# Insurance FAQs Health

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• Contact your health plan directly for this information.
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• The small reduction in Social Security benefits is greatly outweighed by the much larger tax savings. In each case we tested, the increase in take-home pay far exceeded the minor loss in monthly Social Security benefits. Here is a simple formula you can use to estimate the difference in your Social Security benefit:
1. Take the number of years you will participate in premium conversion (from now until your estimated retirement) and divide by 35.
3. Multiply the result of Step 2 by the marginal SSA rate (15% for most Federal employees)
The result is the annual loss of Social Security benefits. (# of Years of Premium Conversion /35) X Annual FEHB Premium X marginal SSA rate = Annual Loss Example You participate in FERS. We assume that you've had a full career of FICA contributions, with an ending salary (today) of \$50,000 and projected retirement at age 66 in January 2016. Your estimated Social Security benefit equals \$1,414 per month. You begin participating in premium conversion and reduce your taxable income by \$2,000, the amount of your FEHB premium. By changing your salary to \$48,000, your monthly Social Security benefit is now \$1,403, an \$11.00 per month difference in today's dollars. 15/35= .4286 X 2000 = 857 X .15 = 128/12 = 10.71 or 11 Compare that to the estimated \$67 increase in take home pay per month. For more specific information on how the Social Security benefit is calculated, refer to www.ssa.gov.
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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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• Be careful. Such a cancellation would be permanent. Annuitants cannot re-enroll in the program except under very limited circumstances, such as to enroll in a Medicare-sponsored health plan, as described below, or TRICARE. Another exception is if your spouse is also a Federal employee and you cancel to be covered by your spouse's FEHB plan. Further, neither you nor your family members would be eligible for continued coverage nor would you be able to convert your coverage to a private non-group policy. Do not drop out of the program unless you are sure of being able to re-enroll.
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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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• 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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• 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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• Spouse Equity:
1. If you qualify for Spouse Equity, you can elect FEHB coverage in your own right.
2. Your coverage continues indefinitely, as long as you continue to meet the requirements (see next section) and pay your premiums.
3. You must pay both the employee and government shares of your plans FEHB premium.
4. You do not have to pay the extra 2% administrative charge.
TCC:
1. Your coverage is limited. It will end 36 months after your divorce or annulment, or earlier if you do not pay your premiums.
2. You must pay both the employee and government shares of your plans FEHB premium, plus an administrative charge equal to 2% of total plan premiums.
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• Yes. Generic drugs are less expensive than brand name products, and so the amount you pay as part of your prescription drug cost-sharing is less than what you pay for brand names. In addition, most plans charge you a lower copay if you use generic drugs.
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• Change in family status
• Change in employment status
• You or a family member lose FEHB or other health insurance coverage
• For more information, see SF 2809 for the Tables of Permissible Changes in Enrollment
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• You can change plans during the annual FEHB Open Season and whenever you have a qualifying life events (QLE) -- such as marriage. Becoming aware of another plan that has better benefits, even if you didn't expect to want the extra benefits when you had a chance to change plans before, does not qualify as a "QLE" that allows you to change plans.
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• 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.