Nursing Care Benefits in the FEHB Program

There are four kinds of nursing care: 

  • Skilled care while in a hospital. 
  • Skilled care in a special extended or skilled care facility.  
  • Care in your own home provided by visiting nurses. 
  • Custodial care either in your own home or in a nursing home. 

No health insurance plan will pay for custodial care, the kind where your principal needs are to be fed, bathed, and clothed and where you need help with ordinary life tasks rather than to recover. At the other extreme, all plans pay for necessary care by nurses while you are in the hospital. Similarly, all plans cover some form of home health care, usually with at least 90 days or visits. 

Plans differ in their coverage of care in an extended or skilled nursing care facility. Most national plans offer no coverage; but a few cover 60 or 90 days per stay, usually at the same cost to you as hospital treatment. Most HMOs, however, cover skilled nursing care, usually 90 or 100 days. 

We did not reflect the value of skilled care in a facility in our plan cost calculations. Since very few younger persons ever need such care, the plan rankings would not have changed much if we had considered the statistical probabilities. Virtually all retirees over age 65 have a good Medicare Part A benefit for skilled nursing care. Accordingly, they will rarely if ever need any FEHB benefit for this care. 

Nonetheless, stays in skilled nursing care facilities cost about half as much as in hospitals. This is one of the potentially substantial expenses to which some plans leave you exposed. If you think you are likely to need more than a month of this care, we recommend careful attention to brochure language in relation to your needs. Remember, moreover, that these stays are subject to plan approval and must involve rehabilitative needs, not simply help with daily living. 

For custodial care, either in your own home or a nursing home, OPM sponsors a Long-Term Care insurance program, separate from the FEHB program. This program pays for long term care services if you can't take care of yourself because of an extended illness, such as Alzheimer's disease. The program covers both institutional and home care. Premiums are substantial, and there is no government contribution. This program is currently having financial problems and new enrollments have been suspended. If your retirement income and assets are relatively low, and you otherwise cannot afford needed custodial care, you can ultimately rely on the Federal/State Medicaid program.

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