Federal Employees
Health Benefits Program
FEHB Program: General
Description
The FEHB program is open to almost all of
the government’s civilian employees on a voluntary basis.
Exceptions are those workers who are serving their first year
of federal employment under a temporary appointment, employed
on an intermittent basis, or otherwise excluded by law or regulation.
The FEHB contains a number of features that
make it one of the nation’s leaders in the provision of
health insurance. For example:
- within 60 days from the date you enter
the government (or become eligible), you may enroll in a health
benefits plan with group-rated premiums and benefits;
- coverage is provided without a medical
examination or restrictions because of age, current health,
or pre-existing conditions;
- there are no waiting periods for benefits
to kick in after the effective date of enrollment;
- there is catastrophic protection against
unusually large medical bills; and
- you have an opportunity, during annual
open seasons, to enroll in a health benefits plan if you are
not already enrolled, or if you are enrolled, to change to another
plan or option.
The FEHB law mandates that special consideration
be given to enrollees of certain FEHB plans who receive covered
health services in states with a critical shortage of primary
care physicians. FEHB fee-for-service insurers are required to
provide benefits to plan participants in medically underserved
areas who use any health care provider licensed to perform the
specific medical service. The following states are medically underserved
areas under the FEHB program: Alabama, Idaho, Kentucky, Louisiana,
Maine, Mississippi, Missouri, Montana, New Mexico, North Dakota,
South Carolina, South Dakota, Texas, Utah, West Virginia, and
Wyoming.
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FEHB Rules and Procedures
Under FEHB you have a wide selection of plans
from which to choose. Currently, there are nearly 190 health plans
in the program. One is a government-wide plan, 12 are employee
organization plans (only six of which are open to all), and the
rest are health maintenance organizations (HMOs). Any eligible
employee may enroll in the government-wide plan. Generally, to
enroll in an employee organization plan you must be a member of
the organization sponsoring the plan. Some organization plans
are open to all employees; others are restricted to specific agencies
or occupations. HMOs are open to those who live or work within
the geographic area serviced by that particular plan. Consult
the plan brochure for more information.
By enrolling in an FEHB plan, employees have
an opportunity to acquire protection against the cost of health
care service for themselves and their families, including individuals
suffering from prolonged illnesses or involved in serious accidents.
Moreover, these health insurance benefits may be retained by employees
after retirement, if they retire under certain conditions and
meet certain requirements.
The cost of FEHB premiums is shared by the
enrollees and the government, with active employees paying their
share through payroll deductions and retirees through annuity
deductions.
Federal and postal workers also are covered
by Medicare hospital insurance (Part A) for which they pay 1.45
percent of salary each bi-weekly period. Employees become eligible
for Medicare coverage when they reach age 65.
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FEHB Eligibility and Enrollment
Rules
Generally, all federal and postal employees
and retirees, as well as many temporary workers, are entitled
to participate in the FEHB program. Enrollment in an FEHB health
plan is not compulsory, and employees may decline to participate.
(For a list of excepted categories of employees, see 5 CFR 890,
or the FEHB Handbook on OPM’s website at www.opm.gov/insure/health.)
Covered employees also include “cooperatives,”
those who serve “in cooperation” with nonfederal agencies
and who are paid in whole or in part from non-federal funds, such
as certain employees of the Agricultural Extension Service, certain
Agricultural Stabilization and Conservation County Committee workers,
employees transferred to public international organizations under
the Federal Employees International Organization Act, and U.S.
commissioners. When spouses are both government employees, each
may enroll individually or one spouse may enroll for the family.
However, the children of such a couple would be covered only if
one spouse enrolls under the family option; enrolling individually
does not cover children.
If your agency denies you coverage and offers
you no supporting documentation, look up the rule yourself in
the sources mentioned above, or contact your agency’s headquarters
insurance officer.
At the time employees become eligible to enroll,
the employing office provides: (1) an FEHB Guide (RI 70-1 for
current employees, RI 70-8 for certain temporary employees, and
RI 70-9 for retirees and survivors), which explains the health
benefits program, compares the benefits under fee-for-service
plans, and contains rates, and (2) Standard Form 2809, which is
the form used by employees to enroll in a plan or elect not to
enroll. Eligible employees may enroll during the annual open season
or at other specified times.
Employees in an authorized leave-without-pay
or other type of non-pay status generally can continue health
insurance coverage for up to one year of the non-pay period. The
365 days of non-pay status may be continuous or may be interrupted
by periods in a pay status that last less than four consecutive
months. Agencies must give employees the opportunity either to
directly pay their share of the premiums for these periods of
FEHB coverage or to incur a debt to the agency, if the agency
advances their salary in the amount of the worker’s share
of the health premium to cover the cost of extended coverage.
