The Foreign Service Benefit Plan is specially created in the United States for all the Government Foreign Service holders to provide health coverage for its employees both inside the country and abroad.
Even today, the reformed American Foreign Service Benefit Plan, or FSBP, provides a detailed and comprehensive coverage for its Foreign Service holders around the world. 60% of the employees and members of the Foreign Service resides inside the US and the rest 40% are scattered all over the world.
The FSBP has been administered and sponsored by the American Foreign Service Protective Association, an association that takes care of all U.S. employees. You need to be a member or employee of the Foreign Services of the US and a member of the American Foreign Service Protective Association to be eligible for this plan.
Review the details Foreign Service Benefit Coverage
The FSBP covers a number of Government organization employees and members, including people working for:
- Department of State;
- Department of Homeland Security;
- Department of Defense;
- Foreign Commercial Service;
- Foreign Agricultural Service;
- NSA, CIA and other similar intelligence organizations;
- Executive branch of Civilian employees hired overseas, or hired to other U.S. territories and possessions; and
- Domestic employees directly hired to support these activities.
To properly understand everything about this benefit plan, you have to, of course, know all the coverage information.
Non Pre-existing Condition Limitation
If you are entering the benefit plan with a pre-existing condition or illness, you will receive treatment for it. In other words, when you are under the Foreign Services Benefit Plan, you will be getting treatment for any condition you have, even when that particular condition or illness started before you were an employee under the Foreign Services or before you were under this benefit plan.
Minimum Essential Coverage
If you are covered under this benefit plan, it means that you also qualify for the Minimum Essential Coverage (MEC), which is a coverage that meets the Affordable Care Act (ACA), i.e. the health insurance that is determined to make health care affordable for everyone. This particular benefit plan meets the shared requirements needed for both the Minimum Essential Coverage (MEC) and the Affordable Care Act (ACA).
Minimum Standard Value
The Foreign Service Benefit Plan also meets the minimum value standard established by the Affordable Care Act (ACA), which is a value of 60%. Anyone covered under the plan would get a 60% coverage of their essential health costs. The 60% amount mentioned in the benefit plan is only an actuarial value. The specific amount that you might have to end up paying will actually the calculated later as needed by the occasion.
How and where can you get information about FEHB Program
In the official website of the U.S. Office of Personnel Management (OPM), you can all the necessary information about the FEHB Program, including answers to questions related to:
- Any kind of information on the Program,
- All the different plans available to you to choose from,
- A tool to make a comparison between the different health plans,
- A complete list of all the agencies that participate in the Employee Express,
- A direct link to the said Employee Express,
- All information on the other different Enrollment systems, and
- Direct links to the other Enrollment systems, etc.
In the same place, you will find brochures informing about everything else that you’d want to know. Based on this information, you can make a decision about your healthcare coverage. You can get the answers from your own employers or retirement office, but the brochures at the FEHB plan can tell you more.
You will find details regarding:
- Ways to change your enrollment;
- Whether your family members will also be covered by the plan;
- What will happen to your benefit plan if you happen to enter military service, go on an extended leave without any official pay, retire or transfer yourself to another Government agency;
- When the next enrollment open season will begin;
- What usually happens when enrollment period ends, and other such important queries.
However, the FSBP office or its employees are not responsible for determining who is eligible for the plan and who isn’t. They cannot change your enrollment status, not unless your employers, your employment agency or your retirement office sends the required information to the FSBP office.
Coverage Available for you and your Whole Family
If you are eligible for the “Self Only Coverage” it means that only you are going to be covered by the benefit plan. On the other hand, “Self Plus One Coverage” means that you and any one family member will be covered by the plan.
You whole family will be covered only if you are eligible for the “Self and Family Coverage” plan. This includes you, your spouse and any number of children until they are 26 years old, as well as any foster children you are responsible for.
However, your foster children will have to be authorized by your employer agency before they are covered by the benefit plan. At the same time, if you have any disabled children over 26 years of age who cannot support themselves financially, they will also be covered by the benefit plan. Parents or siblings are not covered by this plan.
If you were single when you’ve joined your place of employment, you can alter your coverage plan to include your spouse under the “Self Plus One” coverage.
You can again change your benefit status to “Self and Family Coverage” if you give birth, adopt or include a foster child into your family.
