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Insurance FAQs Health

  • Contact your health plan directly for this information.
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  • When you file a disputed claim, you give OPM permission to review any information related to that claim, including medical information your FEHB plan used to make its initial determination as well as medical information you submitted to your FEHB plan or directly to us to support your claim. Information from your plan is provided to OPM so that we may make a determination on benefits.
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  • 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.
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  • You may not need to write to the Office of Personnel Management. If you think you might qualify for a waiver of the 5-year coverage requirement, contact your Human Resources Office for information. If you meet the requirements, your agency will attach a memorandum to your retirement application stating that you meet the requirements for waiver by the Office of Personnel Management.
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  • Some health plans offer dental and vision benefits separate from the officially offered benefits stated in their FEHB brochures. Such separate benefits are described on the "Non-FEHB Benefits" page in FEHB brochures. The plans solely determine what is covered and what is excluded and you must pay any premium associated with these benefits directly to the health or dental plan. There is no government contribution toward the premium on non-FEHB benefits. Also, some health plans offer a separate dental plan that does not require you to be a member of their health plan. And, occasionally, an agency's employee organization offers dental and vision benefits to the agency's employees. Check with your Human Resources Office.
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  • To inquire about how much coverage you have under the Federal Employees Health Benefits (FEHB) Program, go to Retirement Services Online at https://www.servicesonline.opm.gov.  You will need your retirement claim number and Personal Identification Number (PIN) to access information about your health benefits enrollment.    If you cannot access Retirement Services Online, you can inquire about your coverage by contacting 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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  • No. If an annuitant, survivor, or former spouse suspends Self and Family coverage, the coverage of all family members is suspended as well.
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  • The Federal Employees Health Benefits Program runs on a calendar year basis -- from January through December. But the carriers' provider contracts are spread throughout the year, as are the carriers' policies with other employers.
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  • A Plan offering a Point of Service product (POS) has features of both a Health Maintenance Organization (HMO) and a managed Fee-for-Service (FFS) plan. A few years ago, we began permitting plans to offer POS products as part of their benefits packages. Think of it as a hybrid of the two types of plans. In an HMO, the POS product lets you choose to use providers that are not part of the network of providers affiliated with the plan. There is a cost associated with choosing non-plan providers, usually in the form of substantial deductibles and coinsurances that are higher than the copayment you would normally pay for using a plan provider. You will also need to file a claim for reimbursement, like in a FFS plan. The plan wants you to use its network of providers, but it recognizes the desire of some enrollees to see a provider of their choosing on some occasions. In the case of a POS product of a managed Fee-for-Service (FFS) plan, the opposite is true. The plan's normal benefits include deductibles and coinsurance. But in some locations, the plan has set up a network of providers similar to that you would find in an HMO. The plan encourages you to use these providers, usually by waiving the deductibles and applying a copayment that is smaller than the normal coinsurance. Normally, there would not be any paperwork when you use a network provider. Check the FEHB Guide on this website to see where the FFS plan offers a POS product, and what you must do to elect to participate in the plan's POS product.
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  • 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.
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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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  • 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.
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  • 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.
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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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  • Your agency should contact you or your dependent and give you an opportunity to select another plan. If they were unable to reach you and you learned after the enrollment time frame that your plan discontinued, they must use SF 2810 to reinstate your old enrollment code. This is for enrollment history purposes only, and cannot be sent to your old carrier since the plan is discontinued. Your agency should give you an opportunity to select another plan, and process the change retroactive to the date after your enrollment under your former plan terminated. When selecting another plan, please remember you are responsible for determining if any providers used participate in your new plan's network.
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Total Count: 488, Number of Pages: 33, Page: 9
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