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Insurance FAQs

Benefits

  • A. In order for you to continue your health benefits enrollment into retirement, you must: (1) be entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement; and (2) have been continuously enrolled (or covered as a family member) in any Federal Employees Health Benefits (FEHB) Program plan(s) (not necessarily the same plan) for the five years of service immediately before the date your annuity starts, or for the full period(s) of service since your first opportunity to enroll (if less than 5 years). The 5 year requirement period can include the following: the time you are covered as a family member under another person's FEHB enrollment; or the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement.
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  • Annuitants sometimes need a new copy of “Your Federal Retirement Benefits” to show their retirement income to their mortgage lender, bank, underwriter, state income tax office, or low-income housing provider.  To request a new copy of “Your Federal Retirement Benefits”, or to receive a verification of your annuity, 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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  • You are correct. Problems arising from oral discussions are very difficult to settle later because they are impossible to prove or disprove. In contractual situations such as under the Federal Employees Health Benefits Program, oral statements can never be regarded as official and, so, the brochures state that oral statements made by any representative of a carrier cannot modify the benefits described in the brochure. If a serious decision -- such as whether to enroll or not enroll in a plan -- hinges on such a coverage issue, do not rely on a verbal response. This is particularly true if the response disagrees with the plan's brochure benefits description.
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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). 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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  • 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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  • 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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  • First, have your doctor contact the plan to discuss the situation. You and your doctor can provide your plan with information to support your contention that the surgery should be authorized, such as medical records that indicate the need for the surgery, and ask your plan to reconsider its decision. If the plan reconsiders its decision but continues to uphold its denial, and after considering the plan's rationale you still disagree, consult the disputed claims section of your plan's brochure for specific information on how to write to the Office of Personnel Management to ask us to review the claim.
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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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  • 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, if you have family coverage, as long as your child is under age 26. Since you are in an HMO, your child will be covered for services received from Plan providers and for emergency care away from home. Some HMOs offer benefits that are tailored specifically to your situation and others have reciprocal agreements with plans in other areas. Check with your plan.
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  • It depends.  FEHB law requires a retiring employee to be covered under FEHB for the 5 years of service immediately before retirement or, if less than 5 years, for all service since the employee’s first opportunity to enroll in FEHB.  In the above situation, the employee’s 2 years of previous FEHB coverage would count toward his 5-year FEHB coverage requirement if he had a break in service and therefore could not have had FEHB as an employee. For example:  The employee was enrolled in FEHB from 2003-2005 and then separated from Federal employment.  He returned to Federal service in 2010 and was enrolled in FEHB from 2010-2013.  The 2 years he was enrolled in FEHB from 2003-2005 along with the 3 years he was enrolled in FEHB from 2010-2013 enable him to meet the 5-year coverage requirement.  However, if the employee had been continuously employed and eligible for FEHB, but had a break in his FEHB coverage from 2003-2009 because he cancelled his FEHB, he would have to begin the 5-year period over again. 
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  • No.You do not have to change to self and family coverage now.  As an employee or annuitant, you can change to self and family coverage during any Federal Benefits Open Season or if you experience a qualifying life event.  However, you should remember that in the event of your death, the only way that your family members can continue FEHB coverage is if you are currently enrolled in a self and family enrollment and at least one of your family members is eligible for a survivor annuity.
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