Insurance FAQs Health

Original Medicare has four parts:

Part A (Hospital Insurance) helps pay for:

• inpatient hospital care
• critical access hospitals
• skilled nursing facility care
• some home health care
• hospice care

Part B (Medical Insurance) helps pay for:

• doctors' services
• ambulance services
• outpatient hospital care
• x-rays and laboratory tests
• durable medical equipment and supplies
• home health care (if you don't have Part A)
• certain preventive care
• limited ambulance transportation
• other outpatient services
• some other medical services Part A doesn't cover, such as physical and occupational therapy

Part C (Medicare Advantage): If you join a Medicare Advantage Plan you generally get all your Medicare benefits, which may include prescription drugs, through one of the following types of plans:

• Medicare HMOs – You must get your care from primary care doctors, specialists, or hospitals on the HMO's list of network providers, except in an emergency.
• Medicare PPO Plans – In most plans your share of plan costs is less when you use in-network primary care doctors, specialists and hospitals. Using out-of-network providers costs you more.
• Medicare Special Needs Plans – These plans generally limit enrollment to people in certain long-term care facilities (like nursing homes); people eligible for both Medicare and Medicaid; or those with certain chronic or disabling conditions.
• Medicare Private Fee-for-Service Plans – In these plans, you may go to any Medicare-approved primary care doctor, specialist, or hospital that will accept the terms of the private plan's payment.
• Medicare Medical Savings Account (MSA) Plans - These plans include a high deductible plan that will not begin to pay benefits until the high annual deductible is met. They also include a medical savings account into which Medicare will deposit money for you to use to pay your health care costs. Medical Savings Account Plans do not cover prescription drugs.

Part D (Medicare Prescription Drug Coverage) Under this program, private companies provide Medicare Prescription Drug Coverage and you pay a monthly premium. Federal retirees already have excellent access to health benefits coverage for drugs through participation in the FEHB Program. However, if you choose to enroll in Part D, Medicare benefits for drugs will be primary (will pay first) in most cases for FEHB enrollees. (Medicare C plans that include prescription drugs will also be primary to FEHB benefits.) It will almost always be to your advantage to keep your current FEHB coverage without any changes. The exception is for those with limited incomes and resources who may qualify for Medicare's extra help with prescription drug costs. Contact your benefits administrator or your FEHB Program insurer for information about your FEHB coverage before making any changes. It is important to note that FEHB Program prescription drug coverage is an integral part of your total health benefits package. You cannot suspend or cancel FEHB Program prescription drug coverage without losing your FEHB plan coverage in its entirety (in other words, losing coverage) for hospital and medical services which would mean you might have significantly higher costs for those services. Because all FEHB Program plans have as good or better coverage than Medicare, they are considered to offer creditable coverage. So, if you decide not to join a Medicare drug plan now, but change your mind later and you are still enrolled in FEHB, you can do so without paying a late enrollment penalty. As long as you have FEHB Program coverage you may enroll in a Medicare prescription drug plan from November 15 to December 31st of each year at the regular monthly premium rate. However, if you lose your FEHB Program coverage and want to join a Medicare prescription drug program, you must join within 63 days of losing your FEHB coverage or your monthly premium will include a late enrollment penalty. The late enrollment penalty will change each year but will be included in your premium each year for as long as you maintain the coverage.

Medicare does not cover:

• your monthly Part B premium or Part C or Part D premiums
• deductibles, coinsurance or copayments when you get health care services
• outpatient prescription drugs (with only a few exceptions) unless you enroll in a Part C plan which provides drug coverage or a Part D plan
• routine or yearly physical exams
• custodial care (help with bathing, dressing, toileting, and eating) at home or in a nursing home
• dental care and dentures (with only a few exceptions)
• routine foot care
• hearing aids
• routine eye care
• health care you get while traveling outside of the United States (except under limited circumstances)
• cosmetic surgery
• some vaccinations
• orthopedic shoes

Complete Medicare benefits information can be found in the Centers for Medicare and Medicaid Services publication, Medicare & You handbook which can be found on the Medicare website (www.medicare.gov).

