UNCLASSIFIED (U)

16 FAM 520

RESPONSIBILITY FOR PAYMENT OF MEDICAL EXPENSES

(CT:MED-41;   03-07-2019)
(Office of Origin:  MED)

16 fam 521  applicability

(CT:MED-41;   03-07-2019)
(Uniform/State/USAID/USAGM/Commerce/Foreign Service Corps-USDA)
(Applies to Civil Service and Foreign Service Employees)

a. The individual is responsible for all medical expenses related to outpatient care, except when associated with a hospitalization as defined by the insurance company’s Explanation of Benefits (EOB), i.e., the insurance company makes the determination.

b. U.S. Government agencies that participate in the Department of State’s Office of Medical Services medical program abroad will act as a secondary payer for hospitalizations and related outpatient medical expenses provided that the insurance acts as a primary payer and the individual has met their annual insurance deductible.

c.  An individual without medical insurance or whose insurer refuses to act as a primary payer is responsible for all medical expenses.

16 fam 522  responsibility

(CT:MED-41;   03-07-2019)
(Uniform/State/USAID/USAGM/Commerce/Foreign Service Corps-USDA)
(Applies to Civil Service and Foreign Service Employees)

a. Each employee and eligible family member participating in the Medical and Health Program should obtain health insurance coverage, whether under the Federal Employees Health Benefits Program (FEHBP) or by contract with a private insurer.

b. U.S. Government agencies that participate in the Department of State Medical and Health Program serve as secondary payers (with the exception of deductibles and other limitations as noted in 16 FAM 531) for inpatient hospital and related outpatient medical expenses of employees and eligible family members who are covered by medical insurance where the following conditions are met:

(1)  The illness, injury, or medical condition giving rise to the expense is incurred, caused, or materially aggravated while the eligible individual is stationed or assigned abroad or, if the medical condition is pregnancy, the employee or eligible family member is pregnant while stationed or assigned abroad;

(2)  The insurance company reimburses for hospitalization; and

(3)  The Office of Medical Services (MED) or a Foreign Service medical provider (FSMP) is notified and approves hospitalization.  Even with the MED or FSMP approval, there will be no secondary coverage if the insurance company refuses later to become the primary payer.

c.  The outpatient expenses directly related to the condition for hospitalization will be covered for up to 1 year from the date of the hospitalization or the date of the first related outpatient visit claimed by the individual, whichever came first.  Any outpatient evaluation that led to the hospitalization may be claimed but must have occurred within 1 month of the hospitalization.  Exception of the 1-month limitation is made for pre-natal care.

d. MED or an FSMP at post may authorize medical travel for an eligible medical program participant in accordance with the medical travel regulations (see 16 FAM 310).

e. If the employee or eligible family member is not covered by primary health insurance, the employee is responsible for all medical costs.  However, in the event of a medical emergency, the Office of Medical Services or a Foreign Service medical provider may authorize issuance of Form DS-3067, Authorization for Medical Services for Employees and/or Dependents, to secure admission to a hospital located abroad or in the United States while on medical travel provided the employee signs a repayment agreement.   Reimbursement may be made directly or through payroll deductions from the employee’s salary.

16 FAM 523  AUTHORIZATION FOR MEDICAL SERVICES FOR EMPLOYEES AND ELIGIBLE FAMILY MEMBERS

(CT:MED-41;   03-07-2019)
(Uniform/State/USAID/USAGM/Commerce/Foreign Service Corps-USDA)
(Applies to Civil Service and Foreign Service Employees)

a. The Office of Medical Services (MED), principal officer, management officer at post, or designee has the authority to issue Form DS-3067, Authorization for Medical Services for Employees and/or Dependents (eligible family members), to secure admission to a hospital located abroad.  MED has the authority to issue Form DS-3067 for hospitalizations in the United States.

b. The principal officer or management officer at post will consult with the Foreign Service medical provider (FSMP) or post medical advisor (PMA) before issuing a Form DS-3067.  In an emergency, when time does not permit consultation, the authorizing officer may issue a Form DS-3067, providing the principal or management officer at post notifies the FSMP or PMA as soon as possible following such an issuance.

16 FAM 524  ACCOUNTABILITY FOR PAYMENT OF MEDICAL EXPENSES

(CT:MED-41;   03-07-2019)
(Uniform/State/USAID/USAGM/Commerce/Foreign Service Corps-USDA)
(Applies to Civil Service and Foreign Service Employees)

a. When the U.S. Government pays for hospitalization first (e.g., pursuant to Form DS-3067, Authorization for Medical Services for Employees and/or Dependents), then the employee must reimburse the U.S. Government either by insurance payment or directly by the employee, except for the amount of such expenses the U.S. Government is obligated to pay under these regulations.  When the U.S. Government pays the medical expenses of an individual who is covered by insurance, that individual must promptly claim his or her benefits under the insurance policy.  As soon as the individual receives the insurance payment, the individual must reimburse the U.S. Government for the full amount of the insurance due under his or her policy plus any annual deductible that has not been met prior to this claim.   If the insurance company allows, the individual may direct the company to reimburse the U.S. Government directly by having the check sent to the appropriate U.S. embassy.  If an individual is not covered by insurance, he or she must reimburse the U.S. Government for the entire amount of all medical expenses.

b. In the event an employee or eligible family member fails to recover insurance payments or transfer the amount of such payments to the appropriate U.S. Government agency within 90 days of initial funding, the U.S. Government may take appropriate action to collect the payments due, unless such failure is for reasons beyond the control of the employee or the eligible family member (see also 4 FAM 445).

b. In the event an employee or eligible family member fails to recover insurance payments or transfer the amount of such payments to the appropriate U.S. Government agency within 90 days of initial funding, the U.S. Government may take appropriate action to collect the payments due, unless such failure is for reasons beyond the control of the employee or the eligible family member (see also 4 FAM 445).

c.  CGFS/F is the responsible office for collection of medical debts referred by the Office of Medical Services (MED).  MED will submit appropriate documentation to CGFS/F and request that a medical accounts receivable be set up.  Once this account is set up, CGFS/F will monitor the collection and/or refer the claim to the U.S. Department of Treasury for collection.

d. The management officer at post is responsible for submitting the following documents to the Office of Medical Services (MED) within 60 days from the time of the patient’s discharge from the treating facility:

(1)  A final accounting of medical expenses paid;

(2)  A copy of Form DS-996, Medical Care at Government Expense, signed by the patient and the insured;

(3)  A copy of the insurance claim form; and

(4)  A copy of Form DS-3067, Authorization for Medical Services for Employees and/or Dependents, with a signed release authorizing MED to review the status of claim payments and release necessary information related to the claim.

e. Employees departing post are required to settle all hospitalization and/or medical accounts prior to departure.  An employee who is insured must provide proof to post administration that those insurance claims have been submitted to the insurance carrier and that a signed repayment agreement is on record.

16 FAM 525  through 529 unassigned

UNCLASSIFIED (U)