FEHB open seasons for making enrollment changes
are held each year from Monday of the second full workweek in
November through Monday of the second full workweek in December,
or as otherwise announced by the Office of Personnel Management.
During an open season, employees may make enrollment decisions
or changes affecting the health plan coverage of themselves and
their eligible family members.
“Eligible family member” includes
an employee’s spouse and any unmarried dependent children
under the age of 22, including legally adopted children, recognized
children born out of wedlock, and foster children or stepchildren
if they live with you in a regular parent-child relationship.
Unmarried children may be covered regardless of their age if they
are incapable of self-support because of an incapacity that began
before attaining age 22. Parents or other relatives cannot be
covered even though they may live with you.
In some cases, an employee’s former spouse
may be eligible for FEHB coverage. (For details, see 5 CFR 890,
or visit OPM’s website at www.opm.gov/insure.)
Former spouses whose divorce occurred during the spouse’s
federal service should contact the agency that employed the spouse
when the divorce occurred. Former spouses whose divorce occurred
after the spouse’s retirement should contact the Office
of Personnel Management’s Retirement and Insurance Service,
Office of Retirement Programs, P.O. Box 17, Washington, DC 20044;
(202) 606-0500.
Neither employees nor their family members
will be required to pass a physical examination to enroll for
health benefits. Similarly, neither employees nor their family
members can be excluded from joining an FEHB plan because of age
or employment in a hazardous job.
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FEHB Plan Options
The FEHB program generally allows federal
employees and annuitants to choose between fee-for-service plans,
which work on a reimbursement model, and health maintenance organizations
(HMO), which provide comprehensive health care on a prepaid basis
through contracts with physicians and hospitals in a particular
geographic area. The government-wide service health benefit plan
is a fee-for-service plan provided through Blue Cross and Blue
Shield organizations that any employee may join. It is called
a “service benefit plan” because it works on the principle
of paying benefits either to the enrolled participant or directly
to the doctor or hospital that provides the treatment or service.
Blue Cross and Blue Shield also offers a network-only option.
Another type of FEHB fee-for-service plan
is the employee organization plan. Any employee who is a member
of an organization that sponsors a plan approved by the Office
of Personnel Management may enroll in the plan.
In addition to the above plans, the FEHB program
offers employees and annuitants the chance to enroll in a number
of HMOs. Types of HMO options available to FEHB enrollees include:
- Group Practice Prepayment Plans—These
plans have their own medical center or centers and their own
doctors who practice as a group. Employees who live in an area
where there is a group-practice prepayment plan that participates
in the FEHB program may choose to join it instead of one of
the other plans.
- Individual Practice Prepayment Plans—In
these plans, doctors agree to accept payments from the plan
instead of requiring the patient to pay their usual charge.
Like the group practice plans, these plans operate only in certain
areas. Employees residing in a locality that has such an approved
plan may choose to join it.
- "Mixed Model” Prepayment Plans—These
are a combination of group practice and individual practice
plans.
Employees seeking more detailed information
about the types of benefits provided by different plans should
consult the plan brochures that can be obtained from most government
employment offices or from the OPM website at www.opm.gov/insure/health/download_guides.htm.
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FEHB Premium Rates
The premium rates for FEHB plans typically
change each year, following the annual contract negotiations between
OPM and each insurance carrier. Any new plan rates resulting from
these negotiations begin on the first day of the first pay period
in January of the following year for active employees, and Jan.
1 for retirees.
FEHB premium costs are shared by the government
and the participating employee or annuitant. Under the “Fair
Share Formula,” the maximum government contribution is set
at 72 percent of the weighted average cost of all plans, not to
exceed 75 percent of the cost of any specific plan. The enrollee
pays for the balance of the premium cost.
The government contribution is the same for
most federal employees, with the following exceptions:
- Employees appointed under the Federal Part-Time
Career Act of 1978 only receive a portion of the government
contribution paid to full-time employees, with the government’s
share pro-rated in proportion to the percentage of full-time
service regularly performed.
- Temporary employees pay the full premium
(both the employee and government shares).
- The U.S. Postal Service contributes an additional
amount, specified in collective bargaining agreements, toward
the cost of a postal service employee’s enrollment.
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For More Information
You may also learn more about the Federal
Employees’
Health Benefits Program in the current edition of the Federal
Employees Almanac. |
