FEHB and Medicare follow-up


Q. I am following up a July 13 opinion about the allowable charges that FEHB plans can consider when a federal retiree incurs charges from a health care provider. The opinion states that FEHB must apply Medicare allowable rates in determining their plan’s benefits, and does not consider the “actual charge” from the provider. However, my reading of the Federal Register vol. 61, No. 189 (9/27/1996) is that the providers themselves cannot charge the retiree more than the Medicare allowable limits. Therefore, under the law as I understand it, it is illegal for the provider’s “actual charge” to exceed these limits. Is that correct? And if my provider submits a bill that exceeds these limits, am I legally obligated to pay the difference between the “actual charge” and the FEHB determination of the Medicare limit?

A. If your doctors take assignment, they have agreed to accept the Medicare-approved amount as payment in full. If you have nonparticipating doctors, they can bill you up to 15 percent more than Medicare’s official amount for nonparticipating providers for most services and can request full payment upfront for services. If your doctors have opted out of Medicare, they can charge you whatever they want to. They don’t submit any claims to Medicare and aren’t subject to the Medicare law that limits the amount providers may charge patients. If you see such a doctor, you’ll usually pay the entire cost of your care. Medicare will not pay for any of the cost of services you receive.


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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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