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 companys Explanation of Benefits (EOB), i.e., the
insurance company makes the determination.
b. U.S. Government agencies that participate in the
Department of States 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 employees 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 patients 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