# Insurance FAQs

## Health

• First, 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 1-888-767-6738. Before contacting your retirement system, have your annuity information ready: 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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• The small reduction in Social Security benefits is greatly outweighed by the much larger tax savings. In each case we tested, the increase in take-home pay far exceeded the minor loss in monthly Social Security benefits. Here is a simple formula you can use to estimate the difference in your Social Security benefit:
1. Take the number of years you will participate in premium conversion (from now until your estimated retirement) and divide by 35.
3. Multiply the result of Step 2 by the marginal SSA rate (15% for most Federal employees)
The result is the annual loss of Social Security benefits. (# of Years of Premium Conversion /35) X Annual FEHB Premium X marginal SSA rate = Annual Loss Example You participate in FERS. We assume that you've had a full career of FICA contributions, with an ending salary (today) of \$50,000 and projected retirement at age 66 in January 2016. Your estimated Social Security benefit equals \$1,414 per month. You begin participating in premium conversion and reduce your taxable income by \$2,000, the amount of your FEHB premium. By changing your salary to \$48,000, your monthly Social Security benefit is now \$1,403, an \$11.00 per month difference in today's dollars. 15/35= .4286 X 2000 = 857 X .15 = 128/12 = 10.71 or 11 Compare that to the estimated \$67 increase in take home pay per month. For more specific information on how the Social Security benefit is calculated, refer to www.ssa.gov.
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• Be careful. Such a cancellation would be permanent. Annuitants cannot re-enroll in the program except under very limited circumstances, such as to enroll in a Medicare-sponsored health plan, as described below, or TRICARE. Another exception is if your spouse is also a Federal employee and you cancel to be covered by your spouse's FEHB plan. Further, neither you nor your family members would be eligible for continued coverage nor would you be able to convert your coverage to a private non-group policy. Do not drop out of the program unless you are sure of being able to re-enroll.
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• Your employing office will notify you of the choices available to you and provide you with a method to make direct premium payments.
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• No. There is no provision of law that allows for coverage to continue beyond 24 months during your military duty. However, at the end of the 24 months, you have a 31-day extension of coverage and the right to convert to an individual policy offered by the carrier of your plan. You are not required to provide evidence of insurability for this private coverage. There is no provision in FEHB law that allows for Temporary Continuation of Coverage (TCC) after the 24 months of coverage.
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• Your agency should contact you or your dependent and give you an opportunity to select another plan. If they were unable to reach you and you learned after the enrollment time frame that your plan discontinued, they must use SF 2810 to reinstate your old enrollment code. This is for enrollment history purposes only, and cannot be sent to your old carrier since the plan is discontinued. Your agency should give you an opportunity to select another plan, and process the change retroactive to the date after your enrollment under your former plan terminated. When selecting another plan, please remember you are responsible for determining if any providers used participate in your new plan's network.
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• Yes, Qualifying Life Events (QLE).
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• No. According to the FEHB law, if you or your former spouse didnt notify the employing office within the 60-day limit, your opportunity to elect TCC ends 60 days after your divorce or annulment.
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• Because the U.S. Office of Personnel Management (OPM) administers the Federal Employees Health Benefits (FEHB) program, the largest employer-sponsored health insurance program in the world, we believe we have a commitment to you. Following are the standards we follow:
• Your choice of health benefits plans will compare favorably for value and selection with the private sector.
• When you use the Guide to Federal Benefits and plan benefit brochures, you will find they are clear, factual and give you the information you need.
• When you change plans or options, your new plan will issue your identification card within 15 calendar days after it gets your enrollment form from your agency or retirement system.
• Your fee-for-service plan should pay your claims within 20 work days; if more information is needed, it should pay within 60 calendar days.
• If you ask us to review a claim dispute with your plan, our decision will be fair and easy to understand, and we'll send it to you within 60 calendar days. If you need to do more before we can review a claim dispute, we will tell you within 14 work days what you still need to do.
• When you write to us about other matters, we will respond within 30 calendar days after we get your letter. If we need time to give you a complete response, we will let you know.
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• The Open Season dates are set by Federal regulation 5 C.F.R. § 890.301(f), available at http://law.justia.com/us/cfr/title05/5-2.0.1.1.32.3.143.1.html. Each year OPM provides an Open Season from the Monday of the second full workweek in November through the Monday of the second full workweek in December.
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• The TAMP is the Transitional Assistance Management Program, and it offers transitional TRICARE eligibility to certain separating active duty members and their eligible family members for 180 days. Your Human Resources Office can assist you in determining if you are eligible for transitional TRICARE under the TAMP.
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• We ensure that the plans provide the benefits described in the Federal Employees Health Benefits Program brochures. The health plans often make Preferred Provider Agreements and other arrangements with providers which are contractual arrangements between the carriers and the providers. Because of the discounts that a plan realizes through its contracts with PPO providers, the plan is able to reimburse a higher percentage of the negotiated PPO allowance when PPO providers are utilized. It would not be cost effective for the plan to reimburse at the higher level when the provider is not giving a discount. Furthermore, much of the benefit you receive from using PPO providers comes from the PPO provider's agreement not to bill you for more than the negotiated PPO allowance. Non-PPO providers are under no such obligation. In some areas of the country, it is much more difficult for a plan to arrange PPO contracts for all types of services. In areas where there are no PPO providers, you can still receive your plan's regular benefits, as opposed to the incentivized PPO benefit. If you are overseas, check with your plan to see how they pay the claims of non-PPO providers – some plans have special reimbursement allowances for overseas claims.
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• Public Law 107-14 provides beneficiaries over age 65 of the Department of Veterans Affairs (VA) with coverage secondary to Medicare under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). CHAMPVA provides similarly attractive benefits to VA eligible beneficiaries as those benefits provided to uniformed services beneficiaries under the TRICARE or new TRICARE-for-Life programs.
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• No. You would need to wait for Open Season. It is not uncommon for providers to leave plans mid-year. Other plan providers will be available to provide care.
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• Change in family status
• Change in employment status
• You or a family member lose FEHB or other health insurance coverage
• For more information, see SF 2809 for the Tables of Permissible Changes in Enrollment
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• If you are under premium conversion (see www.opm.gov/insure/health/faq/premconversion/index.asp), IRS rules govern when you may cancel your FEHB. You may cancel within 60 days of the date you are restored to a civilian position or have another Qualifying Life Event that permits cancellation (see Health Benefits Election Form, SF 2809, at www.opm.gov/forms/pdf_fill/sf2809.pdf [848 KB]), or during the next FEHB Open Season. If you are not under premium conversion, you may cancel at any time. In either case, you should be aware of the consequences of cancellation as described in the following question.
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• To verify your current health benefits plan, contact 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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• During the FEHB Open Season, you may: enroll in any health benefit plan for which you are eligible; change from one plan, option, or type of enrollment to another;. cancel your enrollment; Change your pre-tax waiver status.