16 FAM 530
MEDICAL COVERAGE LIMITATIONS AND CONDITIONS
(CT:MED-41; 03-07-2019)
(Office of Origin: MED)
16 FAM 531 LIMITATIONS
(CT:MED-41; 03-07-2019)
(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 Departments medical program. Such a request must be submitted to the
Office of Medical Services (MED) and must document the employee family members
(EFM) disability or incapacity at age 21. Periodically, MED will review the
family members medical condition or disability to determine eligibility for
continuing this benefit. The employee is responsible for informing MED of any
changes in the family members 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 agencys 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 patients 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 employees 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-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. 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 Office 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