet begin with capital letters and are defined in the Definitions section or in the section where they appear.

EFFECTIVE DATE OF COVERAGE—NEW ENROLLEES

If you do not pay your first premium when due, your coverage will not take effect.

Your coverage is scheduled to take effect on the Original Effective Date shown on your Schedule of Benefits. However, your coverage will 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 an Employee or a Member of the Uniformed Services, or a Spouse before your Original Effective Date, coverage does not go into effect for you under the Federal 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 sepa-rated, for reasons other than your misconduct, after your Application date but before your Original Effective Date. If you were involuntarily separated because of your misconduct, coverage for you and your Spouse 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:

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· the death of the Employee or a Member of the Uniformed Services who was the basis of your status as a Spouse; or

· the involuntary separation (for reasons other than misconduct) of the Employee or Member of the Uniformed Services who was the basis of your status as a Spouse.

Note: If you were planning to pay your premium through the Employee or Member of the Uniformed Services payroll deduction, you will have to make other arrangements for payment of your premium.

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

If you are an Employee or a Member of the Uniformed Services who submitted an abbreviated underwriting application, you must be Actively at Work at least one day during the calendar week immediately prior to the week which contains the Original Effective Date shown on your Schedule of Benefits. From time to time, OPM may implement revised Actively at Work requirements for specified periods under the Federal Program.

You must inform us if you do not meet this requirement. In the event you do not meet this requirement, we will issue you a revised Original Effective Date, which will be the 1st day of the next month. You also must meet the Actively at Work requirement for any revised Original Effective Date for coverage to become effective, or you will be issued another revised Original Effective Date in the same manner. You must notify us if you do not meet Actively at Work requirements for your new Original Effective Date. In this case, your coverage will not go into effect until you are Actively at Work as required above.

Your Original Effective Date does not change under this Actively at Work requirement if you were involuntarily separated from Federal civilian service (for reasons other than your misconduct) or from the uniformed services (except for a dishonorable discharge) after your Application date but before your Original Effective Date.

EFFECTIVE DATE OF COVERAGE — EXISTING ENROLLEES

As of May 27, 2005, the Effective Date of Coverage requirements above apply to Existing Enrollees before their coverage under the Federal Program first became effective as specified in the Federal Program regulations (5 CFR Part 875), as amended. Before May 27, 2005, the requirements for Existing Enrollees were the same as those described above, except the day the Employees or Members of the Uniformed Services were required to be Actively at Work was the Original Effective Date shown on the Schedule of Benefits or, if that fell on a weekend or holiday, the last work day before the Original Effective Date.

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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, 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), TTY 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 condi-tion (we cannot determine that you are eligible for benefits if we are not given access to your medical records); and/or

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· 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 informa-tion 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 no later than 60 days after the date of the denial. No later than 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. The waiting period applies to payment of benefits for all Covered Services unless otherwise stated. You only have to satisfy the waiting period once in your lifetime. For Existing Enrollees, any days applied toward the waiting period under a prior Benefit Booklet will count toward the waiting period under this Benefit Booklet.

Days applied toward satisfying the waiting period need not be consecutive, nor associated with the same episode of care. The length of your waiting period is 180 days. We do not pay benefits for services you receive during your waiting period, unless otherwise stated.

The waiting period does not apply to Respite Services and Caregiver Training.

Because we do not apply the waiting period to Respite Services and Caregiver Training, these Covered Services do not count toward meeting your waiting period.

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COVERED SERVICES

The Federal Program’s Alternative Insurance Plan 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 Federal Program’s Alternative Insurance Plan.

Nursing Home

On any day you are in a Nursing Home, including a Nursing Home 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.

Bed Reservations

We will pay for actual charges you incur for Bed Reservations in a Nursing Home. We will not pay more than the benefit that we would pay if you had been in the Nursing Home on those days. Benefits for Bed Reservations are limited to 30 days per calendar year and will be reduced by any days you received Bed Reservation benefits under any prior Federal Program Benefit Booklet.

Caregiver Training

We will pay for Caregiver Training. Benefits for Caregiver Training are limited to an amount equal to your Weekly Benefit Amount in your lifetime and will be reduced by any benefits you received for Caregiver Training under any prior Federal Program Benefit Booklet.

The waiting period does not apply to Caregiver Training. Caregiver Training does not count toward meeting your waiting period.

