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Benefits

Health Benefits

Federal Employees Health Benefits Program (FEHB)

FEHB offers eligible employees a choice of plans and options. The Government contributes up to 75% toward the cost of the premiums while employees pay the remaining balance through payroll deductions. FEHB offers immediate coverage from the effective date of enrollment without a medical examination or restrictions because of age or physical condition.

For detailed information, please visit the Office of Personnel Management's (OPM) web site at www.opm.gov/insure/health/ or contact a member of the Retirement and Benefits Staff by calling (301)504-1512.

Types of Plans

The plans under FEHB are divided into 3 categories: Fee-for-Service Plans, Point-of- Service (POS) Product, and Health Maintenance Organizations (HMOs).

Fee-for-Service Plans - Under a fee-for-service plan, employees or health care providers are reimbursed for covered services, and employees are able to choose their own physician, hospital, and other health care providers.

Point-of-Service (POS) - Members have the option of using a selected network of providers which will minimize out-of-pocket expenses, or you can use out-of-network providers, in which case you will be subject to substantial out-of-pocket costs (i.e., deductibles, co-insurance, co-payments).

Health Maintenance Organizations (HMO) - Prepaid health plans that provide a comprehensive array of medical services provided through contracted physicians, hospitals, and other providers.

IMPORTANT: Be sure you live (or work, when applicable) in the service area before enrolling in a POS or HMO plan. Check the "Service Area" on the plan brochure.

Eligibility

All employees are eligible to enroll in a health benefits plan, with a few exceptions. Those exceptions include: employees serving under an appointment limited to 1 year or less and who have not completed 1 year of current continuous employment; employees who are expected to work less than 6 months in each year; non-full-time employees; without a prearranged regular tour of duty; and employees paid on a contract or fee basis.

Employees may enroll for self only coverage or for self and family. Under the FEHB law, the definition of "member of family" is:

1.  The spouse of an employee or annuitant.

2.  An unmarried dependent child under 22 years of age, including an adopted child or recognized natural child; or a stepchild or foster child but only if the child lives with the employee or annuitant in a regular parent-child relationship.

3.  An unmarried dependent child regardless of age who is incapable of self-support because of mental or physical disability which existed before age 22.

The employee should list eligible dependents on the enrollment form to obtain insurance benefits for them. The employing agency is responsible for determining the eligibility of family members. Specific information must be submitted to the employing agency to document eligibility in the following situations:

1.  Common law spouse: Proof of a state-acknowledged common law marriage must accompany the enrollment form.
 
2.  Disabled dependent child, age 22 or older: Medical certification of the mental or physical disability that existed prior to age 22. Specific, detailed information is required. Please contact your personnel office for more information.

3.  Legally adopted or foster children: Copies of adoption, guardianship, or foster parent status must accompany the enrollment form. In the absence of a court order granting full, permanent custody of a foster child, the employee must provide proof of the child's financial dependency on the employee and complete a document certifying (1) his/her intent to raise the child into adulthood, (2) that he/she has provided the agency with proof of financial dependency, and (3) that the child is living in a regular parent-child relationship with the employee.

NOTE: The Office of Personnel Management has determined that an employee's grandchild may be covered under the provisions for a foster child if all requirements detailed above concerning financial dependency, living in a regular parent-child relationship, and the intent to raise the child into adulthood are met. If the natural parent of the grandchild (the employee's child) meets the definition of an unmarried, dependent child under the age of 22 (meets the eligibility requirements for coverage under the employee's FEHB coverage), it is assumed the grandchild meets the financial dependency requirements. If the natural parent does not meet these requirements, the employee must provide proof of the grandchild's financial dependency. In either case, the certification must be completed.

If an employee is already covered under self and family enrollment, he/she should not complete a new SF-2809 to add a new family member. If the new family member is a spouse or natural child, the employee should contact the insurance carrier directly to provide documentation of the family member's eligibility (marriage certificate, birth certificate). To add all other family members, (step-child, foster child, common law spouse), the employee should provide documentation to the employing agency.

