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Insurance FAQs

Disputed Claims

  • Your Human Resources Office will compile your health benefits records and forward them to OPM along with your retirement application and other records. OPM will review your health benefits records to determine if you are eligible to continue your FEHB enrollment into retirement. If you are eligible, OPM will process a transfer-in action and forward you a copy of this action for your records.
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  • The 24-month period begins the day you are separated, furloughed, or placed on leave of absence to serve on military duty. This applies even if part of your military service is covered by paid leave immediately followed by furlough or other leave without pay.
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  • Being sent to a combat zone does NOT cancel FEGLI coverage. Civilian employees who are sent to a war zone or combat zone in a support capacity keep their FEGLI coverage, including Accidental Death & Dismemberment (AD&D) coverage. Being sent to a combat zone does not affect the amount of your FEGLI coverage. If a Federal employee working in a war zone is killed, "regular" death benefits are payable to the employee's beneficiaries. Accidental death benefits are also payable under Basic insurance (and Option A, if the employee had that coverage) unless the employee was in actual combat (or unless nuclear weapons were being used) at the time of the injury that caused the employee's death. The Office of Federal Employees' Group Life Insurance (OFEGLI) decides whether to pay accidental death benefits only after thoroughly studying the facts and documentation surrounding an employee's death. The determination is made on a case by case basis. While we cannot say that in 100% of civilian deaths AD&D benefits will be payable, we can say that it is highly unlikely for a civilian to be in actual combat. Accidental death benefits are in addition to regular death benefits. Even if accidental death benefits are not payable, regular death benefits ARE payable.
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  • Vision plans feature comprehensive eye examinations and coverage for lenses, frames and contact lenses. Other benefits such as discounts on LASIK surgery may also be available.
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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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  • The National Defense Authorization Act for 2001 (Act) extended TRICARE pharmacy coverage to uniformed services Medicare eligible retirees, spouses, and survivors on April 1, 2001. Now uniformed services beneficiaries can get comprehensive prescription drug coverage through TRICARE's retail, mail order, or military treatment facility pharmacies. The Act also reinstated eligibility for TRICARE medical benefits for these beneficiaries on October 1, 2001. Beneficiaries with Medicare Parts A and B are now eligible to use TRICARE coverage for physician, hospital, surgical, and pharmaceutical services.
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  • As long as your spouse has a Self and Family enrollment and you are still married to your spouse, you will be covered under the enrollment. Your eligibility for coverage under your spouse's Self and Family enrollment will cease after a divorce or annulment. You may, however, be eligible for FEHB coverage under either the Spouse Equity provisions or the Temporary Continuation of Coverage provisions of the law. You would be enrolled in your own right and would pay both the Government and employee shares of the premium yourself.
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  • No. An annuitant, survivor, or former spouse can change to Self Only coverage, but this cancels all family members' coverage and takes away their future enrollment eligibility.
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  • You can't cancel a change. You can, however, make another change, using Employee Express. You can change most discretionary personnel and payroll transactions such as direct deposit, Federal and state tax withholdings, savings bonds, etc. at any time. Changes to FEHB and TSP are generally limited to Open Season. During FEHB Open Season, you may change your enrollment and/or waive or begin participation in premium conversion at any time up until the last day of Open Season. Employee Express will process only the last transaction.
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  • Your premiums will not change. The enrollment will be changed to your name and changed to a self only enrollment if there are no other eligible family members.
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  • Although you cannot remain covered as a family member under your spouse's Self and Family enrollment (even if a court order requires it), you may be eligible for FEHB Program coverage under either the Spouse Equity provisions or the Temporary Continuation of Coverage provisions of the law. You would be enrolled in your own right and would pay both the Government and employee shares of the premium yourself.
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  • Yes.  Spouses of federal annuitants are covered under a family enrollment in the Federal Employees Health Benefits (FEHB) Program during the divorce process and during a legal separation.  Spouses of annuitants lose eligibility for FEHB coverage when the divorce is final.  Former spouses of annuitants can apply for coverage in the FEHB Program under the Spouse Equity or Temporary Continuation of Coverage provisions of the FEHB law. Former spouses of annuitants must contact the annuitant’s retirement system within 60 days after the divorce to apply.   For more information on divorce after retirement, please visit http://www.opm.gov/insure/health/faq/divorce.asp.
