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Insurance FAQs Health

  • 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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  • Spouse Equity:
    1. If you qualify for Spouse Equity, you can elect FEHB coverage in your own right.
    2. Your coverage continues indefinitely, as long as you continue to meet the requirements (see next section) and pay your premiums.
    3. You must pay both the employee and government shares of your plans FEHB premium.
    4. You do not have to pay the extra 2% administrative charge.
    TCC:
    1. Your coverage is limited. It will end 36 months after your divorce or annulment, or earlier if you do not pay your premiums.
    2. You must pay both the employee and government shares of your plans FEHB premium, plus an administrative charge equal to 2% of total plan premiums.
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  • No, the children are entitled to receive benefits under only one enrollment.  Generally, when divorce occurs, one parent will enroll in Self Only coverage and the other parent will enroll in Self and Family coverage to provide benefits for the children.  If there is a reason for both parents to enroll in Self and Family coverage (i.e., both parents have remarried and need Self and Family enrollments to cover their new spouses and stepchildren), each enrollee must notify his or her insurance carrier of the name(s) of the child(ren) to be covered under his/her enrollment to prevent ant child from receiving dual coverage under FEHB (which is prohibited by Federal law).
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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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  • 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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  • 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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  • By regulation, an employee who does not change the enrollment during the Open Season is considered to have canceled the plan in which enrolled. The cancellation is effective the day before the first day of the first full pay period in January. The plan is responsible for providing coverage only through midnight of that date. If you're not sure of the date, you should contact your Human Resources Office and not the plan for the effective date. You should be aware that you are not entitled to a 31-day extension of coverage because the action is considered a cancellation and not a termination. You cannot reenroll in the FEHB Program until the next open season. Also, this is considered a break in coverage. The 5-year requirement to continue your enrollment into retirement will begin when you reenroll in the FEHB Program. If you are within five years of retirement, you will have to work additional time to be eligible to continue your enrollment into retirement. If you are an annuitant, you are deemed to have enrolled in the standard option of the Blue Cross and Blue Shield (BCBS) Service Benefit Plan. OPM deems annuitants into the standard option of BCBS by default (and by law) if they do not make a plan selection. If annuitants cancel their FEHB enrollment, they can never reenroll.
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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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  • 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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  • 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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  • 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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  • 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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  • 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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  • 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.
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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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Total Count: 482, Number of Pages: 33, Page: 11
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