Frequently Asked Questions About Benefits
Q. My child is going to college this year. Will my health maintenance organization (HMO) cover him?
A. Yes, if you have family coverage, as long as your child is under age 22 and unmarried. Since you are in an HMO, your child will be covered for services received from Plan providers and for emergency care away from home. Some HMOs offer benefits that are tailored specifically to your situation and others have reciprocal agreements with plans in other areas. Check with your plan.
Q. My plan denied my claim and I think they should have covered the services; what can I do?
A. 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).
Your disputed claim will be reviewed in one of four Insurance Contracts Divisions. 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 before we can decide, or if you need to do more -- such as send us more information -- before we can decide, 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.
Q. I'm enrolled in a fee-for-service plan. How can I get the most value for my benefit dollar?
A. Most FEHB fee-for-service plans offer Preferred Provider Organization (PPO) arrangements. When selecting your health care practitioner, your use of PPO providers whenever possible will help reduce your out-of-pocket expenses. In addition, PPO providers will generally file your claims for you. Read your plan's FEHB brochure carefully to find out about other incentives. Contact your plan to obtain the names of PPO providers in your area. You should also visit your plan's website (identified on the front of the plan's brochure and available by link from this website). Many plans provide up-to-date lists of PPO providers on their website.
Q. I want to take advantage of the better benefits available by using a PPO doctor but my plan doesn't have any in my area. Why can't non-PPO's be paid as PPO's when there aren't any PPO's in my area?
A. 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.
Q. My friend got bad information from a Plan's customer service representative and got care based on that bad information. My friend thinks the Office of Personnel Management should order the plan to pay or allow a mid-year plan change. I don't think it should do either. Who is right?
A. You are correct. Problems arising from oral discussions are very difficult to settle later because they are impossible to prove or disprove. In contractual situations such as under the Federal Employees Health Benefits Program, oral statements can never be regarded as official and, so, the brochures state that oral statements made by any representative of a carrier cannot modify the benefits described in the brochure. If a serious decision -- such as whether to enroll or not enroll in a plan -- hinges on such a coverage issue, do not rely on a verbal response. This is particularly true if the response disagrees with the plan's brochure benefits description.
Q. Why can't the doctors stay with the plan a year instead of dropping out at any time? I can't keep up with who is participating and who is not.
A. 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.
Q. My plan requires that I get preauthorization for surgery. My physician told me that I need this surgery but my plan will not authorize it. What can I do?
A. First, have your doctor contact the plan to discuss the situation. You and your doctor can provide your plan with information to support your contention that the surgery should be authorized, such as medical records that indicate the need for the surgery, and ask your plan to reconsider its decision. If the plan reconsiders its decision but continues to uphold its denial, and after considering the plan's rationale you still disagree, consult the disputed claims section of your plan's brochure for specific information on how to write to the Office of Personnel Management to ask us to review the claim.
Q. I am going to retire soon. What are the requirements to continue health benefits into retirement?
A. In order for you 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 Federal Employees Health Benefits 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.
Q. How would I get a waiver of the 5-year coverage requirement to continue health benefits into retirement with buyout legislation?
A. 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.