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Federal Employees Health Benefits Program

Medicare and FEHB FAQs



A - C - D - E - H - I - M - O - P - R - S


An arrangement where a doctor or medical supplier agrees to accept the Medicare-approved amount (see definition) as full payment for services and supplies covered under Part B. When your doctor accepts assignment, you can be billed only for the difference between the Medicare-approved amount and the combined payments made by Medicare and any secondary payer.


The amount that you pay for each medical service you get, like a doctor visit. Coinsurance is a percentage of the cost of the service; a copayment is usually a fixed dollar amount you pay for a service.

Coordination of Benefits

When you are covered by more than one type of insurance that covers the same health care expenses, one pays its benefits in full as the primary payer and others pays a reduced benefit as a secondary or third payer. When the primary payer doesn't cover a particular service but the secondary payer does, the secondary payer will pay up to its benefit limit as if it were the primary payer.


The amount that you pay for each medical service you get, like a doctor visit. Copayment is usually a fixed dollar amount you pay for a service; a coinsurance is a percentage of the cost of the service.


The amount you must pay for health care, before your health plan begins to pay. There is a deductible for each benefit period - usually a year. There may be separate deductibles for different types of services. Deductibles can change every year.


Leaving or ending your health care coverage with a health plan.

Durable Medical Equipment (DME)

Medical equipment ordered by a doctor for use in the home. DME must be re-usable. DME includes walkers, wheelchairs, and hospital beds.


You enroll when you first sign up to join a health plan.

Health Maintenance Organization (HMO)

A type of health benefits plan that provides care through a network of doctors and hospitals in particular geographic or service areas. HMOs coordinate the health care services you receive. Your eligibility to enroll in an HMO is determined by where you live or, for some plans, where you work. Some FEHB HMOs have agreements with providers in other service areas for non-emergency care if you travel or are away from home for lengthy periods.

Inpatient Care

All types of health services that require an overnight hospital stay.

Managed Fee-For-Service Plan

A traditional type of insurance that lets you use any doctor or hospital, but you usually must pay a deductible and coinsurance or copayment. These plans are called fee-for-service because doctors and other providers are paid for each service, such as an office visit or test. They help control costs by managing some aspects of patient care. Most FEHB managed fee-for-service plans also provide access to preferred provider organizations (PPOs).


The federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (those with permanent kidney failure who need dialysis or a transplant, sometimes called ESRD).

Medicare-Approved Amount

The amount Medicare determines to be reasonable for a service that is covered under Part B of Medicare. It may be less than the actual charge.


A new Medicare program that provides more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (ESRD).

Medicare Managed Care Plan

An HMO that contracts with Medicare to enroll Medicare beneficiaries. Services must be obtained from the HMO's network of doctors and hospitals to receive full plan benefits. The HMO may charge a monthly premium and require copayments.


A supplemental private insurance policy that you can buy for extra benefits either not covered or not fully covered by Medicare. There are 10 standard Medigap plans, ranging from a basic benefits package to ones that cover expenses such as the Part A deductible, Part B deductible, prescription drugs, and/or the skilled nursing coinsurance.

Original Medicare

The traditional fee-for-service arrangement that covers Part A and Part B services.

Out-of-Pocket Costs

Health care costs that you must pay because they are not covered by insurance, such as deductibles, coinsurance, copayments, and noncovered expenses.

Outpatient Care

All types of health services that do not require an overnight hospital stay.

Preferred Provider Organization (PPO)

A fee-for-service option where you can choose plan-selected providers who have agreements with the plan. When you use a PPO provider, you pay less money out-of-pocket for medical service than when you use a non-PPO provider.


The amount you pay monthly or biweekly for insurance.

Preventive Care

Care to keep you healthy or to prevent illness, such as routine checkups and flu shots, and some tests like colorectal cancer screening and mammograms.

Primary Payer

When coordinating benefits, the health plan that pays benefits first on a claim for medical care.


Your primary care doctor's written approval for you to see a certain specialist or to receive certain services. Most FEHB HMOs and some Medicare health plans may require referrals. Important: If you either see a different doctor from the one on the referral, or if you see a doctor without a referral and the service isn't for an emergency or urgently needed care, you may have to pay the entire bill.

Secondary Payer

When coordinating benefits, the health plan that pays benefits only after the primary payer has paid its full benefits. When an FEHB managed fee-for-service plan is the secondary payer, it will pay the lesser of a) its benefits in full, or b) an amount that when added to the benefits payable by the primary payer, equals 100% of covered charges.

Service Area

The geographic area where a health plan accepts members. For plans that make you use their doctors and hospitals, it is also the area where services are given.

Suspension of FEHB Enrollment

When you notify your retirement system that you are giving up your FEHB coverage to enroll in a Medicare managed care plan, but still retain the right to reenroll in FEHB if your enrollment in the Medicare managed care plan ends. Otherwise, if you cancel your FEHB coverage as an annuitant, you probably may never reenroll.