Federal retirees and health care payout limits


Q: I am a 69-year-old federal retiree covered by a Blue Cross/Blue Shield Standard Option 105 health plan as well as Medicare Part A. I recently spoke with Blue Cross about reimbursement levels for doctor care when I received a bill from my internist for $400 and Blue Cross paid  $100. According to Blue Cross, I was responsible for the remaining $300 because Congress had passed rules (they may have meant that the Office of Personnel Management generated a rule, I am not sure) that limited the amount they could reimburse Medicare patients for a given procedure. When I checked with OPM, they said that the doctor could only charge me 115 percent of the Medicare level.

I could not get a clear answer from Blue Cross or OPM: Does this mean that any doctor I go to cannot charge me more than 115 percent of the base Medicare amount? What about doctors who do not participate in Medicare? When I asked Medicare, they said that a doctor can charge you more than the 115 percent if you sign a special contract agreeing to pay his bill in full; however, this measure is related to Medicare Part B, not Blue Cross. Before I argue with my internist about the invoice, I would like to know what the law says regarding federal retirees.

A: The rules governing in-patient hospital charges, physician charges, and Federal Employees Health Benefit benefit payments are found in the Code of Federal Regulations 5 CFR 890, Subpart I, beginning at Section 890.901. That document is available here.


About Author

Reg Jones was head of retirement and insurance policy at the Office of Personnel Management. Email your retirement-related questions to fedexperts@federaltimes.com.

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