When you have a child, your “Self and Family Coverage” will be immediately effective for the new child the next time your pay period begins. The same happens when you marry; your spouse’s coverage begins the next pay day of your work. Unfortunately, the benefits under this coverage , not eligible for unmarried couples, live-in couples or fiancés, only a married couple.
All kinds of offspring – natural, foster, adopted and step – are eligible under the FEHB plan. If your children are married before they are 26 years old, they will still be covered by the plan, but their spouses or children will not. On the same hand, if your children are covered by their own health insurance or employment (Government, Federal or private), they will still be able to use this benefit plan before they are 26 years old.
When a family member becomes ineligible for the benefit, i.e. in case of divorce, annulment or a child growing up more than 26 – neither your employer nor the FSBP would notify you of the matter.
It is your duty to notify the proper authorities when there is a change in the status of your family members.
If anyone else from your family – a spouse or a child – is also enrolled and eligible for the FEBH plan, they will be excluded from your benefit. If they are eligible for some other kind of FEHB plan, they will also not be eligible under your plan.
When would the Benefits or Premiums start?
All the benefit plans under the FEHB start from January 1st every year. However, if you have joined somewhere in the middle during Open Season, your benefits would be eligible from the first pay period of your joining. At the same time, if you are changing your plans during Open Season, your claims would be taken under consideration according to your old plans.
On the other hand, if your plans expire at the end of the year, you will be covered by the old plan before the new plan starts. All kinds of annuity coverage and premiums also begin on January 1st every year; if you have joined in the middle of the year or any other time, your benefits will all depend on your pay period which you will have to learn from your employment office or retirement office.
If you have separated from Federal Services and you are no longer eligible for coverage, your enrollment can still continue throughout the year.
You will not eligible for all benefits during this period since you are no longer a part of the Federal Government. If you use your Government health insurance after leaving your job, you will be directly billed through your previous employer.
Neither you nor any of your family members will be eligible for the benefits, even if it is an emergency. If you still use your health insurance knowing you’re not eligible for it, it will be a federal offence.
When will your Coverage end?
There are certain circumstances when your benefits will come to an end, such as on even of your coverage coming to an end, after a divorce from your partner who was a Federal employee, or if your spouse/parent (the Federal employee) converts to a “Self Only Coverage”.
Even if your benefit plan expires or is cancelled, there will an additional period of 31 days when your medical bills will be covered, and for no extra premium amount.
You will get this additional period of 31 days unless you cancel your enrollment immediately after it ends or you are divorced from or not a part of the family of the person who is the head of the benefit plan.
On the other hand, if you leave the Federal Service for some reason, get divorced or if you are no longer the family member of a Federal employee, you will be still eligible for Temporary Continuation of Coverage (TCC).
You can go on receiving TCC, which is similar to the Affordable Care Act (ACA), even if you do not continue your FEHB enrollment after retirement, or if you happen to be a dependent child of a Federal employee under 26 years of age, or if you lose your Federal job.
However, if you get fired from your Federal job because of misconduct or gross dishonesty, you will not be eligible for FEHB in the future, neither will your family.
If you or a family member is undergoing extensive treatment of in admitted in a hospital or any other institution after the 31 additional days are over, they will be further entitled to the ongoing treatment for another 60 days, but not more than that.
If you are divorced from the person who mainly holds the benefit plan, you will not get further medical benefit via your ex-spouse. However, if you have been just divorced, you might still be eligible for Temporary Continuation of Coverage (TCC) under your spouse’s Equity Law.
This goes for spouses who have just recently undergone divorce or is anticipation divorce in the near future.
To be eligible for TCC, you have to apply for enrollment from the U.S. Office of Personal Management (OPM) website. This website has all the information you will need to know about the Temporary Continuation of Coverage (TCC).
How does Foreign Service Benefit plan works?
The Foreign Service Benefit Plan (FSBP) is also known as a Fee-for-Service (FFS) plan, and it holds these following endorsements: Accreditation Association for Ambulatory Health Care (AAAHC) and the Comprehensive Health Plan Accreditation.
On the other hand, Claims Administration Corporation which is the plan’s administrator also holds the following endorsements: Health Utilization Review and Case Management Programs which is accredited by URAC. You’ll need to form the Foreign Service Benefit Plan Claim Form to start the proceedings.
