16 FAM 530
MEDICAL COVERAGE LIMITATIONS AND CONDITIONS
(CT:MED-50; 06-09-2023)
(Office of Origin: MED)
16 FAM 531 LIMITATIONS
(CT:MED-50; 06-09-2023)
(Uniform/State/USAID/USAGM/Commerce/Foreign Service Corps-USDA)
(Applies to Civil Service and Foreign Service Employees)
Hospitalization and other benefits under the Medical and Health Program are subject to the following limitations:
(1) An unmarried dependent child is covered until his or her 21st birthday. Exception up to the 23rd birthday is made for an eligible family member who travels to post on educational travel orders. If the family member is disabled or is incapable of self-support because of a disabling medical condition at the time of his or her 21st birthday, the employee may request a continuation of hospitalization and other benefits under the Department’s medical program. Such a request must be submitted to the Bureau of Medical Services (MED) and must document the employee family member’s (EFM) disability or incapacity at age 21. Periodically, MED will review the family member’s medical condition or disability to determine eligibility for continuing this benefit. The employee is responsible for informing MED of any changes in the family member’s medical condition that might affect his or her coverage under the program. EFMs eligible for this provision must obtain a valid medical clearance if accompanying the employee to an assignment abroad to be eligible for overseas medical benefits;
(2) The participating agency’s liability as secondary payer is limited to the scope of the underlying policy and the co-pay amounts not covered by the primary insurers (e.g., the participating agencies will not cover outpatient mental health visits in excess of the number of visits covered under the primary insurance plan). Deductibles are not reimbursable;
(3) Covered outpatient treatment is outpatient treatment that is directly related to a hospitalization for an illness, injury, or medical condition incurred, caused, or materially aggravated while stationed or assigned abroad or, if the medical condition is pregnancy, the employee or eligible family member is pregnant while stationed or assigned abroad. Payment for covered outpatient treatment is limited to a maximum of 12 months from the date the U.S. Government issues authorization for the covered outpatient treatment. The Medical Director may extend a patient’s eligible outpatient treatment period, subject to subparagraph (4) of this section, when he or she determines that such treatment is warranted by exceptional circumstances;
(4) The Medical Director may authorize payment for continued outpatient care only until such time that maximum benefit of treatment has been reached. Maximum benefit of treatment is defined as that point beyond which definite medical improvement specifically related to the treatment is unlikely to occur, and further care would be considered supportive or custodial;
(5) MED may authorize payment for outpatient evaluation and treatment for a mental health or substance abuse condition that requires medical evacuation. In such cases, payment for outpatient evaluation and treatment is limited to the time that the patient is on medical evacuation status awaiting a final medical clearance determination;
(6) Payment for cosmetic care or prosthetic care is not authorized, except in cases where the initial need for cosmetic or prosthetic care results from a medical condition or medical treatment authorized under this section;
(7) Secondary payment for dental care is authorized only in cases where the employee or eligible family member is hospitalized as an inpatient;
(8) Claims for payment by an employee for work-related illness or injury caused by or sustained in the performance of duty or temporary duty abroad, must be processed under the Federal Employees Compensation Act through the Office of Workers Compensation Programs (see 3 FAM 3630 and 3 FAH-1 H-3630);
(9) Payment of medical claims may be made only on behalf of a person with a valid medical clearance. If an individual is not covered by health insurance, or is abroad without a medical clearance, the participating agency may advance payment with the issuance of Form DS-3067, Authorization for Medical Services for Employees and/or Dependents, for part or all of the hospital expenses abroad in order to facilitate emergency admission to a medical facility. In such cases, the individual must sign a repayment agreement and will be required to reimburse the agency for advanced expenses either directly or through payroll deductions; and
(10) Benefits under 16 FAM 520, including the issuance of Form DS-3067, do not apply to Foreign Service employees and eligible family members when posted in the United States. Benefits under 16 FAM 520, including the issuance of Form DS-3067, are authorized only while the employee is assigned abroad. This includes periods while on personal leave and rest and recuperation (R&R) at a location abroad. However, if MED determines that an expense is directly related to an illness or injury that was incurred, caused, or materially aggravated while the employee or eligible family member was stationed or assigned abroad or, if the medical condition is pregnancy and the employee or eligible family member was pregnant while stationed or assigned abroad, MED may authorize treatment. Benefits under 16 FAM 520, including the issuance of Form DS-3067, are not authorized for eligible family members attending school in the United States. Benefits under 16 FAM 520, including the issuance of Form DS-3067, are authorized for eligible family members attending boarding school abroad when the employee is assigned abroad.
16 FAM 532 POST SEPARATION BENEFITS
(CT:MED-41; 03-07-2019)
(Uniform State/USAID/Agriculture/USAGM/Commerce)
(Applies to Foreign Service Employees and Civil Service Employees Located in a
Foreign Area)
The Medical Director may authorize payment for the cost of medical evaluation and/or treatment for an employee and eligible family member (EFM) after separation due to resignation, retirement, termination, or for an EFM upon the death of the employee while on active service. This benefit is limited to the following:
(1) Payment of post employment benefits, when authorized, will be made as a secondary payer in accordance with 16 FAM 522;
(2) This benefit is limited to medical evaluation and/or treatment for an illness where treatment has begun at the time of separation and is limited to up to one year from the onset of initiating evaluation and or treatment.
