FEHB Program Handbook Introduction

General Overview

The Federal Employees Health Benefits (FEHB) Program became effective in 1960. It is the largest employer-sponsored group health insurance program in the world, covering over 8 million Federal employees, retirees, former employees, family members, and former spouses.

Law and Regulations

Public Law 86-382, enacted September 28, 1959, created of the FEHB Program; the current law governing the Program is chapter 89 of title 5, United States Code. The 1959 Act became effective generally on the first day of the first pay period that began on or after July 1, 1960. It authorized the Civil Service Commission (now the Office of Personnel Management) to write any regulations necessary to carry out the Act. These regulations are in part 890 of title 5 and chapter 16 of title 48, Code of Federal Regulations.

FEHB Handbook

This Handbook provides the policies and procedures of the FEHB Program and provides additional guidance to those enrolled in the FEHB Program and their employing offices. These policies and procedures reflect operations under title 5, United States Code. This guidance does not cover any authority that individual agencies, such as the U.S. Postal Service, may have under different laws.

Enrollment

As a Federal employee, you are entitled to enroll yourself and cover any eligible family members in a health plan offered under the FEHB Program, unless your position is excluded from coverage by law or regulation. If you meet the requirements, you will be eligible to continue group coverage into retirement.

There are three types of enrollment: Self Only, Self Plus One and Self and Family. A Self Plus One enrollment covers you and one eligible family member you designate to be covered. A Self and Family enrollment covers you, your spouse, and your children under age 26.

Premiums

Each health plan carrier under the FEHB Program charges a different premium. The Government pays up to 75% of the cost of your health benefits coverage, and you pay the remainder, based on a formula set by law.

Who Provides the Coverage?

Over 200 health plans choices are offered under the FEHB Program. Of the available fee-for-service plans, several are open to all enrollees, while others are available only to specific categories of employees. In addition, health maintenance organizations (HMOs) are available in most areas of the United States; you must live or work within a defined area to be eligible to enroll in a particular HMO.

Opportunities to Change Coverage

Each year, an Open Season is held for FEHB Program enrollees to change health plans and/or the type of enrollment they have. Eligible employees may also enroll during this time. Open Season runs from the Monday of the second full workweek in November through the Monday of the second full workweek in December.

There are limited opportunities to enroll, cancel your enrollment, or change your enrollment outside of an Open Season.

Contractual Benefits

Each carrier contracts with the Office of Personnel Management to provide certain health benefits to all persons who enroll in its participating plan. Contract negotiation is a bilateral process, and both OPM and the carrier must approve the final contract. Contract periods are usually one year. Individual policies or contracts are not issued to FEHB Program enrollees.

Once benefits have been agreed upon, OPM and each carrier jointly prepare a brochure describing each plan approved under the FEHB Program. This brochure is intended to be a complete statement of benefits available to the enrollee, including the plan's benefits, limitations, and exclusions.

Legal Actions

The District Courts of the United States have original jurisdiction, concurrent with the United States Court of Federal Claims, in any civil action or claim against the United States founded upon the law. Actions to recover on claims for health benefits must be brought against OPM. Actions to review the legality of OPM's regulations or a decision made by OPM must be brought against OPM. Actions to compel enrollment must be brought against the employing office that made the enrollment decision.

Garnishment

Your plan's carrier may garnish your pay to collect debts you owe to it. Garnishment could occur, among other reasons, if you fail to pay deductibles and copayments or if the carrier overpaid claims in error. Federal employee retirement benefits may not be garnished for this purpose.

Your employing office must follow the provisions of 5 CFR part 582 to process a garnishment. These regulations protect some pay from garnishment, such as amounts to cover health benefits premiums and Basic life insurance withholdings. However, amounts to cover Optional life insurance withholdings are not protected. See the FEGLI Handbook for additional information about the effect of garnishment on life insurance coverage.

