Retirement & 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)504-1526.
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)504-1526.
A R S - A F M : Administrative and Financial Services
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