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Respite Services

If you are eligible for benefits but are being cared for at home (rather than in a Nursing Home), we will pay for Respite Services provided in a Nursing Home.

Benefits for Respite Services are limited to an amount equal to 4 times your Weekly Benefit Amount per calendar year and will be reduced by any Benefits you received for Respite Services under any prior Federal Program Benefit Booklet.

The waiting period does not apply to Respite Services. Respite Services do not count toward meeting your waiting period.

International Benefits

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 the Benefit Amounts shown on your Schedule of Benefits.

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

MAXIMUM BENEFIT WE WILL PAY

All benefit payments are limited by your Maximum Lifetime Benefit. If you receive more than one Covered Service during the same Week, the most we will pay for all those services is the Weekly Benefit Amount shown on your Schedule of Benefits.

For Existing Enrollees, your Maximum Lifetime Benefit will be reduced by any benefit payments made under any prior Benefit Booklet issued to you under the Federal Program.

Exception for Caregiver Training

We will pay up to the Benefit Amount shown on your Schedule of Benefits for Caregiver Training without considering benefits we pay for other Covered Services you receive during the same Week. In addition, we will not consider Caregiver Training when determining the maximum we will pay for other Covered Services you receive during the same Week. For example, if you incur charges for Nursing Home services and Caregiver Training during the same Week, we will pay up to 100% of your Weekly Benefit Amount for each service.

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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 long term care services; and

4. monitor and reassess from time to time the long term care services that you receive; and

5. provide access to discounts for services, when available.

Our care coordinators will provide the services described above for your Qualified Relatives. These services will be provided regardless of whether your Qualified Relatives are enrolled in the Federal 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. For Qualified Relatives who are not enrolled in the Federal Program, we would only assess, not approve, their need for long term care services under item 2 above. Our care coordinators can provide you or your Qualified Relatives with information on the applicable charges for care coordination services for your Qualified Relatives.

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 Federal Program’s Alternative Insurance Plan.

The Federal Program’s Alternative Insurance Plan 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

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

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

Your Coverage Does Not Have a War Exclusion

Your coverage does not have a war exclusion. As a result, 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.

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 Federal 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 (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. This COB provision does not apply to international benefits, except that we will not pay international benefits that duplicate international benefits paid under any prior Benefit Booklet issued to you under the Federal Program.

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 this case, we will require you to submit the explanation of benefits you received from that other plan or program showing that you submitted a claim to it and how that claim was decided. 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 the amount payable by your other coverage(s) 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 you as a member, an employee, or Member of the Uniformed Services is considered primary over that covering you as a dependent.

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

3. The plan or program covering you as a dependent of a member, an em-ployee, or a Member of the Uniformed Services, is considered primary over that covering you as a dependent of a laid-off or retired employee.

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

In no event will we pay benefits that duplicate benefits paid under any prior Benefit Booklet issued to you under the Federal Program.

Government Programs

Unless otherwise required by law, any benefits for long term care services that you receive under other plans or programs established by the Federal or a state government are primary (pay first) to the Federal 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 within 12 months after the date you incurred charges for Covered Services, or by April 1st of the year following the year you incurred charges for Covered Services, whichever is later. 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 condi-tion 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 docu-mentation 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.

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Notice and Review of Claim Determination

We will send you Written notice of our claim determination as soon as possible after we receive all the information we need. In general, that means within 10 business days.

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 no later than 60 days after the date of the denial. No later than 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

As stated in the Notice and Review of Benefit Eligibility Decision subsection of the Eligibility for Benefits section, and the Notice and Review of Claim Determi-nation subsection of the Claims section, the Federal Program includes an appeals process. This section explains your right to appeal in the event we initially deny your eligibility for benefits or your claim and then, on review, we uphold our denial.

Appeals Committee

If you choose to appeal our eligibility for benefits or claim decision, you must send a Written request to us, with any additional information that you wish to have us consider, no later than 60 days after the date of our review decision.

Your appeal will be reviewed by an appeals committee composed of one or more representatives of John Hancock and other person(s) if mutually agreed upon by OPM and us.

The appeals committee will provide you with Written notice of its final decision no later than 60 days after the date we receive your Written request for appeal.

If the appeals committee upholds the denial and that denial is eligible for appeal to an independent third party (as explained below), our Written notice will let you know how to request such an appeal.

