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If you are the surviving spouse and you receive a survivor annuity, you can continue the deceased's Self and Family enrollment for all eligible family members. The enrollment will be changed to your name and premiums withheld from your survivor annuity. If you are the only person eligible for coverage, the enrollment will be changed to Self Only. After the change, the carrier will send you a new identification card.
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The National Defense Authorization Act for 2001 (Act) extended TRICARE pharmacy coverage to uniformed services Medicare eligible retirees, spouses, and survivors on April 1, 2001. Now uniformed services beneficiaries can get comprehensive prescription drug coverage through TRICARE's retail, mail order, or military treatment facility pharmacies. The Act also reinstated eligibility for TRICARE medical benefits for these beneficiaries on October 1, 2001. Beneficiaries with Medicare Parts A and B are now eligible to use TRICARE coverage for physician, hospital, surgical, and pharmaceutical services.
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You will be covered only for emergency care. Unless your HMO has a "reciprocity" agreement with a plan in your new area that allows you to get routine care, you must travel back to your HMO for care, or change plans. You can change plans anytime after moving; contact your retirement system.
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There are no exclusions or waiting periods for pre-existing conditions in any plan in the FEHB Program. This is also true after you retire.
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The time limit for notification is 60 days from your divorce or annulment. Either you or your former spouse must notify the employing office in writing that you want TCC. If your former spouse is retired, notify the retirement system.
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You are eligible for Medicare if you are age 65 or over. Also, certain disabled persons and persons with permanent kidney failure (or End Stage Renal Disease) are eligible. You are entitled to Part A without having to pay premiums if you or your spouse worked for at least 10 years in Medicare-covered employment. (You automatically qualify if you were a Federal employee on January 1, 1983.) If you donï't automatically qualify for Part A, and you are age 65 or older, you may be able to buy it; contact the Social Security Administration. You must pay premiums for Part B coverage, which are withheld from your monthly Social Security payment or your annuity. You must be enrolled in both Medicare Parts A and B before you can enroll in Part C. You must be enrolled in either Part A or Part B before you can enroll in Part D. The cost of any additional premium will vary depending on the Part C or Part D plan that you select.
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Yes. FEHB regulations provide that an employee’s FEHB is automatically reinstated upon return to employment following active duty. An annuitant’s FEHB is automatically reinstated on the day of separation from the uniformed services.
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Unfortunately, there are areas of the country that HMOs have simply chosen not to participate in the FEHB Program. Reasons for this vary, but most cases involve population size or demographics.
There is no minimum requirement for the number of HMO options available to enrollees throughout the country. We have encouraged HMO participation in the Program because many of our participants have asked for that choice of health plan. In fact, under the FEHBP, the only types of health plans that can be added to the Program are HMOs. And, HMOs have an annual opportunity to submit their applications to participate in the Program.
If you have HMOs in your local area that do not currently participate in the FEHBP, we encourage you to ask these HMOs to consider the FEHBP market for their geographic areas. New plan application packages for the FEHB Program are available at
www.opm.gov/insure/health/carriers/index.asp. Applications are due to OPM by January 31 of each year for the next contract term.
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If you believe that OPM is not complying with a requirement of the Privacy Rule you may file with either OPM or the Department of Health and Human Services (HHS) Office of Civil Rights a written complaint, either on paper or electronically. This complaint must be filed within 180 days of when the complainant knew or should have known that the act had occurred. For more information on how to file a complaint with OPM, please review our NPP. For instructions and information on how to file a complaint directly with HHS, please refer to their website
www.hhs.gov/ocr/hipaa/.
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No. An annuitant, survivor, or former spouse can change to Self Only coverage, but this cancels all family members' coverage and takes away their future enrollment eligibility.
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You can use Employee Express anytime, 24-hours a day, seven days a week.
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No. When you lose FEHB coverage other than by cancellation (including cancellation by nonpayment of premiums) you have a 31-day temporary extension of coverage, at no cost. This coverage is provided in the same enrollment category so you may convert to an individual contract with your current health benefits plan. Please review the Temporary Continuation of Coverage (TCC) pamphlet.
www.opm.gov/insure/health/eligibility/tcc
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Although you cannot remain covered as a family member under your spouse's Self and Family enrollment (even if a court order requires it), you may be eligible for FEHB Program coverage under either the
Spouse Equity provisions or the
Temporary Continuation of Coverage provisions of the law. You would be enrolled in your own right and would pay both the Government and employee shares of the premium yourself.
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If you do not meet these requirements, the authority for you to continue your FEHB comes from the Uniformed Services Employment and Reemployment Rights Act (USERRA) (38 U.S.C. 4317). Public Law 108-454 amended this Act to allow you to continue your FEHB for 24 months if you were called to military duty and elected to continue your health insurance coverage on or after December 10, 2004. If you made your election before December 10, 2004, you are eligible to continue your FEHB for 18 months.
If your FEHB continues under this provision, your agency does not have authority to pay your premiums while you are on military duty. For additional information, see
Benefits Administration Letter 06-401 at BAL 06-401 Federal Employees Health Benefits (FEHB) Program: Extended Coverage for Employees Called to Active Military Duty. [54 KB]
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No. Approximately half of all drugs on the market have generic versions.
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The Health Insurance Portability and Accountability Act (HIPAA) requires that we prepare and distribute our Notice of Privacy Practices. Since all individuals enrolled in the Federal Employees Health Benefits (FEHB) Program receive a copy of their Plan brochure, we believe that this was the most cost-effective way to ensure that we complied with this requirement.
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If you file claims after the deadline because you requested the 6 additional months of FEHB coverage, your plan will waive any timely filing restrictions. Fee-for-service plans must accept and process any claims for services received during the additional 6-month period, and reconsider any claims incurred during the additional 6 months that were previously denied for non-coverage. HMOs must provide benefits for services rendered during the additional 6 months if the provider was part of the HMO network at the time. They do not need to provide benefits if the services received during the additional 6 months were provided by non-network providers.
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First, check your plan's brochure to see if the service is covered, limited or excluded. The next step is to review the disputed claims section of your brochure. Briefly, the disputed claims section will direct you to write to the plan to explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered, and to ask the plan to reconsider your claim. If the plan again denies the claim, read the plan's decision letter carefully and then check your plan's brochure again. If you still disagree with the plan's decision, the disputed claims section of your brochure will show you how to write to the Office of Personnel Management to ask us to review the claim. We can't review a denied claim unless your plan has reconsidered it first (or at least been given an opportunity to reconsider it). Generally, we will acknowledge your request within 5 days. After we complete the review, we will send you a final response within 60 days. If we need more time or if you need to do more -- such as send us more information - we will contact you within 14 work days of the time we get your request and tell you what you still need to do, if anything. We are sorry but we cannot give you a decision over the phone until the review has been completed and a written copy of the final decision has been issued.
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Yes. You should still send a copy of the court order to your Human Resources Office to review and make a determination if any action is required. They will file the copy in your OPF and flag it so that they know a court order relating to health benefits has been filed. If your children aren't listed as family members on the SF 2809, they will send a copy of the court order to your FEHB plan.
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A brand name drug is approved by the Food and Drug Administration (FDA), and is supplied by one company (the pharmaceutical manufacturer). The drug is protected by a patent and is marketed under the manufacturer's brand name.
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