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Insurance FAQs

Health

  • 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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  • 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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  • 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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  • Contact your health plan directly for this information.
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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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  • 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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  • The Federal Employees Health Benefits Program runs on a calendar year basis -- from January through December. But the carriers' provider contracts are spread throughout the year, as are the carriers' policies with other employers.
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  • Some health plans offer dental and vision benefits separate from the officially offered benefits stated in their FEHB brochures. Such separate benefits are described on the "Non-FEHB Benefits" page in FEHB brochures. The plans solely determine what is covered and what is excluded and you must pay any premium associated with these benefits directly to the health or dental plan. There is no government contribution toward the premium on non-FEHB benefits. Also, some health plans offer a separate dental plan that does not require you to be a member of their health plan. And, occasionally, an agency's employee organization offers dental and vision benefits to the agency's employees. Check with your Human Resources Office.
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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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  • No. Approximately half of all drugs on the market have generic versions.
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  • Premium conversion may slightly reduce the Social Security benefit you will receive upon retirement. The extent of the impact depends upon several factors:
    • the retirement system that you participate in;
    • whether your salary exceeds the Social Security wage base; and
    • the number of years left until your retirement.
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  • A Plan offering a Point of Service product (POS) has features of both a Health Maintenance Organization (HMO) and a managed Fee-for-Service (FFS) plan. A few years ago, we began permitting plans to offer POS products as part of their benefits packages. Think of it as a hybrid of the two types of plans. In an HMO, the POS product lets you choose to use providers that are not part of the network of providers affiliated with the plan. There is a cost associated with choosing non-plan providers, usually in the form of substantial deductibles and coinsurances that are higher than the copayment you would normally pay for using a plan provider. You will also need to file a claim for reimbursement, like in a FFS plan. The plan wants you to use its network of providers, but it recognizes the desire of some enrollees to see a provider of their choosing on some occasions. In the case of a POS product of a managed Fee-for-Service (FFS) plan, the opposite is true. The plan's normal benefits include deductibles and coinsurance. But in some locations, the plan has set up a network of providers similar to that you would find in an HMO. The plan encourages you to use these providers, usually by waiving the deductibles and applying a copayment that is smaller than the normal coinsurance. Normally, there would not be any paperwork when you use a network provider. Check the FEHB Guide on this website to see where the FFS plan offers a POS product, and what you must do to elect to participate in the plan's POS product.
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  • You may not need to write to the Office of Personnel Management. If you think you might qualify for a waiver of the 5-year coverage requirement, contact your Human Resources Office for information. If you meet the requirements, your agency will attach a memorandum to your retirement application stating that you meet the requirements for waiver by the Office of Personnel Management.
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  • You can change plans during the annual FEHB Open Season and whenever you have a qualifying life events (QLE) -- such as marriage. Becoming aware of another plan that has better benefits, even if you didn't expect to want the extra benefits when you had a chance to change plans before, does not qualify as a "QLE" that allows you to change plans.
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  • No. If an annuitant, survivor, or former spouse suspends Self and Family coverage, the coverage of all family members is suspended as well.
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  • If you are a surviving child of the enrollee and the enrollee also has a surviving spouse or child eligible to receive a CSRS or FERS survivor annuity benefit, you can be covered under the survivor annuitant’s  Self and Family enrollment until age 26. You can continue coverage beyond age 26 if you are incapable of self-support because of a mental or physical disability that existed before age 26.  If you are a surviving child of the enrollee who is eligible for a CSRS or FERS survivor annuity benefit and the enrollee has no other survivors, the enrollment will be changed to a self only enrollment in your name. You will be responsible for paying the premiums either by having them withheld from your survivor annuity or through direct billing.  You can continue this FEHB coverage until your survivor annuity ends at age 18, or age 22 if you are a full-time student.  You can continue coverage beyond age 18 if you are incapable of self-support because of a mental or physical disability that existed before age 18. Your coverage will continue for 31 days after eligibility ends, unless the enrollment is cancelled. During that time, you may enroll in Temporary Continuation of Coverage (TCC) or convert to an individual policy offered by your FEHB plan.
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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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  • The plans print their provider directories and have them available during Open Season. Many plans also provide this information on their websites. If your agency has an Open Season health fair this fall, the plans probably will be there to hand out their brochures and provider directories. You can also call the plan at the number listed in the Guide to Federal Benefits. You can also find specific plan contact information on the FEHB website.
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  • To inquire about how much coverage you have under the Federal Employees Health Benefits (FEHB) Program, go to Retirement Services Online at https://www.servicesonline.opm.gov.  You will need your retirement claim number and Personal Identification Number (PIN) to access information about your health benefits enrollment.    If you cannot access Retirement Services Online, you can inquire about your coverage by contacting OPM’s Retirement Office at 1-888-767-6738 or retire@opm.gov.  The phone lines are open from 7:30 am to 7:45 pm (Eastern Standard Time). It is a busy phone number so we encourage you to call early in the morning or after 5:00 pm when the phone lines are less busy.
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  • The FEHB Program runs on a calendar year basis - from January through December. The carriers' provider contracts, however, which are between the provider and the carrier, are spread throughout the year, as are the carriers' policies with other employers.
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Total Count: 482, Number of Pages: 25, Page: 7
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