OPM Responsibilities

OPM has the overall responsibility for the administration of the FEHB Program. This includes:
• contracting for and approving or disapproving carriers for participation in the FEHB Program;
• negotiating benefit and rate changes with carriers;
• approving the certified text on benefits for the brochures;
• publishing FEHB regulations, instructions, forms, and documents;
• receiving and depositing premium withholdings and contributions, remitting premiums to carriers, and accounting for the Employees Health Benefits Fund;
• making final determinations of the applicability of the FEHB law to specific employees or groups of employees;
• studying and evaluating the operation and administration of the FEHB law and the plans offered under it, and reporting findings to Congress;
• ordering corrections of administrative errors if it would be against equity and good conscience not to do so;
• providing guidance to agencies;
• auditing carriers' operations under the law;
• resolving disputed health insurance claims between the enrollee and the carrier;
• conducting employing agency FEHB responsibilities for retired employees and survivor annuitants.

Agency Responsibilities

Headquarters Benefits Officer

The head of each agency must designate a person to serve as the headquarters benefits officer (Benefits Officer) for the agency. The agency head must notify OPM in writing of the designee's name or any change in the designation. The Benefits Officer is OPM's contact for agencywide insurance matters.

Agency heads can send their notification to Office of Personnel Management, Retirement and Insurance Service, Agency Services Division, P.O. Box 57, Washington DC 20044 or fax the notification to 202-606-1108.

Field Installation Responsibilities

The head of each agency must arrange for the designation of employees at the employing office level. This person will be responsible for explaining the FEHB Program to employees and other eligible persons. He/she will determine individual eligibility for enrollment, effective dates of health benefits actions, and other related matters.

An agency may also delegate responsibility for counseling and advising employees and maintaining records to decentralized local operating offices or field installations or provide the services in some other way.

Information and Counseling

Each agency has a responsibility to provide health insurance information and counseling to its employees. Agencies must become especially familiar with the participation requirements for continuing FEHB coverage into retirement and make this information available to employees, especially those considering retirement. OPM encourages agencies to develop counseling programs that meet the needs of their own employees. While these services must be provided, agencies are using many different approaches. Specific information on resources within your agency should be available to you at your work site.

Contacts between Employees and Carriers

Authorized agency insurance officials should develop contacts with carrier representatives to assist their employees. These contacts must be limited to agency personnel who have FEHB Program responsibilities and to those employees enrolled in the carrier's plan, except during an Open Season. An agency may allow carrier representatives on agency premises to help enrollees with claim or service problems.

A carrier representative may give information only about the plan's benefit provisions and claim procedures. Carrier representatives must be qualified to explain and assist with problems involving the plan's benefit structure and claims procedures and they must confine themselves to these matters. If you have any other questions, such as questions on the law, the regulations, or the FEHB Program in general, you should ask authorized agency insurance officials.

Carrier representatives may address groups of employees during Open Seasons about their plan's benefits structure, methods of obtaining services, and similar matters. An agency may allow the use of its facilities or services for the distribution of OPM-authorized, carrier-supplied information on health benefits plans. An agency must treat employee organization carriers in accordance with current policies on labor-management relations in the Federal service, found in chapter 71 of title 5, United States Code.

Distribution of materials is limited to official brochures and other carrier-supplied information on a health insurance plan that the carrier certifies are in compliance with OPM's supplemental literature guidelines.

Employing Office Questions

Employing office questions concerning the FEHB Program must be directed to the headquarters Benefits Officer. This person may refer questions to OPM's Insurance Services Program. Questions about the benefits or claims procedure of a specific plan should be directed to a local office of that plan.

Other Agency Responsibilities

Agencies also are responsible for:

• providing eligible persons with information on their rights and responsibilities under the FEHB Program and ensuring that they have free choice among all plans in which they are eligible to enroll;
• determining the eligibility or ineligibility of, and enrolling employees, former employees, former spouses, and children (including decisions on belated enrollment and change of enrollment requests);
• reviewing enrollment reconsideration requests;
• ensuring that election forms are properly completed, including the enrollee's social security number;
• processing health benefits actions and determining proper effective dates;
• determining capability of self-support of children 26 and over;
• stocking and distributing health benefits forms and literature;
• maintaining a controlled system of transmitting health benefits enrollment information to carriers;
• remitting and accounting for withholdings and contributions;
• maintaining and certifying necessary records;
• working with carriers to reconcile enrollment records.