Under this benefit plan, all services are offered through our fee-for-service plan. Certain health institutes and care providers inside the Aetna Choice POS II network are the ones that covers the health care services at a much reduced cost.
A primary care provider is assigned to each individual when they come for a service. The assigned care provider looks into all the details of the treatment so that everything can be done as cost-effectively and as safely as possible.
A list of all in-network providers under this benefit plan can be found here.
The list of service providers might be more extended in some locations compared to others. These in-network providers also work to provide treatment outside the primary 50 states of America.
However, there is no guarantee that all different kinds of specialty treatments will be available everywhere; at the same time, it cannot be guaranteed that the specialized treatment will be continued until needed.
How can you get Care from FEHB Program?
After you enroll yourself as a part of this benefit plan, the service providers will send you an identification card. Anytime you need medical services from any of the Foreign Service Benefit Plan Providers, you’ll need to show this ID card.
Your ID card is supposed to reach you within 30 days of enrollment. If you haven’t received your card or if you need a replacement, you can always contact the office.
If you are covered by this benefit plan, you will get the best medical care from our in-network care providers. What you’ll have to pay at the end of your treatment depends on the extension of your care, or the type of facility or provider you have used. You will have to pay significantly less if you use our in-network providers for your treatment.
You can get covered benefits from:
- Birthing Centers for any kind of prenatal care, deliveries and postpartum care;
- Convenient Care Centers that provide basic health care services and non-emergency services for walk-in patients;
- Hospice Centers that are properly licensed and experienced in caring for the terminally ill or chronically ill;
- Hospitals with doctors in attendance 24 hours a day, experienced nursing services, and provides major surgical facilities, medical services, diagnostic services and other general services;
- Urgent Care Center that has a free-standing ambulance which can provide emergency medical care in emergency situations outside the hospital;
- Residential Treatment Center licensed by the state that provides treatment for every kind of medical health conditions, mental health conditions and substance or drug abuse;
- Specialty Care Centers where the chronically ill or disabled people get treated; and
- Skilled Nurse’s Facility that provides constant nursing services around the clock.
If you were already hospitalized before your benefit plan, your treatments will still be covered by the plan. The amount you had to pay before the benefit started will be reimbursed to you via the office.
How much do you have to pay for Covered Services?
While the Foreign Service Benefit Plan will pay for the major portion of your treatment costs, you might end up having to pay some amount out of your pocket. This is known as “cost-sharing” when you pay a portion of your costs beside the amount covered by the benefit plan, i.e. in forms of deductibles, copayments and coinsurance.
- A copayment amount is what you have to pay your facility, provider or pharmacy after your benefit plan covers a portion of the cost. For example, if you order medicines for home delivery, you have to co-pay an amount of $15 for any generic brand and an amount of $60 for a brand of your preference. In the same way, you have to say a sum of $200 per hospital stay for one person every time you are hospitalized somewhere out-of-network.
Copayment amounts are not reimbursed after you have spent it.
- Deductible amounts are not reimbursed, either. This is a fixed amount of money that you have to pay for your treatment costs before the benefit plan comes into action. Any kind of copayments or coinsurance payments also do not count as a deductible amount. For an in-network provider, the deductible each calendar year is $300 and $400 for providers in out-of-network facilities.
- If you are under a “Self Only” Enrollment, your deductible amount is considered to be suitable for you under the calendar year. You will be eligible for $300 deductible for every in-network providers and $400 for every provider out-of-network. On the other hand, if you are covered under the “Self Plus One” Enrollment, the same deductibles apply.
- Under the “Self and Family” Enrollment, the deductible is considered to be satisfactory for all the members of your family. Your family members are eligible for $600 deductible for in-network providers and $800 deductible for out-of-network providers.
- Coinsurance refers to the percentage of the allowance that Foreign Service members are supposed to pay for getting care, i.e. if you are getting a surgery from an in-network provider, you have to pay 10% of the total cost.
- If your provider decides to waive your deductibles, coinsurances, and copayments, leaving you to pay for nothing, they will actually be violating the law. If this happens, the service will be the one to calculate the amount that can be waived.
- If your in-network provider has asked you to sign a waiver, it might mean that you are accepting responsibility for the whole amount outside what the plan is going to pay. So before signing any kind of waiver with your provider, know that you might have to end of paying for the whole care if your benefit plan is denied.
