Insurance FAQs

If you believe that OPM is not complying with a requirement of the Privacy Rule you may file with either OPM or the Department of Health and Human Services (HHS) Office of Civil Rights a written complaint, either on paper or electronically. This complaint must be filed within 180 days of when the complainant knew or should have known that the act had occurred. For more information on how to file a complaint with OPM, please review our NPP. For instructions and information on how to file a complaint directly with HHS, please refer to their website www.hhs.gov/ocr/hipaa/.

Unfortunately, there are areas of the country that HMOs have simply chosen not to participate in the FEHB Program. Reasons for this vary, but most cases involve population size or demographics. There is no minimum requirement for the number of HMO options available to enrollees throughout the country. We have encouraged HMO participation in the Program because many of our participants have asked for that choice of health plan. In fact, under the FEHBP, the only types of health plans that can be added to the Program are HMOs. And, HMOs have an annual opportunity to submit their applications to participate in the Program. If you have HMOs in your local area that do not currently participate in the FEHBP, we encourage you to ask these HMOs to consider the FEHBP market for their geographic areas. New plan application packages for the FEHB Program are available at www.opm.gov/insure/health/carriers/index.asp. Applications are due to OPM by January 31 of each year for the next contract term.

You can use Employee Express anytime, 24-hours a day, seven days a week.

You will be able to enroll through BENEFEDS at www.BENEFEDS.com during Open Season. Those without access to a computer will be able to enroll by phone at 1-877-888-FEDS (3337), TTY 1-877-889-5680.

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

If you do not meet these requirements, the authority for you to continue your FEHB comes from the Uniformed Services Employment and Reemployment Rights Act (USERRA) (38 U.S.C. 4317). Public Law 108-454 amended this Act to allow you to continue your FEHB for 24 months if you were called to military duty and elected to continue your health insurance coverage on or after December 10, 2004. If you made your election before December 10, 2004, you are eligible to continue your FEHB for 18 months. If your FEHB continues under this provision, your agency does not have authority to pay your premiums while you are on military duty. For additional information, see Benefits Administration Letter 06-401 at BAL 06-401 Federal Employees Health Benefits (FEHB) Program: Extended Coverage for Employees Called to Active Military Duty. [54 KB]

No. Approximately half of all drugs on the market have generic versions.

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.

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.

No. Under the Federal Employees Dental and Vision Insurance Program (FEDVIP), there is no extension of coverage, temporary continuation of coverage (TCC), spouse equity coverage, or right to convert to an individual policy (conversion policy).

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.

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.

Yes. You should still send a copy of the court order to your Human Resources Office to review and make a determination if any action is required. They will file the copy in your OPF and flag it so that they know a court order relating to health benefits has been filed. If your children aren't listed as family members on the SF 2809, they will send a copy of the court order to your FEHB plan.

For FEDVIP, eligible family members are your: -          spouse (Public Law 104-199, Defense of Marriage Act, states, " the word 'marriage' means only a legal union between one man and one woman as husband and wife, and the word 'spouse' refers only to a person of the opposite sex who is a husband or a wife."), -          unmarried dependent child(ren) under age 22 (including an adopted child, stepchild, foster child, and recognized natural child), and -          child(ren) age 22 or over who are incapable of self-support because of a mental or physical disability that existed before age 22. Please note that family member eligibility under the Federal Employees Dental and Vision Insurance Program (FEDVIP) is NOT the same as for the Federal Employees Health Benefits (FEHB) Program.   Changes in dependent eligibility under the Affordable Care Act (also known as health care reform) do NOT affect eligibility for children under FEDVIP.

If you file claims after the deadline because you requested the 6 additional months of FEHB coverage, your plan will waive any timely filing restrictions. Fee-for-service plans must accept and process any claims for services received during the additional 6-month period, and reconsider any claims incurred during the additional 6 months that were previously denied for non-coverage. HMOs must provide benefits for services rendered during the additional 6 months if the provider was part of the HMO network at the time. They do not need to provide benefits if the services received during the additional 6 months were provided by non-network providers.

A brand name drug is approved by the Food and Drug Administration (FDA), and is supplied by one company (the pharmaceutical manufacturer). The drug is protected by a patent and is marketed under the manufacturer's brand name.

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.

Send the completed form with a certified copy of the death certificate to the insured's agency if he/she died as an employee. If you are the deceased's widow(er) and the agency told you to send your claim form and other documents directly to OFEGLI, you should do that. If the deceased was retired, send the form with a certified copy of the death certificate to: Office of Federal Employees' Group Life Insurance  P.O. Box 6512 Utica, NY 13504-6512

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.   If you have a complaint that is not related to a disputed claim, email your complaint to FEHB@opm.gov.