NOTE: It is the employee's responsibility to be informed about his/her health benefits coverage. The employee is responsible for advising the employing office when a spouse loses coverage due to divorce or annulment or a child loses coverage due to marriage, attainment of age 22, or no longer being financially dependent on the employee. The employing agency will then provide information concerning conversion and temporary continuation of benefits to the family member(s) losing coverage. If the employee does not advise the employing office within 60 days of the event that causes the family member's loss of coverage, the family member's eligibility to temporarily extend coverage ends.

Enrollment Procedures

To enroll in a FEHB plan, eligible employees must submit a FEHB Registration Form (Standard Form SF-2809).

NEW EMPLOYEES must submit their registration form within 60 calendar days of their Entrance on Duty (EOD) date. The registration form is a multiple-page form, which should not be separated. New employees who do not submit their forms within 60 days must wait for the next FEHB Open Season or until they meet one of the requirements for a permissible change. All new employees eligible for Federal benefits who choose not to enroll in a FEHB plan must complete a SF-2809 to certify that they elect not to enroll in the FEHB program.

Effective Dates

Enrollment in a FEHB plan becomes effective on the first day of the pay period after the employee's enrollment form is received in the employing office and follows a pay period during any part of which you were in a pay status (Exception: Open Season changes in enrollments become effective the first pay period in January. New enrollments during Open Season are effective the first pay period in January that follows a pay period any part of which you were in a pay status). New employee elections do not become effective on the employee's first day of employment.

Employees should receive a health insurance identification card from the insurance plan within six weeks of their enrollment. An additional identification card will be provided when an employee elects family coverage.

The deductions for the FEHB plan appear an the employee's Earning and Leave Statement the pay period in which the enrollment became effective. Keep in mind that you are paid 10 days after the pay period ends. If a deduction does not appear then, employees should notify their personnel liaison.

Claims

Procedures for submitting claims vary depending on the elected plan. The booklet describing the FEHB plan should be consulted for specific claim submission procedures.

Part-Time Employees

Part-time employees do not receive the full government contribution toward the FEHB premium. The governments contribution will be a prorated amount based on the employees regularly scheduled hours. For example, an employee scheduled to work 60 hours per pay period is equal to 75% of a full-time employee (60 divided by 80). The employee receives 75% of the government contribution and must pay the regular employee premium plus 25% of the government contribution.

Leave Without Pay (LWOP)

Generally, your enrollment may continue for up to 365 days of Leave Without Pay (LWOP) unless you want it to terminate or do not respond to your employing office's notice about continuing coverage during a period in LWOP status. You must pay the employee share of premiums for every pay period that your enrollment continues.

Termination: Your enrollment will terminate at the end of the pay period which includes the 365th day in consecutive LWOP status. You will have a 31-day extension of coverage and conversion rights.

4-Month Rule: The 365 days of continued enrollment during LWOP status is not considered to be broken by any period(s) in pay status of less than 4 consecutive months. If you are in LWOP status and return to pay status for less than 4 consecutive months, then return to LWOP status, you do not begin a new 365-day period of continued enrollment. Instead, the second (and any other) period in LWOP status is treated as continuation of the first. If you are in a pay status during any part of a pay period, the entire pay period is not counted toward the 365-day limit. If you return to pay status for at least 4 consecutive months during which you are paid for at least part of each pay period, you are entitled to begin a new 365-day period of continued enrollment while in LWOP status.

Return to Pay Status After 365 Days in LWOP Status: If your enrollment terminated because you exhausted the 365 days continuation of coverage while in LWOP status, you must elect to enroll when you return to pay status (if you are eligible). If you enroll, and then work less than 4 months, your enrollment must again be terminated on the last day of your last pay period in pay status. You are not eligible for another 365-day period of continued coverage unless you are in pay status for at least 4 months.

If you elect to continue coverage during LWOP status or insufficient pay, you can choose either to pay the premiums directly or to incur a debt.

Pay-As-You-Go Option: Under this option, you pay your share of FEHB premiums directly to your employing agency while on LWOP. These payments generally will be made with after-tax monies, since there is no pay from which to make deductions. If you choose this option, you are agreeing that if you do not pay the premiums, you will be incurring a debt to your employing office. You will have to repay this amount once you return to pay status. If you do not return to work or your employing office cannot recover the debt in full from your salary, it may recover the debt from:

    a lump sum payment of accrued leave;

    income tax refunds;

    amounts payable under the Civil Service Retirement System (CSRS) or the Federal Employees Retirement System (FERS);

    any other source normally available for the recovery of a debt due the United States.