Independent Third Party

If the appeals committee upholds a denial of your eligibility for benefits or your claim due to its evaluation of your medical condition/functional capacity (such as your ability to perform Activities of Daily Living or your cognitive status), you may request to appeal that decision to an independent third party mutually agreed to by OPM and us. You must make this request in Writing no later than 60 days after the date of our notice informing you of the appeals committee’s decision.

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The independent third party will provide you with Written notice of its final decision no later than 60 days after we receive your request for appeal to the independent third party. The decision of the independent third party is final and binding on us.

The following is an example of when a denial by the appeals committee will be eligible for appeal to an independent third party: the appeals committee upholds a denial of your eligibility for benefits because its review indicates that you can perform 5 out of 6 Activities of Daily Living.

The following is an example of when a denial by the appeals committee will not be eligible for appeal to an independent third party: the appeals committee upholds a denial of your claim for benefits for Nursing Home services because you exhausted your Maximum Lifetime Benefit.

Exhaustion of the Appeals Process

Once you have exhausted this appeals process, you may seek judicial review of a final denial of eligibility for benefits or a claim. Please see the Limits on Legal Actions subsection of the General Provisions section for more information.

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. You may not assign benefits prior to a claim.

If you have any unpaid premiums that are due, we will deduct these premiums from any claim that is payable.

If we determine that the benefits paid to you or on your behalf for a claim were more than the total benefits owed, we have the right to recover the excess amount from you or the person or entity we paid, provided we seek recovery within two years from the date on which the claim in question was paid.

However, we may not recover any benefit payments paid to you or on your behalf in the event that we Void your coverage.

BENEFIT CHANGES

Your Weekly Benefit Amount may increase under one or both of the following subsections. Anytime your Weekly Benefit Amount changes, all those benefit amounts that are determined based on your Weekly Benefit Amount will change accordingly.

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Automatic Weekly Benefit Amount Increase

Your initial Weekly Benefit Amount is $200. If your coverage remains in effect for 24 months and you do not become eligible for benefits during this period, your Weekly Benefit Amount will increase to $300 on the first day of the next month. If your coverage remains in effect for 48 months, and you do not become eligible for benefits during this period, your Weekly Benefit Amount will increase to $400 on the first day of the next month. If your coverage remains in effect for 72 months, and you do not become eligible for benefits during this period, your Weekly Benefit Amount will increase to $500 on the first day of the next month. These increases will not cause your premium to increase. However, your premiums may still increase under the conditions described in the Premiums section and the When We May Increase Your Premium section.

Future Purchase Option (For Inflation Protection)

If your Weekly Benefit Amount increases to $500, every two years we will further increase your Weekly Benefit Amount and the remaining portion of your Maximum Lifetime Benefit, as described below. The first increase notice was sent in the fall of 2009, for an effective date of January 1, 2010. Increases will occur every two years on January 1st, thereafter. Your Weekly Benefit Amount must have increased to $500 in order for you to receive your first increase under this provision. 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. Please note that your premiums may also increase under the conditions described in the Premiums section and the When We May Increase Your Premium section.

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 Weekly Benefit Amount.

If you do not want the increase, we must receive your rejection before the date specified in the increase notice. 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, including increases under any prior Benefit Booklets issued to you under the Federal Program.

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.

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You may request a decrease in your coverage after one or more increases have taken effect under this subsection. A decrease must be in an amount that is equal to one or more of the increases that took effect under this subsection. A decrease cannot exceed the amount of any increases that took effect under this subsection. You may request such a decrease by calling us at 1-800-LTC-FEDS

(1-800-582-3337), TTY 1-800-843-3557.

The amount of the decrease in premium associated with the decrease in coverage will be computed assuming that the levels of benefits purchased last are discontinued first.

PREMIUMS

Your premium is payable when due. It must be paid in United States currency.

Please be sure to review your Application for premium payment options and requirements. If you elected to pay your premium via automatic bank with-drawal, we reserve the right to collect any past due premium by withdrawing up to 2 months of premiums from your account until current. In addition, if you pay your premium via payroll or annuity deduction, you will be directly billed for any required premium that we are unable to collect via such deduction.

The amount of your premium when coverage first goes into effect is based upon your Original Issue Age as shown on your Schedule of Benefits. 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 increase 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.

