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Insurance FAQs

Health

  • 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). Your disputed claim will be reviewed in one of three Health Insurance Groups. 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 before we can decide, or if you need to do more -- such as send us more information -- before we can decide, 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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  • The premiums for the FEHB plan you are currently enrolled in are in the brochure you will receive from your plan during the annual Federal Benefits Open Season. The Guide to Federal Benefits is a comparison of the plans and their benefits and premiums. There are a variety of Guides targeted to specific groups of enrollees. The average premium is recalculated every year.  Per FEHB law, the government will pay the lesser of: 75% of the carrier’s total premium, or 72% of the average premium.  The enrollee is responsible for the difference between the government contribution and the total premium. If the average premium increases, the maximum government contribution also increases. The total premium is the same for all enrollees, but the Government contribution is based on your employment. Some agencies, such as the Postal Service, contribute additional money towards the total premium. As a result, the share you must pay will depend upon your employment status. All Guides are available on this website or through your Human Resources Office.
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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 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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  • 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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  • 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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  • You can use Employee Express anytime, 24-hours a day, seven days a week.
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  • If you are a current Federal employee, you should contact your Human Resources Office and ask them to find out on what date and carrier report number your enrollment information was forwarded to your new health insurance carrier. With this information, your new carrier will be able to locate your enrollment data and forward ID cards to you. If you are an annuitant, call your plan. If they tell you they haven't gotten the paperwork yet from your retirement system, you may contact your retirement system. If you are a Civil Service Retirement System (CSRS) annuitant or a Federal Employees Retirement System (FERS) annuitant, contact OPM at retire@opm.gov. Before contacting your retirement system, have your annuity information ready, for instance, your name, civil service annuity number (beginning with CSA or CSF), phone number and address, and information about your plan, such as the carrier enrollment code.
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  • Your new plan is NOT responsible for providing coverage until the effective date of your enrollment change which for most employees is the first day of the first full pay period in January. If you need medical services before the effective date of your Open Season enrollment, you should contact your old plan. Please remember, while the new enrollments are not effective until the first full pay period in January, the new plan benefits are effective January 1. Your old plan, therefore will provide coverage according to the new contract. These expenses will count toward your prior year's deductible. If you are an annuitant, you should contact your new plan. Your Open Season enrollment is effective January 1.
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  • Enrollees may choose from Self Only coverage or Self and Family coverage. Other coverage types -- such as Medicare enrolled and/or Medicare eligible -- are not available. Data shows that there is not a significant difference in the cost to the FEHB Program between employees and enrollees covered by both Medicare and an FEHB plan. The cost to employees or Medicare-eligible enrollees would not reduce substantially be creating a separate Medicare category. Interestingly, your enrollees often benefit from older enrollees' Medicare enrollment. This is because substantial savings can be realized from an aggressive coordination of benefits program between the plan and Medicare; the savings are applied to all enrollees' rates.
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  • “Changes to Federal Benefits Eligibility Due to Health Reform” are now available on OPM’s website at http://www.opm.gov/insure/health/aca/index.asp.  These FAQs provide your employees with important information about child eligibility and Federal Benefits under the Affordable Care Act. FastFacts offering a basic understanding of the Affordable Care Act and child eligibility under the Federal Benefits Health Benefits (FEHB) Program are now available on our website at http://www.opm.gov/insure/fastfacts/reform.pdf.  The FastFacts is a two-page document designed to be easily posted to a bulletin board as well as distributed electronically. These and additional resources about health care reform are available on our website at www.opm.gov/insure/health/reform.   If you have specific questions, please contact your agency’s benefits officer. If you do not know who this person is, please go to http://apps.opm.gov/abo/ where you will find a list of agencies and their Headquarters Benefits Officers.
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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. Your agency can postpone automatic reinstatement of your FEHB until your transitional TRICARE ends if you sign a Waiver of Immediate Reinstatement of FEHB, which is available through your Human Resources Office.
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  • Most FEHB fee-for-service plans offer Preferred Provider Organization (PPO) arrangements. When selecting your health care practitioner, your use of PPO providers whenever possible will help reduce your out-of-pocket expenses. In addition, PPO providers will generally file your claims for you. Read your plan's FEHB brochure carefully to find out about other incentives. Contact your plan to obtain the names of PPO providers in your area. You should also visit your plan's website (identified on the front of the plan's brochure and available by link from this website). Many plans provide up-to-date lists of PPO providers on their website. Another way to cut costs is to request generic drugs instead of brand name drugs. A generic medication is a copy of a brand name drug. It has the same active ingredients and receives the same Food and Drug Administration approval but costs less. Most plans charge you a lower copay if you use generic drugs.
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  • When you file a disputed claim, you give OPM permission to review any information related to that claim, including medical information your FEHB plan used to make its initial determination as well as medical information you submitted to your FEHB plan or directly to us to support your claim. Information from your plan is provided to OPM so that we may make a determination on benefits.
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  • The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that provides far-reaching health insurance reforms and medical privacy protections for all Americans. Title I of HIPAA offers important, though limited, Federal protections that improve the availability and continuity of health coverage for workers and their families. Under certain conditions, this law guarantees the availability of new health coverage with no exclusions for pre-existing conditions for individuals who lose employment-based health coverage due to changes in employment or family status. The Departments of the Treasury, Labor, and Health and Human Services are jointly responsible for Federal rules concerning health insurance portability and accessibility requirements. However, since HIPAA gives enforcement authority to the individual states and allows states to impose more generous protections than those under HIPAA, a key source of information for individuals is your State Insurance Commissioner.
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  • Yes. Generic drugs are less expensive than brand name products, and so the amount you pay as part of your prescription drug cost-sharing is less than what you pay for brand names. In addition, most plans charge you a lower copay if you use generic drugs.
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  • No. Approximately half of all drugs on the market have generic versions.
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  • You can find information about Medicare and resources on how to address issues with your Medicare enrollment at medicare.gov.
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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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Total Count: 488, Number of Pages: 25, Page: 6
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