16 fam 533 FINANCIAL ASSISTANCE FOR MEDICAL CARE
16 FAM 533.1 Authority
(CT:MED-41; 03-07-2019)
(Uniform State/USAID/Agriculture/USAGM/Commerce)
(Applies to Foreign Service Employees and Civil Service Employees Located in a
Foreign Area)
The authority for this policy is 5 U.S.C. 5927, as amended by Section 337 of the Foreign Relations Authorization Act, fiscal year 2000.
16 FAM 533.2 Eligibility
(CT:MED-41; 03-07-2019)
(Uniform State/USAID/Agriculture/USAGM/Commerce)
(Applies to Foreign Service Employees and Civil Service Employees Located in a
Foreign Area)
a. Those persons eligible for financial assistance for medical care are U.S. citizen employees who are officially assigned or located outside the United States on U.S. Government authorization, and who require (or have an accompanying family member who requires) specified medical treatment outside the United States.
b. In order for an employee to receive an advance for a family member's medical treatment under this section, such family member must be assigned outside the United States, included on the employee’s travel orders, and in need of specified treatment outside the United States.
c. Other eligible members are nonfamily member U.S. citizen employees hired at post pursuant to Section 311(a) of the Foreign Service Act, i.e., individuals hired under the provision of the Rockefeller Amendment (Rockefeller hires), outside their country of employment, and who require specified medical treatment outside their country of employment.
NOTE: Locally employed staff (LE staff) are eligible for medical emergency assistance under 5 U.S.C. 5927. For guidance on the administration of the LE Staff Medical Emergency Assistance Program, see 3 FAM 7000.
16 FAM 533.3 Purpose
(CT:MED-41; 03-07-2019)
(Uniform State/USAID/Agriculture/USAGM/Commerce)
(Applies to Foreign Service Employees and Civil Service Employees Located in a
Foreign Area)
The purpose of this policy is to provide an advance of up to three months pay to an eligible employee or family member assigned or located outside of the United States on U.S. Government authorization (e.g., on temporary duty) when the employee or family member must undergo outpatient medical treatment in a foreign area.
16 FAM 533.4 General Provisions
(CT:MED-41; 03-07-2019)
(Uniform State/USAID/Agriculture/USAGM/Commerce)
(Applies to Foreign Service Employees and Civil Service Employees Located in a
Foreign Area)
a. Financial assistance for medical care of up to six pay periods may be paid in advance when all of the following conditions are met:
(1) The money is necessary to cover the cost of outpatient medical treatment;
(2) The cost of the treatment exceeds $100;
(3) The money is for treatment where the health care provider requires advance payment or payment at the time of service;
(4) The Department would not otherwise act as a secondary insurer; and
(5) The Department would not otherwise issue a Form DS-3067, Authorization for Medical Services for Employees and/or Dependents, or otherwise advance payment for the treatment.
b. If another medical emergency occurs prior to the time the previous advance is fully paid, the employee will receive only the difference between what currently is owed and the maximum allowable, not to exceed six (6) pay periods. See 4 FAH-3 H-536.3, Issuing Advance of Pay.
c. Payment under this medical emergency assistance section is administered independently of other advance of pay. For regulations pertaining to nonmedical emergency advances of pay, refer to 3 FAM 3280.
d. There shall be no payment under this subchapter if the expenses in question are paid by the U.S. Government under other authority.
16 FAM 533.5 Procedures
(CT:MED-50; 06-09-2023)
(Uniform State/USAID/Agriculture/USAGM/Commerce)
(Applies to Foreign Service Employees and Civil Service Employees Located in a
Foreign Area)
a. Eligible employees (or family members) who require financial assistance for medical care will be required to submit to the principal officer, administrative officer, management officer at post or designee at post of assignment or post nearest to treatment, a signed letter from the treating facility/physician documenting the need for outpatient treatment, including anticipated date and estimated cost of care.
b. Upon receipt of this information, the authorizing officer or designee after consultation with a competent medical authority (e.g., regional medical officer, Foreign Service health practitioner, attending physician or nurse, or the Bureau of Medical Services (MED) in Washington, DC), will arrange for and approve the need for financial assistance for medical outpatient care.
c. If approved, the advance of pay is made directly to the employee via direct deposit if possible. See 4 FAH-3 H-536.3, Issuing Advance of Pay.
d. Also refer to 4 FAH-3 H-536.3 for requirements to request, calculate and process an advance of pay, etc.
e. An eligible employee who wishes to request another advance payment prior to liquidating a current advance of pay may follow the procedures set forth in 4 FAH-3 H-536.3-4.
f. The information is forwarded to the payroll office for processing.
16 FAM 533.6 Repayment
(CT:MED-41; 03-07-2019)
(Uniform State/USAID/Agriculture/USAGM/Commerce)
(Applies to Foreign Service Employees and Civil Service Employees Located in a
Foreign Area)
a. Repayment of financial assistance for medical care under this section shall be made in accordance with the repayment rules for other types of fund advances. See 4 FAH-3 H-536 and 3 FAM 3280. Repayment of advance of pay for financial assistance for medical care is collected on a biweekly basis through deductions from an employee's salary. The deductions from salary will begin on the pay day that falls during the second full pay period following the pay period in which the advance was paid, as cited in 4 FAH-3 H-536 and 3 FAM 3280.
b. Repayment for advances shall be made to the Department of State by payroll deductions in not more than 18 pay periods from the time that deductions commence.
16 FAM 534 through 539 unassigned