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Insurance FAQs Health

  • Annuitant Open Season changes are effective January 1.
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  • No. If you remarry, your new spouse and his/her children cannot receive health benefits coverage under your survivor annuitant enrollment. If, however, you are a widow(er) survivor annuitant who is also receiving an annuity based on your own Federal career or who is a current Federal employee, you may be eligible to transfer your enrollment to your retirement annuity or your employing agency in order to provide coverage for your new spouse and his or her children.
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  • If you cancel your FEHB, you need to be aware of the following consequences that apply to all employees who cancel their FEHB, including:
    • You and your dependents are no longer covered under the FEHB Program.
    • You may not reenroll in FEHB until you lose your TAMP coverage or have another qualifying life event (QLE) that permits enrollment, or until the next FEHB Open Season. If you reenroll because you lose TAMP coverage, you must do so from 31 days before to 60 days after your TAMP ends, and use Code 1M on Health Benefits Election Form, SF 2809, at www.opm.gov/forms/pdf_fill/sf2809 [848 KB]. Additional QLEs that permit enrollment, for example, a change in family status, are listed on SF 2809. If you have one of these QLEs, you must enroll within the timeframes shown.
    • If you transfer to another Federal agency, your cancellation follows you and you may not reenroll until you lose your TAMP coverage or have another QLE that permits enrollment, or until the next FEHB Open Season. See above bullet for details.
    • If you separate from your employment, you will not be eligible for temporary continuation of coverage (TCC) because you will not have any FEHB enrollment to continue. Also, you will not have an FEHB enrollment to convert to an individual policy with your former insurance carrier.
    • If you retire, you will not have an FEHB enrollment to continue into retirement.
    • If you die, you will not have an FEHB family enrollment for your survivors to continue, even if they are eligible for a survivor annuity.
    Note: Your agency may ask you to sign a statement stating that you understand these consequences.
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  • The time limit for notification is 60 days from your divorce or annulment. Either you or your former spouse must notify the employing office in writing that you want TCC. If your former spouse is retired, notify the retirement system.
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  • 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.
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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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  • Open Season changes for most Federal employees are effective the first day of the first full pay period that begins in January. Generally, mid-year changes are effective on the first day of the pay period which begins after your enrollment is received by your Human Resources Office.
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  • If you elect to terminate your enrollment before you go on active duty, the termination will be effective on the day you are separated, furloughed, or placed on leave of absence to enter military service. Your employing office must use SF 2810 to terminate your enrollment. This means that you are entitled to a 31-day extension of coverage and if needed, have the right to convert to an individual policy offered by the carrier of your plan.
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  • 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/.
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  • Your former Human Resources Office should send the new agency your Waiver of Immediate Reinstatement of FEHB along with your FEHB records, so that your postponement may continue. Your new agency should reinstate your FEHB and transfer it in to their payroll office on the date you requested by using the Notice of Change in Health Benefits Enrollment (Standard Form 2810). It is important that you check your leave and earnings statement to be sure that your FEHB is reinstated on the date you requested.
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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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  • The premiums for the FEHB plan you are currently enrolled in are in the brochure you will receive from your plan during the annual Federal Benefits Open Season. The Guide to Federal Benefits is a comparison of the plans and their benefits and premiums. There are a variety of Guides targeted to specific groups of enrollees. The average premium is recalculated every year.  Per FEHB law, the government will pay the lesser of: 75% of the carrier’s total premium, or 72% of the average premium.  The enrollee is responsible for the difference between the government contribution and the total premium. If the average premium increases, the maximum government contribution also increases. The total premium is the same for all enrollees, but the Government contribution is based on your employment. Some agencies, such as the Postal Service, contribute additional money towards the total premium. As a result, the share you must pay will depend upon your employment status. All Guides are available on this website or through your Human Resources Office.
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  • 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.
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  • Yes. FEHB regulations provide that an employee’s FEHB is automatically reinstated upon return to employment following active duty. An annuitant’s FEHB is automatically reinstated on the day of separation from the uniformed services.
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  • 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.
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Total Count: 488, Number of Pages: 33, Page: 7
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