Federal Employees Health Benefits (FEHB)

Program

Background

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Did You Know?

• Became effective in 1960• Largest employer-sponsored

group health insurance program in the world

• Over 8 million covered lives• FEHB annually provides over

$40 billion in health care benefits

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Who Can Join?

• Urban Indian Organizations carrying out programs under title V of the Indian Health Care Improvement Act (IHCIA)

• Tribes and tribal organizations carrying out programs under the Indian Self-Determination and Education Assistance Act (ISDEAA)

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FEHB Features

• No pre-existing condition limitations

• No waiting periods - immediate coverage upon enrollment

• Enrollee out-of-pocket maximum

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FEHB Features (cont.)

• 95 available plans

• Plans contract with doctors and hospitals (provider network)

• No broker fees

• Disputed claims process

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FEHB Features (cont.)Continuing Coverage

•31-day extension of FEHB benefits (at no additional cost to member)

•Temporary Continuation of Coverage (TCC)

•Conversion to individual contract with your plan

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FEHB Program Benefits

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FEHB Benefits Snapshot• All plans cover:

– Preventive care and immunizations– Medical care– Diagnostic treatment services– Maternity care– Treatment therapy such as chemotherapy,

radiation therapy, and kidney dialysis – Inpatient hospital– Surgical and anesthesia services

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FEHB Benefits Snapshot (cont.)

– Emergency and ambulance service– Prescription drugs– Mental health and substance abuse

treatment– Catastrophic cost protection through out-of-

pocket maximums for covered benefits

The benefit information listed is only a snap shot of benefits available under the FEHB Program.

Each plan’s FEHB brochure is the official statement of benefits.

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Preventive Care

• All FEHB plans cover a wide variety of preventive services with no cost sharing for enrollees

• Services include:– Periodic Physical Exam– Immunizations– Mammograms– Childhood Immunizations– Well Child Care

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Health and Wellness

Most plans offer incentives for participating in the following:

• Disease Management Programs for chronic conditions such as:

–Asthma –Diabetes• Wellness Program• Smoking Cessation • Health Risk Assessment

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Mental Health and Substance Abuse Parity

• Comparability for mental health and medical benefits;

o Same Cost-sharing such as - Deductibles- Coinsurance- Copays

o Same Limitations

- Covered providers- Generally Accepted Treatment

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Tobacco Cessation

• Provided at no cost– Four tobacco cessation counseling

sessions for at least two quit attempts per year

– All seven Food and Drug Administration (FDA) - approved tobacco cessation medications with a doctor's prescription

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Maternity Benefits

• Complete maternity care

– Prenatal

– Delivery

– Postpartum

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Choosing a Health Plan

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What Types of Plans Are Offered?

• Fee-for-Service (FFS) with Preferred Provider Organization (PPO)

• Health Maintenance Organization (HMO)

• Consumer-Driven Health Plan (CDHP)• High Deductible Health Plan (HDHP)

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How Many Choices Are Available?

• Plan Choices– 10 FFS

– 164 HMO

– 15 HDHP

– 13 CDHP

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FFS

• Offers health coverage in which doctors and other providers receive a fee for each service

• All FFS plans offer nationwide and international coverage

• Lower costs if PPO provider is used

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HMOs

• HMO is managed care

• HMOs operate in a specific geographic area (service/enrollment area)

• Generally members must use HMO network providers and get referrals from primary care doctor 21

CDHPs

• Combine traditional health plan with a separate medical fund

• Annual medical fund used first for covered expenses

• When medical fund is exhausted, must meet deductible before traditional health insurance coverage pays

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HDHPs• Provide coverage for high-cost medical

events and a tax advantaged way to build savings for future medical expenses

• 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 including annual deductible

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Ways to Compare Plans

•OPM’s Plan Comparison Tool

•PlanSmartChoice

•FEHB Guide for Tribal Employees

www.opm.gov/tribalprograms

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Eligibility

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Tribal Employee Eligibility

• Eligible– Meet Internal Revenue Service’s “definition”

of common law employee– Meet FEHB requirements for type of

employment

• Ineligible employment types include:– Contract Employees– Intermittent Employees – Tribal Retirees– Volunteers

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Tribal Employee Eligibility

• All tribal employees are eligible based on common law standard

• This includes:

– Full-time

– Part-time

– Seasonal (over 6 months)

– Term

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Family Member Eligibility• Spouse

State-recognized marriages such as: - Common law marriages- Tribal marriages

•Children up to age 26Married children, adopted, recognized natural children, foster children, and stepchildren and children over 26 who are incapable of self-support due to a disability that existed before age 26

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Which Family Members Are Not Eligible?

