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Insurance FAQs

Health

  • Several years ago we stopped allowing plans to add new dental and vision packages or to increase packages they already had in place. We allow one exception -- when an HMO offers the benefits under their community package of benefits (at no additional cost to members). We do this because we firmly believe that Federal employees are best served by benefit packages that are strong in the traditional areas of hospital, surgical, and medical benefits and that provide protection against significant and largely unforeseeable health care expenditures. Everyone wants to keep premium increases as low as possible so, generally, to increase benefits plans make trade-offs. We would not want to sacrifice medical benefits to get dental or vision benefits.   It is important that you do not choose a health plan based on dental benefits alone. You may find yourself without other benefits when you need them, which could result in large unexpected medical expenses. Remember to look at the entire benefits package when making your health plan decision.
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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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  • 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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  • Generally, no. OPM does not process claims, and does not have access to your personal medical information. The exception is if you have filed a disputed health benefits claim with us. If you have not filed a disputed claim we do not have any of your personal health information.
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  • If you are enrolled in the FEHB Program but are employed outside the Executive Branch, or your pay is not issued by an agency of the Executive Branch, you may be eligible if your employer agrees to adopt our plan and offer participation in premium conversion.� All non-Executive branch agencies were contacted by OPM with instructions on how to become part of the plan.
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  • 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.
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  • Your FEHB enrollment will continue unless you elect to have it terminate. You should also consider:
    • Any family members covered under your enrollment
    • Payment of your premiums
    Note: If your enrollment continues and you participate in premium conversion, you may not cancel your enrollment at any time. If you think you might want to stop your FEHB at some time during your military service, you should consider waiving premium conversion at this time.
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  • 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 plan’s 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.
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  • You receive a salary and then your contribution to pay for FEHB coverage is withheld (post-tax). You pay tax on the salary received -- the amount before the health insurance premium is withheld. Thus, you pay tax on a larger amount of income.
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  • Check their FEHB brochures' index. Regular dental and vision benefits that are part of a health plan's FEHB benefit offering will be in the brochure's benefit sections and on the summary page. Separate dental benefits will only be on the brochure's Non-FEHB Benefits page. Go to our plan choice pages.
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  • You will usually pay more for a non-formulary drug when a formulary version is available.
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  • The Health Insurance Portability and Accountibiliy Act of 1996 (HIPAA) is a Federal law that provides far-reaching health insurance reforms and medical privacy protections for all Americans. Title 1 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 guaranteees the availability of new health coverage with no exclusions for pre-existing conditions for individuals who lose employment-based health coveragedue to changes in employment or family status. The department of the Treasury, Labor, and Health and Human Services are jointly responsible for Federal rules conserning health enforcment authority to the individual sstates and allows states to impose more generous protections that those under HIPAA, a key source of information for individuals is your State Insurance Commissioner.
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  • Yes. The loss of your transitional TRICARE is a Qualifying Life Event and you may request an enrollment change from 31 days before to 60 days after you lose your TRICARE. See Code 1M on Health Benefits Election Form, SF 2809, at www.opm.gov/forms/pdf_fill/sf2809.pdf [848 KB]. Once your agency reinstates your enrollment on the Notice of Change in Health Benefits Enrollment (Standard Form 2810), they should immediately process your request to change your enrollment.
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  • Tribal employees who are considered common law tribal employees and meet FEHB requirements for the type of employment are eligible to enroll in FEHB.  Tribal employees with eligibility questions should contact their tribal employer.
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  • Yes. You will receive a separate Notice of Privacy Practices from your FEHB plan, as well as any providers that you see -including physicians and hospitals.
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  • Each state has a law that allows pharmacists to substitute less expensive generic drugs for many brand names. However, if your doctor specifies that a brand name must be dispensed, then the pharmacist may not substitute the generic. Sometimes an acceptable generic is available that your doctor may not be aware of. In this case, your pharmacist may be able to consult with your doctor to suggest an effective medication that costs less.
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  • You may not be eligible to enroll in an HMO plan but there are ten fee- for-service plans available nationwide to all Federal employees and annuitants. These plans are: APWU Health Plan, Blue Cross and Blue Shield Service Benefit Plan - Standard Option, Blue Cross and Blue Shield Service Benefit Plan - Basic Option, GEHA Benefit Plan - HDHP, Mail Handlers Benefit Plan, Mail Handlers Benefit Plan - HDHP, NALC, SAMBA – High Option, and SAMBA – Standard Option. Please review the brochures of each of these plans to determine which plan best meets your medical needs. If Federal enrollees have HMOs in their local areas that do not currently participate in the FEHB Program, we encourage them to ask their 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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  • Your Social Security benefits are calculated on your taxable earnings, so any reduction in your taxable income will affect your Social Security calculations.
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  • Your Health Plan is required to provide coverage until Open Season enrollments are effective. Since Open Season enrollments generally become effective the first day of the first pay period in January, your Plan will provide coverage until that date.
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  • Cost increases are due to several factors.
    • Pharmaceutical companies are producing a record number of medications and many carry a high price tag. It cost an average of $500 million to discover and develop one new medicine, and it takes an average of 12 to 15 years to bring a new medicine from the laboratory to the pharmacy shelf.
    • Drugs are used more and more to avert illness and hospital admissions. Asthma, heart disease, and ulcers are among conditions successfully being treated with drugs.
    • The over-age 65 population is growing larger and living longer and this leads to an increase in the utilization of prescription drugs.
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Total Count: 581, Number of Pages: 30, Page: 9
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