- Plan Allowances are the amount used to calculate the payment required by covered services. The allowances may vary, so the fee-for-service plan’s allowance comes at different times. When you use an in-network provider, the payment is much lower than when you use out-of-network providers.
- In-network providers always agree to a certain limit when they give you the final bill. This is why, if your treatment is done by an in-network provider, the amount you will have to pay only consists of your deductible and coinsurance amount. For this, you will need to verify that the provider you are seeing comes under your in-network list and keep your Foreign Service Benefit Plan ID card with you at the time. Also, you cannot pay for directly to your in-network provider but wait for the bill to be delivered to the plan.
- Your out-of-network providers, on the other hand, has no limit to the amount they can bill you. If you are using such a provider, you will have to pay the coinsurance and the deductible amount directly before the bill is directly sent to the benefit plan office.
Foreign Service Benefit Summary Offered by AFSPA
The foreign service benefit plan covers most of the treatments and cares you might need in your entire life, and we will be discussing all of those foreign service health plans here.
- Medical Services and Supplies Provided by Physicians and Other Health Care Professionals
Every kind of service rendered by a professional physician, be it at a hospital, a nursing facility, a health care center, a consultation office or the physician’s private home – comes under this benefit plan. This includes the charges of a video consultation for a patient hospitalized outside the US border; it also includes any drugs or any other medical supplies, the physician.
This benefit plan also includes any kind of non-emergency services rendered in a clinic. Telehealth facilities under Doctors of Medicine (MD), Registered Dieticians (RD), Licensed Clinical Social Workers (LCSW) and Psychologists are also included in the benefit plan to members in all 50 states of USA.
If you have to take any tests – blood tests, urine analysis for drug testing, pathology tests, X-rays, CT-Scan, PET Scan and MRI, etc.–can be covered by the plan. This includes Ultra sonogram, EEG, hearing test, Electrocardiogram, mammogram, etc. as well.
For preventive tests such as a complete history and physical checkup, BMI measurement, Complete Blood Count (CBC), screening of different cancers, etc., the Federal Service Benefit plan will also cover you partially.
Children’s immunization services are completely covered by the benefit plan, as well as any doctor’s visits and examinations until they are 22 years old. Any immunization recommended by the Center for Disease Control and Prevention (CDC) fall under this category.
Every kind of care related to childbirth and pregnancy, i.e. prenatal care, laboratory tests, any kind of complications, sonograms, postnatal care as well as delivery, comes under the Federal Service Benefit Plan. Even the purchase or rental of a breast pump can be sponsored by the benefit plan to a certain limit. 48 hours of hospital stay after a vaginal delivery and 96 hours after a cesarean delivery is also covered by the plan.
All kinds of contraceptive drugs, vaginal rings, diaphragms, hormonal patches and cervical caps are also covered by the benefit plan. If you are having infertility problems, all kinds of fertility drugs, hormonal therapy and surgical procedures will be covered by the benefit plan. However, infertility will only be considered if you haven’t been able to conceive after 12 months of trying.
If you are suffering from cancer and need chemotherapy or radiation therapy, all the services will be covered by the benefit plan. This also includes growth hormone therapy, cardiac rehabilitation therapy, renal dialysis, and respiratory and inhalation therapies.
While routine eye checkups are not covered, eyeglasses, accidental ocular injury, glaucoma, and keratoconus treatments are covered by the benefit plan. If you have to go through routine foot care because of peripheral vascular disease or metabolic diseases, your costs will be covered by the plan.
The benefit plan also covers the cost for wigs needed after a chemotherapy session.
- Surgical and Anesthesia Services
Any kind of operative procedures, fractures, correction of strabismus and amblyopia, endoscopy, biopsy, and surgery to remove tumors and cysts are covered by the benefit plan. If all requirements are met, the benefit will also cover gender reassignment surgery.
Bariatric surgery, i.e. surgery to treat morbid obesity is also covered by this benefit plan, but the BMI has to more than 40 to be considered for this service. All kinds of sterilization for both men and women are under this plan, as well. If covered by the “Self and One” or “Self and Family” plan, circumcision of newborn baby will be covered by the plan.
