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Insurance FAQs

Health

  • 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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  • 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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  • As long as the annuitant was enrolled in Self and Family coverage when he/she suspended FEHB coverage and made arrangements to leave a survivor annuity, the survivor annuitant can reenroll in the FEHB Program under the same conditions as an annuitant.
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  • No, premiums that are paid under TCC are not eligible for premium conversion. Although we realize that you may make the premium payments on behalf of your child, the TCC policyholder is the child. 
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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 your FEHB is retroactively reinstated for 6 additional months, FEHB will become the primary payer and TRICARE the secondary payer during the additional 6 month coverage period. Thus, any payments made by TRICARE during that 6-month period could be reconciled with the FEHB carrier and any benefit adjustments could cause a difference in the amounts that you owe. Factors such as covered vs. non-covered services, network vs. out-of-network providers, deductibles, copayments, coinsurance, Health Maintenance Organization (HMO) geographic considerations, and catastrophic coverage applications may alter your total out-of-pocket expenses. Some additional issues for you to consider are:
    • If your FEHB plan covers services that TRICARE does not, having FEHB coverage could work to your advantage.
    • If TRICARE covers services that FEHB does not, TRICARE as the secondary payer should not adversely work against you since TRICARE would pay its normal benefits in the absence of benefits from the FEHB carrier.
    • If your FEHB plan becomes primary and you used TRICARE providers that were out of your FEHB plan's network, you need to determine if you would be better off with just the TRICARE coverage paying benefits alone or would you be better off having FEHB pay as primary and TRICARE as secondary for the out-of-network services.
    • You need to determine if shifting deductibles, copayments, and coinsurance from TRICARE to FEHB as the primary carrier enhances or decreases your overall benefits.
    • You need to determine how the geographic restriction of having an HMO Plan as primary payer affects the benefits received for you and your family members and how it affects payment from TRICARE as the secondary payer.
    • You need to determine if requesting retroactive FEHB for 6 additional months would enable you to meet your catastrophic protection benefits, thus, potentially enhancing your overall payment receipts.
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  • The Office of Personnel Management in Macon, Georgia (OPM-Macon), will mail a PIN to you within your first two weeks on the job.
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  • The TCC provisions allow children who no longer qualify as an eligible child (e.g., child reaches age 26, foster child no longer lives with the employee, foster child is no longer financially dependent on the employee) to continue their FEHB coverage for up to 36 months. The child is enrolled in his/her own right and pays both the employee’s and the Government's share of the premium, plus an additional 2% administrative cost. You should notify your employing office within 60 days after the child no longer qualifies for coverage as a family member. A child who loses FEHB coverage for any reason other than by cancellation has a 31-day temporary extension of coverage, at no cost, for the purpose of converting to a non-group contract with his/her current health benefits plan. To convert the child's coverage to a non-group plan, you or your child must apply directly to the health benefits plan within 31 days after the child's eligibility ends. For further information on health benefits, contact your personnel office.
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  • Only you and the children born to or adopted by you and your former spouse (the Federal employee or annuitant) are covered.
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    • It saves time.
    • It's convenient.
    • It's reliable.
    Employee Express eliminates the need for completing and submitting forms by replacing forms with user-friendly technology. You'll never again have to make a special trip to personnel to drop off forms; instead, you can process changes or review your current information anytime and nearly anyplace. And perhaps best of all, Employee Express automatically checks your transaction -- a feature that wasn't available using paper forms.
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  • A formulary is a list of both generic and brand name drugs that are preferred by your health plan. Often, many drugs on the market produce the same results equally well. Health plans will choose formulary drugs that are just as safe and effective as the alternatives but cost less. A team of pharmacists and physicians meet to review the formulary and make changes as necessary.
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  • No. The termination is not considered a break in the continuous enrollment necessary for continuing FEHB coverage during retirement. If you decide not to continue your coverage, your enrollment is terminated, not canceled. To avoid a gap in your coverage after you return to work, you must reinstate your enrollment on or before the last day of your TRICARE coverage. See our questions and answers on Return from Military Service.
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  • If you are enrolled in the FEHB Program but are employed outside the Executive Branch, or your pay is not issued by an agency of the Executive Branch, you may be eligible if your employer agrees to adopt our plan and offer participation in premium conversion.� All non-Executive branch agencies were contacted by OPM with instructions on how to become part of the plan.
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  • If you disagree with the plan’s decision on your claim, the Federal Employees Health Benefits (FEHB) Program provides for an appeal process.  Check your plans FEHB brochure to see if the service is covered, limited, or excluded. Review and follow the directions in the disputed claims section (Section 8) of the brochure. This section will tell you how to ask the plan to reconsider your claim. You must explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered.   If the plan again denies the claim, read the plan's decision letter carefully. Then, check your plan's brochure again. If you still disagree with the plan's decision, the disputed claims section of the brochure will tell you how to write to the U.S. Office of Personnel Management to ask us to review the claim.
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  • Several years ago we stopped allowing plans to add new dental and vision packages or to increase packages they already had in place. We allow one exception -- when an HMO offers the benefits under their community package of benefits (at no additional cost to members). We do this because we firmly believe that Federal employees are best served by benefit packages that are strong in the traditional areas of hospital, surgical, and medical benefits and that provide protection against significant and largely unforeseeable health care expenditures. Everyone wants to keep premium increases as low as possible so, generally, to increase benefits plans make trade-offs. We would not want to sacrifice medical benefits to get dental or vision benefits.   It is important that you do not choose a health plan based on dental benefits alone. You may find yourself without other benefits when you need them, which could result in large unexpected medical expenses. Remember to look at the entire benefits package when making your health plan decision.
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  • If you disagree with the plan’s decision on your claim, the Federal Employees Health Benefits (FEHB) Program provides for an appeal process.  Check your plan’s FEHB brochure to see if the service is covered, limited, or excluded. Review and follow the directions in the disputed claims section (Section 8) of the brochure. This section will tell you how to ask the plan to reconsider your claim. You must explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered.   If the plan again denies the claim, read the plan's decision letter carefully. Then, check your plan's brochure again. If you still disagree with the plan's decision, the disputed claims section of the brochure will tell you how to write to the U.S. Office of Personnel Management to ask us to review the claim.
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  • Yes. You will receive a separate Notice of Privacy Practices from your FEHB plan, as well as any providers that you see -including physicians and hospitals.
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  • The Health Insurance Portability and Accountibiliy Act of 1996 (HIPAA) is a Federal law that provides far-reaching health insurance reforms and medical privacy protections for all Americans. Title 1 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 guaranteees the availability of new health coverage with no exclusions for pre-existing conditions for individuals who lose employment-based health coveragedue to changes in employment or family status. The department of the Treasury, Labor, and Health and Human Services are jointly responsible for Federal rules conserning health enforcment authority to the individual sstates and allows states to impose more generous protections that those under HIPAA, a key source of information for individuals is your State Insurance Commissioner.
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  • You can keep your Spouse Equity coverage indefinitely if you pay your premiums on time, don't remarry before age 55, and don't lose your entitlement to an annuity or survivor annuity.
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  • Yes. The loss of your transitional TRICARE is a Qualifying Life Event and you may request an enrollment change from 31 days before to 60 days after you lose your TRICARE. See Code 1M on Health Benefits Election Form, SF 2809, at www.opm.gov/forms/pdf_fill/sf2809.pdf [848 KB]. Once your agency reinstates your enrollment on the Notice of Change in Health Benefits Enrollment (Standard Form 2810), they should immediately process your request to change your enrollment.
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Total Count: 498, Number of Pages: 25, Page: 9
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