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Insurance FAQs Health

  • 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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  • 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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  • To verify your current health benefits plan, contact 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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  • First, call your plan. If they tell you they haven't gotten the paperwork yet from your retirement system, you may contact your retirement system. If you are a Civil Service Retirement System (CSRS) annuitant or a Federal Employees Retirement System (FERS) annuitant, contact OPM at 1-888-767-6738. Before contacting your retirement system, have your annuity information ready: your name, civil service annuity number (beginning with CSA or CSF), phone number and address, and information about your plan, such as the carrier enrollment code.
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  • No. You would need to wait for Open Season. It is not uncommon for providers to leave plans mid-year. Other plan providers will be available to provide care.
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  • Your employing office will notify you of the choices available to you and provide you with a method to make direct premium payments.
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  • Yes, Qualifying Life Events (QLE).
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  • The Open Season dates are set by Federal regulation 5 C.F.R. § 890.301(f), available at http://law.justia.com/us/cfr/title05/5-2.0.1.1.32.3.143.1.html. Each year OPM provides an Open Season from the Monday of the second full workweek in November through the Monday of the second full workweek in December.
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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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  • As long as the annuitant was enrolled in Self and Family coverage when he/she suspended FEHB coverage and made arrangements to leave a survivor annuity, the survivor annuitant can reenroll in the FEHB Program under the same conditions as an annuitant.
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  • Because the U.S. Office of Personnel Management (OPM) administers the Federal Employees Health Benefits (FEHB) program, the largest employer-sponsored health insurance program in the world, we believe we have a commitment to you. Following are the standards we follow:
    • Your choice of health benefits plans will compare favorably for value and selection with the private sector.  
    • When you use the Guide to Federal Benefits and plan benefit brochures, you will find they are clear, factual and give you the information you need.  
    • When you change plans or options, your new plan will issue your identification card within 15 calendar days after it gets your enrollment form from your agency or retirement system.  
    • Your fee-for-service plan should pay your claims within 20 work days; if more information is needed, it should pay within 60 calendar days.  
    • If you ask us to review a claim dispute with your plan, our decision will be fair and easy to understand, and we'll send it to you within 60 calendar days. If you need to do more before we can review a claim dispute, we will tell you within 14 work days what you still need to do.  
    • When you write to us about other matters, we will respond within 30 calendar days after we get your letter. If we need time to give you a complete response, we will let you know.
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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 TAMP is the Transitional Assistance Management Program, and it offers transitional TRICARE eligibility to certain separating active duty members and their eligible family members for 180 days. Your Human Resources Office can assist you in determining if you are eligible for transitional TRICARE under the TAMP.
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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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  • No, premiums that are paid under TCC are not eligible for premium conversion. Although we realize that you may make the premium payments on behalf of your child, the TCC policyholder is the child. 
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Total Count: 581, Number of Pages: 39, Page: 10
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