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New / Prospective Employees
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General Information
Introduction
Federal Employees Health Benefits (FEHB) law enacted September 28, 1959
FEHB Program administered by the Office of Personnel Management (OPM)
Minimum of 15 choices available in the FEHB Program in any given geographical location
Over 8 million covered lives
Over $40 billion in annual premiums
OPM Responsibilities
Administer contracts with carriers
Negotiate benefits and rates
Approve plan‘s FEHB brochures
Audit plans
Publish FEHB regulations and informational material
Prepare Open Season materials
Maintain OPM and FEHB websites
Provide guidance to agencies and plans
Resolve disputed health benefits claims
Carrier Responsibilities
Furnish a plan identification card to each enrollee
Process claims and/or provide services to enrollee and covered family members
Maintain provider networks
Reconsider disputed claims
Print and distribute plan brochures
Tribal Employer's Responsibilities
Determine tribal employer/employee contributions toward FEHB premium
Provide FEHB information and guidance to tribal employees
Enroll tribal employees in health insurance plan of their choice
Deduct premiums from employee pay
Picking a Health Plan
What types of plans are offered?
Fee-for-Service (FFS) with Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
Which plan is best?
Highly individual answer
Employees must make an informed choice
FFS Plans
Nationwide
Fifteen choices open to all employees
Others open only to specific groups, such as postal workers
Fewer costs are incurred if PPO providers are used
Some paperwork if PPO provider is not used
HMOs
Enrollee must “live” or “work” in HMO‘s enrollment area to enroll (plan may be changed if enrollee or a family member moves)
Plans operate in a specific geographic area (service area)
Generally members must use the network and get referrals from primary care doctor
Out-of-pocket costs are generally limited to copays
Little, if any, paperwork
FEHB Program Features
No waiting periods
No pre-existing condition limitations
Enrollment
Coverage is effective on first day of pay period after enrollment request is received
Three enrollment types:
Self Only
Self Plus One
Self and Family
Do not need to reenroll each year
Family Member Eligibility
Spouse
Children under age 26
Includes:
Married children
Adopted children
Stepchildren
Foster Children (as long as all requirements are met)
Family Members not Eligible
Grandchildren, unless foster child requirements are met
Parents
Siblings
In-laws
Open Season
Held annually from mid-November to mid-December
Enrollments and changes become effective on the first day of January, the year following the Open Season
During Open Season can:
Enroll
Cancel enrollment
Change type of enrollment
Change from one plan or option to another
Additional Opportunities to Enroll or Change Enrollment
When you experience a Qualifying Life Event
Common QLEs include:
Change in Family Status
Enrollee or family member loses coverage under other insurance coverage
Enrollee enrolled in an HMO moves from plan‘s service area
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