Please refer to the When We May Increase Your Premium section at the beginning of this Benefit Booklet for a description of when we may increase your premium.

How Benefit Changes Affect Your Premium

Your premium will not increase with each automatic Weekly Benefit Amount increase. However, your premiums may still increase under the conditions described in the above paragraph and the When We May Increase Your Premium section at the beginning of this Benefit Booklet.

Your premium will increase for each inflation increase under the future inflation purchase 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.

Please refer to the above Premiums section and the When We May Increase Your Premium section at the beginning of this Benefit Booklet for a description of when we may increase your premium.

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

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Contingent Benefit Upon Lapse

We will provide a contingent benefit upon lapse as provided in the Group Policy.

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 Cover-age Will End section for more information).

Protection Against Unintended Lapse (“PAUL”)

To help protect you from unintended lapse of your coverage, you should name 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 name will not be responsible for your premium payment. You must notify us of any change in the person that you name.

WAIVER OF PREMIUM

You will not have to pay your premium if you are eligible for benefits and have satisfied the waiting period. 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 may do so provided you have not ex-hausted your Maximum Lifetime Benefit. 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

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· 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 Federal Program is portable.

This means that you can keep your coverage if you are no longer an Employee, a Member of the Uniformed Services or Spouse, 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.

EXTENSION OF BENEFITS

The purpose of this extension of benefits provision is to continue your coverage in the event that it ends while you are confined in a Nursing Home.

If, as of the date your coverage ends, you are eligible for benefits and are in a Nursing Home, we will extend payment of benefits under the Federal Program’s Alternative Insurance Plan for Covered Services you receive while you are so confined. 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

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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 Void your coverage or to deny an otherwise valid claim, unless the statement was contained in a Written form that you signed and a copy of such form was provided to you.

If your coverage has been in force for less than 6 months, we may Void your coverage 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 Void your coverage upon a showing of Misrepresentation that pertains to the condition for which benefits are sought.

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

If we Void your coverage, no claims for benefits will be paid, and the Notice and Review of Claim Determination and Appeals sections will not apply. If we Void your coverage, our letter notifying you will explain the process for requesting review of our decision. If you believe that your coverage was Voided in error, you may request that we review our decision. You must submit your request in writing to us within 30 days of the date of the letter Voiding your coverage.

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If you request a reinstatement of coverage and the information provided in support of your request contains a Misrepresentation, we may Void the reinstatement or deny any reinstated benefits on an otherwise valid claim in accordance with the above provisions, provided that the time limits shall refer to the time period that the reinstatement has been in effect.

For purposes of determining how long your coverage has been in force, your coverage under any prior Benefit Booklet issued to you under the Federal Program will be considered.

Age

If your date of birth is not correct as shown on your Application, we may make a retroactive adjustment in premium and/or benefits that we deem appropri-ate, 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.

Insurer

Your coverage is underwritten by John Hancock Life & Health Insurance Company.

Right to Change Contract Provisions

We reserve the right to make changes in this Benefit Booklet, the Group Policy, or the administration of the Federal Program consistent 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 reason-ably possible.

Interpretation of Terms, Conditions and Provisions

The Group Policy, this Benefit Booklet and your Schedule of Benefits determine the governing contractual provisions. We will apply them consistent with the Act and Federal Program regulations. We have discretion to interpret the terms, conditions and provisions of the Group Policy, this Benefit Booklet and your Schedule of Benefits. OPM may consult with us about our interpretation.

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Limits on Legal Actions

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

· 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 Federal Program may be started against OPM or the independent third party that reviews a denial on appeal.

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

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

Refund of Premiums

We will refund any premium that you paid and that has not already been refunded to cover any period:

· after the date of your death; or

· after the effective date of your cancellation of coverage; or

· during which your premium is waived. Please see the Waiver of Premium section.

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 Federal Program administrator nor we will be liable as a result of any payment made in good faith under this provision.

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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 an approved work location and work at least ½ of your regularly scheduled hours for that day; and

· you are able to perform all the usual and customary duties of your employment on your regular work schedule;

· 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:

· 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.

(If you need Substantial Assistance from another person to complete any one of these activities, you are dependent for bathing);

· 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.

(If you need Substantial Assistance from another person to complete any one of these activities, you are…