Cosmetic surgery is covered, but only for accidental injuries, not for beautification purposes. Solid organ transplants for the cornea, heart/lung, kidney, intestine, liver, and pancreas are covered by the benefit plan.
All kinds of anesthesia required for the surgery performed in a hospital, nursing facility, ambulance or office will be covered.
- Hospital, ambulance and Nursing Services
Any kind of hospital stay in a ward, a semiprivate room or intensive care, complete will general nursing care and all meals provided in the hospital are included under the Federal Service Benefit Plan. Private rooms are not covered unless the patient requires isolation.
All examinations, tests and rehabilitation services, drugs, dressings and casts, anesthesia, and medical equipment prescribed by the physician also fall under this benefit plan.
If needed, ambulance transportation to nearby health care centers are covered by the plan; this includes air ambulance services, too.
When required, semi-private rooms in a nursing facility is also covered when admission is necessary for a patient
- Accident Services
Every kind of service in a hospital Emergency Room (ER) are covered by the benefit plan. This includes all medical services, supplies, X-ray and laboratory tests, anesthesia, etc. required for the emergency procedure. In case of an accident, ambulance services to the nearest hospital are also covered.
- Mental Health and other Disorder Benefits
Every kind of professionals dealing with mental health, i.e. a psychiatrist, psychologists, social workers, professional counselors or therapists, are covered by this plan. Mental health can also be provided at home if you are home bound or if your physician prescribes it.
If required, psycho-pathological testing is also covered by the plan.
- Prescription Drug Benefits
Only a physician or dentist licensed by the US Government can write the patient a prescription for drugs. You need your Foreign Service Benefit Plan ID card with you when buying the prescribed prescription drugs from a pharmacy. If you purchase the drugs from an in-network pharmacy, your prescriber must also hold a license under the US Government.
You will not be covered if you purchase prescription drugs from an out-of-network provider.
- Dental Benefits
If you need any kind of repair work on your teeth, all services will be covered by the plan, including X-rays, replacement of teeth, partial or full restoration of teeth, etc. Only two preventive care sessions with a licensed dentist will be covered for a person every year, which includes oral exams, cleaning, and surgery.
- Wellness and other special features
Members under the Federal Service Benefit Plan who are over 18 years old and follows a healthy lifestyle can earn up to $250 from the Wellness Incentive Fund when they participate in the “Simple Steps to Living Well Together” Program. For this, a participant need to complete a bio-metric screening test. This reward money will be only available once every year.
How can you fill up a Foreign Service Benefit Plan Claim Form for Covered Services?
You have to visit the official website to fill out a Foreign Service Benefit Plan claim form. You’ll need to fill out the following information in these forms:
- Patient’s name
- Date of Birth
- Address and phone number
- Relationship to Enrollee
- Patient’s ID number
- Name, address and the TIN number of the company/person providing the service
- Type of service
- Charge for Service
- Valid dental or medical code
The decision will be made and notified within 30 days of claiming a service. If the decision takes more time, another 15 days might be needed to come to a final decision. All records of the claim will be kept for future reference. The original records should be kept with the patient and the duplicates sent to the office for safety.
All claims must be made as soon as possible after taking a service, at least before December 31 of the running year. In case the office needs any information, they must be sent as soon as possible.
How can you dispute the claim process?
If the office does not follow required claim process, all appeals must be made directly to the Office of Personal Management (OPM). If the patient or the person enrolled to the benefit plan wishes to file a dispute, they can also do so.
Dispute can be made via the official website with any kind of records, medical certificates and review copies available, by logging in with the given username and password. The dispute must be made within 6 months of the first claim and the request should be sent to Foreign Service Benefit Plan, 1620 L Street, NW, Suite 800, Washington DC 20036-5629.
You should write about why you think the claim was right and our decision was wrong, based on all the rules of the plan. You need to include everything relevant to the claim, from your physician’s letter to bills, medical records, and operative reports.
You will receive another decision within 30 days of the dispute. Within this time, the service plan will pay the claim or send you another denial, or ask for more information.
If you still don’t agree with the decision, you can write again to the OPM for interference in the matter. This must be done within 90 days of the first decision. The OPM will review the dispute and make the final decision.
If the matter is urgent or if you are suffering from any life-threatening illness, you can directly contact the office at 202-833-4910.