Insurance FAQs Health

You can find information about Medicare and resources on how to address issues with your Medicare enrollment at medicare.gov.

You can reenroll in the FEHB Program for any reason during a future Open Season. If you are involuntarily disenrolled from TRICARE or CHAMPVA, you are eligible to immediately reenroll in the FEHB Program. Your request to reenroll must be received within the period beginning 31 days before and ending 60 days after your TRICARE or CHAMPVA coverage ends. Otherwise, you must wait until Open Season.

The plans print their provider directories and have them available during Open Season. Many plans also provide this information on their websites. If your agency has an Open Season health fair this fall, the plans probably will be there to hand out their brochures and provider directories. You can also call the plan at the number listed in the Guide to Federal Benefits. You can also find specific plan contact information on the FEHB website.

You can change plans during the annual FEHB Open Season and whenever you have a qualifying life events (QLE) -- such as marriage. Becoming aware of another plan that has better benefits, even if you didn't expect to want the extra benefits when you had a chance to change plans before, does not qualify as a "QLE" that allows you to change plans.

No, you will pay the same premium as you paid while you were an employee. However, annuitants are paid on a monthly basis so you will pay them at the monthly rate. You may see an increase if you are employed by an agency, such as the Post Office, that contributes additional money towards the total premium. Retirees receive the same government contribution as most Federal employees.

For a small number of individuals it may make sense to waive premium conversion. There are two items to consider in making a decision to waive participation and they are: Flexibility Under IRS rules, you may reduce coverage (cancel, or change from Self and Family to Self Only) only during an Open Season or at the time of a qualifying life event. Social Security Paying your premiums with pre-tax money reduces your earnings reported to the Social Security Administration. When you begin to collect Social Security (normally this occurs at age 65), you may receive a slightly lower Social Security benefit. The extent of the impact will vary depending upon the retirement system you participate in, your salary compared with the Social Security wage base ($87,000 in 2003) and the number of years until you retire.

Most FEHB fee-for-service plans offer Preferred Provider Organization (PPO) arrangements. When selecting your health care practitioner, your use of PPO providers whenever possible will help reduce your out-of-pocket expenses. In addition, PPO providers will generally file your claims for you. Read your plan's FEHB brochure carefully to find out about other incentives. Contact your plan to obtain the names of PPO providers in your area. You should also visit your plan's website (identified on the front of the plan's brochure and available by link from this website). Many plans provide up-to-date lists of PPO providers on their website. Another way to cut costs is to request generic drugs instead of brand name drugs. A generic medication is a copy of a brand name drug. It has the same active ingredients and receives the same Food and Drug Administration approval but costs less. Most plans charge you a lower copay if you use generic drugs.

Your employing office will notify you of the choices available to you and provide you with a method to make direct premium payments.

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.

Premium conversion may slightly reduce the Social Security benefit you will receive upon retirement. The extent of the impact depends upon several factors:

• the retirement system that you participate in;
• whether your salary exceeds the Social Security wage base; and
• the number of years left until your retirement.

The FEHB Program runs on a calendar year basis - from January through December. The carriers' provider contracts, however, which are between the provider and the carrier, are spread throughout the year, as are the carriers' policies with other employers.

The "Federal Employees Health Benefits Children's Equity Act of 2000" requires mandatory Self and Family enrollment coverage for FEHB-eligible employees who do not comply with a court or administrative order to provide health insurance coverage for their child(ren). You should send a copy of the court order to your ex-spouse's Human Resources Office. They will ensure that your ex-spouse has an FEHB Self and Family enrollment that provides coverage for the children. If your ex-spouse does not have a Self and Family enrollment, his Human Resources Office will enroll him in the Self and Family option of his current FEHB plan. If his current plan is an HMO and the child(ren) don't live within the service area of this plan, they will enroll him in the Basic Option of the Blue Cross and Blue Shield Service Benefit Plan. Please be sure to include your home address in your notification so that the Human Resources Office can make this determination. The Human Resources Office will send you a copy of the SF 2809, Health Benefits Election Form. They will also send a copy to the FEHB plan so the plan can update their records and send ID cards to you. The Human Resources Office will flag your ex-spouse's health insurance records to prevent him from making a change to a Self Only enrollment for as long as the court order requires him to provide health insurance coverage to your child(ren) or until the youngest child reaches age 26, whichever occurs first.

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).

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that provides far-reaching health insurance reforms and medical privacy protections for all Americans. Title I of HIPAA offers important, though limited, Federal protections that improve the availability and continuity of health coverage for workers and their families. Under certain conditions, this law guarantees the availability of new health coverage with no exclusions for pre-existing conditions for individuals who lose employment-based health coverage due to changes in employment or family status. The Departments of the Treasury, Labor, and Health and Human Services are jointly responsible for Federal rules concerning health insurance portability and accessibility requirements. However, since HIPAA gives enforcement authority to the individual states and allows states to impose more generous protections than those under HIPAA, a key source of information for individuals is your State Insurance Commissioner.