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 [email protected]– 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 [email protected]– 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: [email protected]
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Questions?
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