Federal Employees Health Benefits program carriers are obligated to follow standard coordination of benefit rules established by the National Association of Insurance Commissioners (NAIC) in order to make sure that payments to providers and customers do not duplicate payments of other health benefits coverages the member may have.
OPM allows retired and former spouse enrollees to suspend FEHB coverage to enroll in any one of the following programs if eligible, thus eliminating the FEHB premium: a Medicare HMO, Medicaid, Tricare, or CHAMPVA. OPM does not contribute to any applicable premiums. If the individual later wants to re-enroll in the FEHB program, generally they may do so only at the next open season unless they have involuntarily lost the other coverage.
The most common instances where OPM coordinates with other programs are the following:
* Tricare and CHAMPVA. FEHB carriers coordinate Tricare /CHAMPVA benefits according to their statutes. Tricare is the health care program for eligible dependents of military persons and retirees of the military. Tricare includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. When Tricare or CHAMPVA and FEHB cover the enrollee, FEHB pays first.
* Medicaid. When the enrollee has Medicaid and FEHB, FEHB pays first, according to the Medicaid statute.
* Medicare. Retirees are eligible for Medicare at age 65. FEHB carriers coordinate with Medicare according to Medicare statute and Medicare makes the final determination regarding who is primary. The most common situation is when the enrollee or spouse is age 65 or over and has Medicare. Generally, in that case, if the person is an active federal employee, FEHB pays first and, if retired, Medicare pays first. Of course, there are other situations. The full range of Medicare’s rules for coordinating benefits is laid out in enrollees’ FEHB plan brochures. To facilitate benefits coordination with Medicare, OPM and carriers work with Medicare, including through an OPM-Medicare data matching agreement whereby enrollees with Medicare are identified so that Medicare and FEHB claims payment systems will be set up to pay claims correctly.
* Spouse coverage. Benefits of enrollees (whether active employees or retirees) with coverage both through FEHB and through a spouse’s private sector employer are coordinated according to the NAIC guidelines. The NAIC guidelines are used by all group health plans in the country. Generally speaking, an enrollee’s own coverage is primary to coverage through a spouse.
* Other group coverage. Benefits of enrollees who have other of their own, such as coverage as a retiree from private employment, are coordinated according to the NAIC guidelines. Generally speaking, the plan that covers a person as a current employee pays first before the plan that covers the person as a retiree.
* No-fault coverage. FEHB carriers coordinate the payment of medical and hospital costs under no-fault or other automobile insurance that pays benefits without regard to fault according to the NAIC guidelines.