Catch-up Option: Under the catch-up option, you agree in advance of the LWOP period that:

    You will continue FEHB coverage while on leave without pay;

    Your employer will advance your share of FEHB premiums to OPM during your LWOP period; and

    You will repay the advanced amounts when you return from LWOP

    The repayment of the amount owed will be treated on a pre-tax basis, if it's deducted from pay and you participate in premium conversion at the time the deduction is made. If you choose to repay the amount owed to your agency directly out-of-pocket your taxable income is not reduced.

Prepay Option: Your agency may (but is not required) to offer you the option to prepay your FEHB premiums from salary before you go on a period of LWOP. The amount of FEHB premiums you prepay in advance may either be deducted from your pay or paid directly "out-of-pocket" to your agency. Payments made "out-of-pocket" do not reduce your taxable income. The amount of FEHB premiums that you prepay will be treated on a pre-tax basis, if it is deducted from your pay and you participate in premium conversion. IRS rules limit the amount you may prepay on a pre-tax basis. If your period of LWOP will span two tax years, the amount that you may prepay on a pre-tax basis may not exceed the amount of FEHB premiums due for the remainder of the current tax year. If you wish to prepay the amounts due for the subsequent tax year as well, the deductions must be made after-tax. You may use the "pay-as-you-go" or "catch-up" options for amounts due in the subsequent tax year.

EXCEPTION: If an employee is receiving compensation benefits from the Office of Worker's Compensation (OWCP), the premium will be withheld from that benefit while on LWOP.

Separations

Retirement - Employees who have been enrolled or covered by the FEHB program for 5 continuous years immediately prior to retirement, or have been enrolled from their first opportunity, are eligible to continue their health insurance into retirement. Employees must also meet the age and length of service eligibility requirements for an immediate retirement benefit.

Death - The spouse and/or eligible unmarried, dependent children under the age of 22 are entitled to continue the FEHB coverage of an employee or annuitant who dies if (1) the individual was covered by the deceased's FEHB self and family coverage, and (2) the individual is eligible for a survivor annuity (includes the death benefit under FERS.

Transfers - When an employee transfers to another Federal agency, the FEHB coverage also transfers. A transfer does not afford the employee an opportunity to enroll if coverage was previously waived nor to change enrollments (unless the transfer involves a move outside the service area for an employee enrolled under a POS or HMO plan).

Other Separations - FEHB coverage terminates the last day of the pay period in which the employee separates. The employee's coverage is temporarily extended for a period of 31 days, at no cost to the employee. During this 31 day period, the employee may convert to a non-group (individual) contract with the same health carrier. The health carrier must insure the individual regardless of health status. The benefits and premiums under a non-group contract will differ from those under the FEHB Program. The separating employee also has the option to temporarily continue coverage with any plan that he/she is eligible for under the FEHB Program. The employee must elect coverage under Temporary Continuation of Coverage (TCC) provisions within 60 days of the loss of coverage or the date notification of eligibility for TCC coverage is received from the employing agency, whichever is later. A TCC packet will be provided to the separating employee that provides all necessary information and forms. TCC coverage is effective on the 32nd day after loss of coverage as an employee (day after temporary 31 day extension of coverage) to avoid a lapse of health benefits coverage. A separating employee may continue TCC coverage for a maximum of 18 months.

Temporary Continuation of Coverage
(TCC) for Dependents

Former spouses (except those whose loss of coverage results from the death of the employee or annuitant and who are ineligible for a survivor benefit) and dependent children are entitled to elect TCC coverage if their coverage as a family member terminates for any reason other than cancellation. It is the employee's responsibility to notify the employing agency within 60 days of the loss of coverage. TCC benefits for a former spouse or eligible dependent may continue for a maximum of 36 months.

Opportunities to Enroll
or Make Changes in Enrollment

Initial opportunity to enroll - An employee who becomes eligible may elect to enroll within 60 days after becoming eligible.

If an employee is not covered under the Health Benefits (HB) Premium Conversion Plan, he/she may change from Family coverage to Self-Only coverage at any time. If under the HB-Premium Conversion Plan, an employee can change enrollment if one of the requirements for a permissible change after a life event occurs. All other changes must be made during open season.

