How Coordination of Benefits May Impact FEHB Enrollees

According to the standard coordination of benefits rules established by the National Association of Insurance Commissioners, or NAIC, the Federal Employees Health Benefit (FEHB) program is obligated to ensure payments to customers and providers do not duplicate other health benefits coverages made available to members. Therefore, the FEHB premium and coverage may be eliminated if they opt for another plan. In most cases, the coordination of benefits (or COB) impacts which provider pays first or second.

The Office of Personnel Management, also known as the OPM, permits qualified retired enrollees to suspend their FEHB coverage, but it does not contribute to the applicable premiums. As a result, plan retirees are often most eligible to choose from, including CHAMPVA, Tricare, Medicaid, and Medicare HMO. Furthermore, should the enrollee decide to reenroll in the FEHB program later, they are typically given the option to do so during the open season unless they have involuntarily lost their coverage.

CHAMPVA and Tricare benefits are typically coordinated with FEHB carriers depending on their status. While disabled veterans and their eligible dependents can obtain health coverage through CHAMPVA, Tricare is a healthcare program catered toward eligible military personnel, their dependents, and eligible military retirees. For example, when FEHB, CHAMPVA, or Tricare covers an enrollee, FEHB pays first, followed by the additional provider.

Depending on current employment status, FEHB typically pays first, even with additional coverage through Medicaid and Medicare. However, if a federal employee has retired and is currently covered by Medicare and FEHB, Medicare would pay first. This determination is made when the FEHB carrier coordinates efforts with Medicare to make a final decision regarding the primary provider (according to Medicare statute). So, an enrollee or their spouse is 65 years old or older. In addition, if the federal government actively employs the enrollee, FEHB would pay first.

Efforts are also coordinated in the event a benefits enrollee has coverage through the FEHB and their spouse’s coverage (through a private sector employer). This coordination is also completed in adherence to the NAIC guidelines, which apply to all group healthcare plans. In most cases, an FEHB enrollee’s coverage is primary to their spouse’s; however, there are benefits for enrollees who maintain their additional coverage. Typically, whichever plan covers the individual as a current employee will pay first before the plan covers them as a retiree.

In a no-fault or secondary automobile insurance situation, FEHB carriers are meant to coordinate medical and hospital cost payments. This practice of benefits is done in adherence to guidelines set forth by the NAIC without regard to fault. While Medicare may cover injuries sustained in an automobile accident, it only pays after your car insurance pays. Therefore, if a car insurance carrier covers your damages, they typically only pay a share of the cost rather than the entirety.

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