Carrier Responsibilities

Each carrier is responsible for:

• adjudicating claims of, and providing health benefits to, enrollees and covered family members in accordance with its contract with OPM;
• typesetting, printing, and distributing brochures;
• furnishing each person enrolled in its health plan an identification card or other evidence of enrollment;
• contacting and working with agency payroll offices to reconcile enrollment records;
• acting on enrollee requests for reconsideration of disputed claims;
• maintaining financial and statistical records and reporting on the operation of its plan;
• developing and maintaining effective communication and control techniques to ensure that its subcontractors and local offices comply with regulations and OPM instructions.

Identification Cards

Your plan carrier will mail your identification cards directly to you. You will receive a new identification card if you change the type of enrollment within your plan or if your name changes. You will not receive a new identification card if you retire or change payroll or employing offices without changing your enrollment.

If you want a duplicate identification card, you must request the card from your carrier. Include in the request your date of birth, social security number, and any additional identifying number the plan may use. Your carrier will not display your social security number on your identification card.

Claim Kits

Some carriers provide claim kits as a convenient way for you to maintain claims expense records. Generally, carriers issue the kits to their enrollees at the same time they issue identification cards. Employing offices wanting information copies of these kits may obtain them from the nearest office of the plan.

Enrollee Responsibilities

Your responsibilities include:

• being aware of your plan's benefit package and premium charges;
• being aware of your plan's exclusions and limitations;
• reviewing the benefit and rate changes made to your plan during Open Season;
• during Open Season, determining whether your plan will still meet your needs in the upcoming year;
• filing the appropriate forms with your employing office on a timely basis to enroll, change, or cancel enrollment;
• ensuring that the proper deduction has been recorded on your earnings and leave statement;
• examining plan provider directories or checking directly with a health care provider to see if that provider participates or will continue to participate in any plan networks or preferred provider arrangements;
• being aware of and following plan precertification and preauthorization requirements;
• filing claims on a timely basis with the necessary documentation;
• being aware of requirements for continuing your enrollment into retirement;
• promptly asking your employing office for information about temporary continuation of coverage if a family member ceases to be eligible under your enrollment;
• promptly requesting conversion to an individual contract when FEHB eligibility ends;
• notifying the carrier of your plan when your address changes;
• notifying your agency or retirement office when you are switching a covered family member on your Self Plus One enrollment;
• notifying the carrier of your plan when a new family member is added to your Self and Family enrollment;.
• notifying the carrier of your plan when a family member is no longer eligible under your Self and Family enrollment.

>Health Insurance Questions

If you are a current employee, a former employee or family member covered under temporary continuation of coverage (TCC), a compensationer, or a former spouse of a current employee, you must direct questions about the FEHB Program to your servicing employing office. If you are an annuitant or a former spouse whose divorce occurred after the enrollee left Federal service, you can direct your questions to OPM's Retirement Information Office at 1-88USOPMRET (1-888-767-6738) or (202) 606-0500 from the metropolitan Washington area, or you can write to OPM's Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045.

Questions from agency personnel offices and field installations must be directed to the agency headquarters Benefits Officer.
Designated headquarters Benefits Officers can direct their questions to OPM, Center for Retirement and Insurance Service, Human Resources Products and Services Division, Insurance Services Program, Washington, DC 20415. Questions also may be sent through the email address on the OPM website.

Customer Service Standards

Our customers include Federal employees and retirees, or their survivors, who are eligible to enroll in the FEHB Program. This is our commitment to our health benefits customers:

• Your choice of health benefits plans will compare favorably for value and selection with the private sector.
• When you use the FEHB Guide and plan benefit brochures, you will find they are clear, factual and give you the information you need.
• When you change plans or options, your new plan will issue your identification card within 15 calendar days after it gets your enrollment form from your agency or retirement system.
• Your fee-for-service plan should pay your claims within 20 work days; if more information is needed, it should pay within 60 calendar days.
• If you ask us to review a claim dispute with your plan, our decision will be fair and easy to understand, and we will send it to you within 60 calendar days. If you need to do more before we can review a claim dispute, we will tell you within 14 work days what you still need to do.
• When you write to us about other matters, we will respond within 30 calendar days after we get your letter. If we need time to give you a complete response, we will let you know.

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