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Insurance FAQs Health

  • We ensure that the plans provide the benefits described in the Federal Employees Health Benefits Program brochures. The health plans often make Preferred Provider Agreements and other arrangements with providers which are contractual arrangements between the carriers and the providers. Because of the discounts that a plan realizes through its contracts with PPO providers, the plan is able to reimburse a higher percentage of the negotiated PPO allowance when PPO providers are utilized. It would not be cost effective for the plan to reimburse at the higher level when the provider is not giving a discount. Furthermore, much of the benefit you receive from using PPO providers comes from the PPO provider's agreement not to bill you for more than the negotiated PPO allowance. Non-PPO providers are under no such obligation. In some areas of the country, it is much more difficult for a plan to arrange PPO contracts for all types of services. In areas where there are no PPO providers, you can still receive your plan's regular benefits, as opposed to the incentivized PPO benefit. If you are overseas, check with your plan to see how they pay the claims of non-PPO providers – some plans have special reimbursement allowances for overseas claims.
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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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  • If you file claims after the deadline because you requested the 6 additional months of FEHB coverage, your plan will waive any timely filing restrictions. Fee-for-service plans must accept and process any claims for services received during the additional 6-month period, and reconsider any claims incurred during the additional 6 months that were previously denied for non-coverage. HMOs must provide benefits for services rendered during the additional 6 months if the provider was part of the HMO network at the time. They do not need to provide benefits if the services received during the additional 6 months were provided by non-network providers.
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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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  • 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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  • 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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  • 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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  • 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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  • 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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  • Your child age 26 or over who is incapable of self-support because of a disability that existed before age 26 may be eligible for coverage under your FEHB enrollment. For more information, please see the FEHB Handbook for Enrollees and Employing Offices.
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  • Yes, Qualifying Life Events (QLE).
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  • You can keep your Spouse Equity coverage indefinitely if you pay your premiums on time, don't remarry before age 55, and don't lose your entitlement to an annuity or survivor annuity.
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  • Only you and the children born to or adopted by you and your former spouse (the Federal employee or annuitant) are covered.
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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: 582, Number of Pages: 39, Page: 10
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