If you are entitled to Part A without paying the premiums, you should take it, even if you are still working. This may help cover some of the costs that your FEHB plan may not cover, such as deductibles, coinsurance, and charges that exceed the plan's allowable charges. There are other advantages to Part A, such as (if you also enroll in Part B,) being eligible to enroll in a Medicare Advantage Plan.

Outside of Open Season, you can make changes due to certain events, called qualifying life events (QLEs) The most common QLEs for changing enrollment type or plan are: marriage, acquiring a child, moving away from the area served by your Health Maintenance Organization (HMO), losing health insurance coverage, or changing employment status.

When you enroll in a Medicare Advantage plan, you may not need FEHB coverage because the Medicare Advantage plan will provide you with many of the same benefits. You should review the Medicare Advantage Plan benefits carefully before making a decision to suspend or cancel FEHB coverage. You should contact your retirement system to discuss suspension and reenrollment.

Yes, you may change your FEHB enrollment to any available plan or option at any time beginning 30 days before you become eligible for Medicare. You may use this enrollment change opportunity only once. You may also change your enrollment during the annual Open Season, or because of another event that permits enrollment changes (such as a change in family status).

You need to complete the SF 2809 if you change your enrollment from Self and Family to Self Only or vice versa. For example, if you have Self and Family coverage and you plan to keep Self and Family coverage, you do not need to complete any forms. You must let the health plan know the date of the divorce so that your ex-spouse can be removed from your enrollment. If you have Self and Family coverage and you now plan on enrolling in Self Only coverage, you must notify your Human Resources Office. You will have to complete an SF 2809.

You can use Employee Express by touch-tone phone and through the Internet (https://www.employeeexpress.gov/DefaultLogin.aspx). For security reasons, we don't recommend using a cellular phone. For information about Employee Express in your agency, contact your Human Resources Office. If you have forgotten your username or password please visit their Online Password and Login ID Request page. 

You can reach the Help desk by phone at 478-757-3030 or email at EEXHELP@opm.gov. When you email the Help Desk, be sure to include this information in your message:

• Your full name
• Your agency's name
• Your phone number
• A brief description of your problem

Do NOT include your SSN or PIN in your email.

Generally, plans under the FEHB Program help pay for the same kind of expenses as Medicare. FEHB plans also provide coverage for emergency care outside of the United States which Medicare doesn't provide. Some FEHB plans also provide coverage for dental and vision care. Medicare covers some orthopedic and prosthetic devices, durable medical equipment, home health care, limited chiropractic services, and some medical supplies, which some FEHB plans may not cover or only partially cover (check your plan brochure for details).

To continue your health benefits enrollment into retirement, you must: (1) have retired on an immediate annuity (that is, an annuity which begins to accrue no later than one month after the date of your final separation); and (2) have been continuously enrolled (or covered as a family member) in any FEHB Program plan (not necessarily the same plan) for the five years of service immediately preceding retirement, or if less than five years, for all service since your first opportunity to enroll.

Spouse equity is a provision of the law that allows the former spouse of a Federal employee or annuitant to enroll in FEHB if he or she meets certain requirements.

You must apply for Temporary Continuation of Coverage (TCC) with your agency Human Resources Office within 60 days from the date you separate from Federal service. TCC coverage becomes effective the day after the qualifying event. After your 31-day extension of your group coverage ends, you pay the full premium (the enrollee and Government contribution) plus a 2 percent administrative fee. For more information, contact your agency's Human Resources Office and review the TCC pamplet at www.opm.gov/insure/health/eligibility/tcc.

If the union agrees to adopt our plan, premium conversion may apply to Federal employees on LWOP to work for a union.

Once Medicare becomes the primary payer, you may find that a lower cost FEHB plan is adequate for your needs, especially if you are currently enrolled in a plan's high option. Also, some plans waive deductibles, coinsurance, and copayments when Medicare is primary.