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  • When you return to work after a break in service of less than 180 days, your human resources office will automatically enroll you in the same coverage that you had before you left your prior position. You will have to qualify to elect other coverage (Open Season, physical exam or life event). When you return to work after a break in service of 180 days or more, your human resources office will automatically enroll you in Basic and the same Optional insurance that you had in your prior position. You will have this coverage the first day you are in pay and duty status. Any previous waiver of insurance is automatically cancelled. Unless you file a new waiver, Basic insurance becomes effective your first day in pay and duty status in a position in which you are eligible for coverage. You may elect more insurance (if you don't already have the maximum) within 31 days of returning to service in an eligible position, regardless of the coverage you had during previous employment. If you do not make a new election, you will automatically get back whatever Optional insurance you had immediately before your separation. Any coverage that you had previously waived will be waived again.
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  • Examples Susan L. has $100 per pay period deducted from her salary for her contribution towards FEHB coverage. Ms. L's employing agency mistakenly deducts $150 during the last pay period prior to the effective date of her participation in premium conversion. To correct the error, the agency deducts $50 for FEHB from Ms. Lee's pay in the following pay period, during which she has begun participating in premium conversion. Except for agency error, $100 would have been deducted from her pay. However, only $50 is treated on a pre-tax basis. Ms. L's employing agency mistakenly makes no FEHB deduction during the last pay period prior to the effective date of her participation in premium conversion. To correct the error, the agency deducts $200 from Ms. L's pay in the following pay period, during which she has begun participating in premium conversion. Since the deduction for FEHB coverage is taken after she begins participation in premum conversion, $200 is afforded pre-tax treatment. Ms. L's employing agency mistakenly does not process her participation in premium conversion. As a consequence, Ms. L's $100 FEHB deduction is not afforded pre-tax treatment. To correct the error, the agency changes Ms. L's premium conversion status to "participant" in the following pay period. If not for the error, Ms. L. would have had $200 deducted from her pay on a pre-tax basis. However, only $100 is eligible for pre-tax treatment. As you can see, under these rules an error correction may result in a greater or lower tax benefit than would otherwise have occurred.
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  • Medicare beneficiaries may enroll in Original Medicare (Parts A and B) or choose to get their benefits from an array of Medicare Advantage Plans (Part C) plan options. Depending on where you live, Part C options may include Medicare Advantage Plans that are approved by Medicare but run by private companies. Medicare Advantage plans offer Medicare Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), private fee-for-service plans (PFFS), Medicare Special Needs Plans, and Medicare Medical Savings Account (MSA) plans. The Medicare Prescription Drug, Improvement and Modernization Act (MMA) established a voluntary outpatient prescription drug benefit, Medicare Part D, effective January 1, 2006. Medicare enrollees are able to receive prescription drug coverage by enrolling in a Medicare Part D plan. Medicare Advantage Plans (Medicare Part C) may also offer prescription drug coverage that follows the same rules as the Medicare Part D coverage. Other Medicare plans include Medicare Cost Plans, demonstration/pilot programs, and PACE (Programs of All-inclusive Care for the Elderly).
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  • No. Employees can only enroll in Basic, Option A and Option B this way. Obtaining a physical does not allow you to enroll in Option C. You must either enroll during an unrestricted Open Season or else in connection with a life event — marriage, divorce, death of spouse or acquisition of eligible children.
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  • You should contact your Human Resources Office for the appropriate information for employees covered under FEHB who are called to military duty.
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  • No. When you lose FEHB coverage other than by cancellation (including cancellation by nonpayment of premiums) you have a 31-day temporary extension of coverage, at no cost. This coverage is provided in the same enrollment category so you may convert to an individual contract with your current health benefits plan. Please review the Temporary Continuation of Coverage (TCC) pamphlet. www.opm.gov/insure/health/eligibility/tcc
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  • We suggest that you look at The Department of Health and Human Services website (specifically HHS's Office of Civil Rights), since they are tasked with writing and enforcing these regulations. Here are two links:
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  • The Privacy Rule permits OPM to impose reasonable, cost-based fees. The fee may include only the cost of copying (including supplies and labor) and postage, if you request that the copy be mailed. We expect to charge an amount similar to that used for Freedom of Information Act (FOIA) requests.
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Total Count: 712, Number of Pages: 36, Page: 7
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