Open Season - You may enroll during the open season if you are an eligible employee. If you are enrolled, you may change plans, options, type of enrollment, or premium conversion status.

Change in Family Status (Marriage, divorce, death of eligible family member, birth of child) - An eligible employee may enroll and an enrolled employee may change the enrollment from self only to self and family, change from one plan or option to another, or make any combination of these changes, when the employee's family status changes. Time Limit: From 31 days before to 60 days following the date of change in family status.

Change in Employment Status - An eligible employee may enroll and an enrolled employee may change the enrollment from self only to self and family, change from one plan or option to another, or make any combination of these changes, when the employee's employment status changes. Examples of qualifying employment status enrollments or changes that may be made within 60 days following the event are:

    1.  Return to pay status following loss of coverage due to expiration of 365 days in leave without pay or the election to terminate coverage while in a leave without pay status.

    2.  Re-employment after a break in service of more than 3 days.

    3.  Restoration to duty after serving in the uniformed services.

    4.  Change from temporary appointment where employee pays full premium to appointment where eligible to receive Government contribution.

    5.  Change to part-time career employment from full-time employment or to full-time employment from part-time career employment.

    6.   An employee who transfers from a post of duty within a State of the United States or the District of Columbia to a post of duty outside a State of the United States or District of Columbia (or reverse) may enroll or change enrollment within 31 days after leaving the old post of duty and ending 60 days after arriving at the new post of duty.

    7.   An employee who is separating from Federal employment and who is pregnant or whose spouse is pregnant may enroll or change enrollments during his or her final pay period of employment.

Loss of Coverage Under FEHB or Under Another Group Insurance Plan - An eligible employee may enroll and an enrolled employee may change the enrollment from self only to self and family, change from one plan or option to another, or make any combination of these changes when the employee or an eligible family member of the employee loses coverage under the FEHB Program or another group health benefits plan. Examples of qualifying loss of coverage events that allow enrollment or changes to enrollment beginning 31 days before the date of loss of coverage and ending 60 days after the loss of coverage are:

    1.  Loss of coverage under another FEHB enrollment due to termination, cancellation, or change to self only coverage of the covering enrollment.

    2.  Loss of coverage under another federally-sponsored health benefits program.

    3.  Loss of coverage due to the termination of membership in an employee organization sponsored or underwritten FEHB plan.

    4.  Loss of coverage due to the discontinuance of an FEHB plan in whole or in part.

    5.  Loss of coverage under the Medicaid program or a similar State-sponsored program of medical assistance for the needy.

    6.  Loss of coverage under a non-Federal group health plan.

    7.  Loss of coverage under a non-Federal group health plan because the employee moves out of the commuting area to accept another position and the employee's non-federally employed spouse terminates employment to accompany the employee. Time Limit: Beginning 31 days before the date the employee leaves employment in the old commuting area and ending 180 clays after entry on duty at the place of employment in the new commuting area.

    8.  Move from comprehensive medical plan's service area. An employee who is enrolled in a comprehensive medical plan who moves or becomes employed outside the service area of the plan may change the enrollment upon notifying the employing office of the move or change of place of employment. Similarly if the employee's covered family member moves outside the area (for example, covered child who goes to college), the employee may change the enrollment upon notifying the employing office.

    9.  On becoming eligible for Medicare -. An employee may change the enrollment from one plan or option to another at any time beginning on the 30th day before becoming eligible for coverage under Medicare.

    NOTE: A CHANGE OF ENROLLMENT BASED ON BECOMING ELIGIBLE FOR MEDICARE MAY BE MADE ONLY ONCE.
     
    10.  Salary of temporary employee insufficient to pay withholdings. If the salary of a temporary employee who is eligible for FEHB coverage after one year of employment and who must pay the entire premium is not sufficient to pay the withholdings for the plan in which the employee is enrolled, the employing agency will notify the employee of the plans available at a cost that does not exceed the employee's salary. The employee may enroll in another plan whose cost is no greater than his/her salary within 60 days after receiving notification from the employing office.

For detailed information, please visit the Office of Personnel Management's (OPM) web site at www.opm.gov/insure/health/ or contact a member of the Retirement and Benefits Staff by calling (301)504-1512.

 

Last Updated: 08/21/2008