• Same-sex marriages (Defense Of Marriage Act) or domestic partners

• Grandchildren

• Parents

• Siblings

• Boyfriends, girlfriends, or fiancés

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Enrolling in an FEHB Plan

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FEHB Enrollment Types

• Self Only

• Self and Family (covers anyone who is an eligible family member)

FEHB statute does not permit any other type of enrollment

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When Can Tribal Employees Enroll in FEHB?

• Initial Enrollment Opportunity • New tribal employee (or newly

eligible to enroll)

• Annual Open Season

• Certain Qualifying Life Events (QLEs)

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Standard Form (SF) 2809

Health Benefits Election Form• Tribal employees complete SF

2809 to request a health benefits action

• SF 2809 is located at www.opm.gov/forms/pdf_fil/sf2809.pdf

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SF 2809

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Premium Costs

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FEHB Premiums

• OPM negotiates benefits & rates annually with the plans

• FEHB premiums will be fully funded by the tribal employer and tribal employee contributions with no contribution from the Federal government

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Tribal Employer Contribution

• The Tribal Employer contribution must be at least as much as the Government contribution for Federal employees

• Tribal employers can pay up to 100% of the premium

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How Do Tribal Employees Pay?

• Salary deduction

• Premium conversion

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Roles

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What Does OPM Do?

• Administers contracts with FEHB plans

• Negotiates benefits and rates

• Resolves disputed health benefit claims

• Maintains FEHB tribal website

www.opm.gov/tribalprograms

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What Do Tribal Employers Do?

• Provide general guidance to tribal employees

• Administer Initial Enrollment Opportunity and conduct the annual Open Season

• Withhold premiums

- Inform tribal employees how much they will pay in premiums

- Deposit the total premiums into a bank account for NFC to withdraw the premiums that are due each month

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What Do Tribal Employers Do? (cont.)

• Enter enrollment data into National Finance Center’s (NFC) online enrollment portal called Tribal Insurance Processing System (TIPS)

• Work with NFC and FEHB plans to reconcile enrollments

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What Does the National Finance Center (NFC) Do?

• Receives enrollment data from tribal employers via TIPS

• Transmits enrollment data to health plans

• Collects total premiums due from tribal employer’s designated account

• Transmits premiums to U.S. Treasury which sends them to OPM where funds are distributed to health plans

• Makes enrollment reports available to tribal employers and OPM

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What Do FEHB Plans Do?

• Provide plan brochures• Furnish a plan identification card for

each enrollee/family member• Maintain provider networks• Provide benefits to enrollee and

covered family members• Process claims • Reconcile enrollment records• Reconsider disputed claims

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How Do I Join the FEHB Program?

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Notification of Interest• At least 3 months before the

effective coverage date, notify OPM by either:– Emailing at tribalprograms@opm.gov– Calling the Tribal Desk: 202.606.2530

• OPM confirms the interest– Sends Expressed Interest Fact Sheet

• OPM confirms eligibility– Sends application packet

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Application Package

• At least 2 months before the effective coverage date

• Application Packet– Agreement– Contact Information– Billing Unit Information– Bank Account Information– Temporary Continuation of Coverage

Memorandum of Understanding

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Signed Agreement

• Email tribalprograms@opm.gov– Mail to OPM

U.S. Office of Personnel Management

Federal Employee Insurance Operations

Attn: Demi Mozian

1900 E Street NW, Room 3425

Washington, D.C. 20415

• Receive Acknowledgement Letter from OPM

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Resources

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Resources

www.opm.gov/tribalprograms

•Tribal Programs Listserv– Tribal Benefit Administration Letters

(TBALs)

•Tribal Desk – Phone: 202.606.2530– Email: tribalprograms@opm.gov

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Questions?

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