Federal Employees Health Benefits FEHB Program

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• Federal Employees Health Benefits (FEHB) Program

Presented by Mary Hartman
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Introduction

• Federal Employees Health Benefits (FEHB) law
  enacted September 28, 1959
• Enrollments effective 1st pay period that began
  on or after July 1, 1960
• FEHB Program administered by OPM

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Introduction (contd)

• 129 plans (222 choices) in the FEHB Program in
  2006
• Over 4 million enrollees
• 2.2 million employees
• 1.8 million retirees, surviving spouses, other
• Cover more than 8 million lives
• 25 billion in annual premiums

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OPM Responsibilities

• Approve new plans
• Administer contracts with carriers
• Negotiate benefits and rates
• Approve plans FEHB brochure text
• Audit plans
• Monitor plan performance
• Publish FEHB regulations, informational material,
  and forms
• Prepare Open Season materials
• Maintain OPM and FEHB websites

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OPM Responsibilities (contd)

• Maintain the FEHB Fund
• Make final decisions on applicability of the FEHB
  Law
• Report to Congress on the operation and
  administration of FEHB law and plans
• Provide guidance to agencies and plans
• Resolve disputed health benefits claims

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Agency Responsibilities

• Designate a Benefits/Insurance Officer
• Provide FEHB information and ensure employees
  make an informed choice
• Hold health fairs and service days
• Determine employees eligibility to enroll and
  whether family members meet FEHB requirements
• Review enrollment reconsideration requests
• Ensure elections forms are properly completed

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Agency Responsibilities (contd)

• Process health benefits actions and determine
  proper effective dates
• Make belated change determinations
• Determine capability of self-support of children
  over age 22
• Stock and distribute FEHB forms and literature
• Maintain and certify necessary records
• Account for and remit premiums
• Reconcile enrollment records with carriers

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Carrier Responsibilities

• Determine eligibility to enroll in plan
• Furnish a plan identification card to each
  enrollee
• Process claims and/or provide services to
  enrollee and covered family members
• Reconsider disputed claims
• Reconcile enrollment records with agencies
• Print and distribute plan brochures

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Carrier Responsibilities (contd)

• Maintain financial and statistical records and
  report on plan operations
• Develop and maintain effective communication and
  control tools

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Picking a Health Plan

• What types of plans are offered?
• Fee-for-Service (FFS) with Preferred Provider
  Organization (PPO)
• Health Maintenance Organization (HMO)
• Point-of-Service
• Consumer Driven Health Plan
• High Deductible Health Plan
• Which plan is best?
• Highly individualized answer
• Employees must make an informed choice

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FFS Plans

• Nationwide
• Some open to all employees
• Some open only to specific groups
• PPO providers must be used for full benefits
• Fewer costs are incurred if PPO provider is used
• BC/BS Service Benefit Plan Basic requires members
  to use PPO providers or no benefits will be paid
• Some paperwork if PPO provider is not used
• No new FFS plans without change in FEHB law

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HMOs

• Enrollee must live or work in HMOs
  enrollment area to enroll (plan may be changed if
  enrollee or a family member moves)
• Plans operate in a specific geographic area
  (service area)
• Generally members must use the network and get
  referrals from primary care doctor
• Out-of-pocket costs are generally limited to
  copays
• Little, if any, paperwork

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Point of Service (POS)

• A product offered by an HMO that has both
  in-network and out-of-network features
• Network must be used for full benefits
• Going outside the network will cost more
• Little paperwork if the network is used
• Claims must be filed if members do not use the
  network

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Newer Plan Products

• Consumer Driven Health Plans (CDHP)
• Funded health spending account member may use to
  pay for traditional health services and some
  additional care
• When funds in the account are gone, a higher
  deductible must be met before traditional health
  insurance coverage becomes effective
• Service/enrollment area for Aetnas CDHP differs
  from its HMO

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Newer Plan Products (cont.)

• High Deductible Health Plans (HDHP)
• Annual deductible and cost sharing
• Premium contribution to Health Savings Account
  (HSA) or Health Reimbursement Arrangement (HRA)
• Tax-free withdrawals from accumulated funds to
  pay for qualified out-of-pocket expenses

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FEHB Program Features

• No waiting periods
• No pre-existing condition limitations
• Choice of coverage
• Self Only
• Self and Family
• A government contribution of up to 75
• Salary deduction
• On a pre-tax basis, or
• Premium conversion can be waived

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FEHB Program Features (cont.)

• Enrollment opportunities
• Annual Open Season
• Qualified Life Events (QLE)
• Continued Group Coverage
• 31 day extension of coverage
• Temporary Continuation of Coverage (TCC)
• Spouse equity
• Military service
• Conversion to non-group (private) coverage

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FEHB Program Features (cont.)

• Consumer protections
• Appeal rights to OPM if member has a dispute with
  plan over a claim
• Patients Bill of Rights
• Privacy protection of medical information

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FEHB Website

• www.opm.gov/insure/health
• FEHB Handbook
• Frequently Asked Questions
• FEHB Guides
• Plan Brochures
• Links to other sites
• FEHB Law 5 U.S.C. Chapter 89
• FEHB Regulations 5 CFR Part 890

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OPM Website

• www.opm.gov/asd
• Benefits Administration Letters (BAL)
• 200 series FEHB BALs
• 400 series FEHB Open Season BALs
• 300 series Payroll Guidance
• Agency Benefits Officers Listing
• Forms
• SF 2809
• SF 2810

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Contact Information

• For more information
• visit us on the web at
• www.OPM.gov
• mary.hartman_at_opm.gov
• Telephone Number [phone]

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Any FEHB Program questions?