|
D. BENEFIT
LEVELS. There will be two benefit payment levels—either 100 percent or
50 percent of the maximum weekly benefit chosen. Enrollees who spend less than
the maximum weekly benefit may extend their policy beyond the length of years
originally intended by using less expensive types of care. Assisted living
facilities and home health care can be less expensive than nursing homes and are
preferred by most people because they can remain in familiar surroundings while
receiving care.
1. Up to 100 Percent.
Up to 100 percent of the maximum weekly benefit will be paid for (1) nursing
home care; (2) assisted-living expenses; (3) hospice care expenses, whether in
an institution or at home; (4) up to four weeks respite care—care given by
informal caregivers to relieve family caregivers; and (5) care received while
living at home when provided under the care coordination program (see section
D3).
2. Up to 50
Percent. Up to 50 percent of the maximum weekly benefit will be paid
for care received while still living at home (home care, home health care, and
adult day care) if the policyholder does not participate in the care
coordination program (see section D3).
3. Care
Coordination Program. Enrollees and their families will be offered the
services of professional care coordinators to help them make appropriate care
choices, locate quality services in their area at discounted rates, and develop
a cost-effective plan to extend their pool of money (see section C3). The care
coordination program can arrange for care received at home to be reimbursed at
100 percent of the maximum weekly benefit chosen (see section D1).
The purpose of the care
coordination program is to control the possibility of fraud and overcharging in
home health care. When NARFE questioned OPM as to whether care coordinators
could prevent benefits from being paid to informal caregivers, especially in
rural areas where there are no other options, NARFE was assured that care
coordinators would not limit benefits in that situation.
4. When Benefits
Start. Policyholders will be eligible for benefits to begin when they
(1) can no longer perform two of the activities of daily living (listed in the
next paragraph) and their doctor certifies that the condition is expected to
last at least 90 days or (2) have a severe cognitive impairment. In either
case, the waiting period must also be met before eligibility begins.
The activities of daily
living (ADLs) are the common activities that people perform every day: eating,
transferring from bed or chair, bathing, dressing, and using a toilet and
remaining continent. The LTC program may include other definitions for ADLs:
“standby assistance” where the insured could perform the ADL but would need
someone standing by to help or “hands-on assistance” where the insured could not
perform the ADL without assistance. Cognitive impairment is any impairment in
(1) short- or long-term memory; (2) orientation as to person, place, and time;
(3) deductive or abstract reasoning that places a person in jeopardy of harming
himself or others. The most common form of cognitive impairment is advanced
Alzheimer’s disease.
Policyholders will no
longer pay premiums once the waiting period (see section C4) is satisfied and
they begin to use covered services. If they participate in the care
coordination program, they will not pay premiums during the waiting period.
Return to Top
Table of Contents
|
