Federal Civilian Employee Benefits Ebis
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Federal Civilian Employee Benefits Ebis

FEHBFederal Employees Health Benefits Federal Employees Health Benefits (FEHB) Facts Program.Employees on the Federal Employees Health Benefits United States Office of Retirement And Insurance Service Personnel Management RI 75-13 January 2001 Table of ContentsPage What Is the Federal Employees Health Benefits (FEHB) Program? ...........1When Can I Change From a Self and Family Enrollment To a Self OnlyCan My Former Spouse Continue Federal Employees Health BenefitsCan Someone Be Covered Under More Than One Federal Employees HealthCan I Enroll? ....................................1Do I Have to Join? .................................1What Does the Federal Employees Health Benefits (FEHB) Program Offer?...

2How Do I Stay Informed About FEHB and Participating Health Plans? .....2Do I Pay for Federal Employees Health Benefits (FEHB) Coverage?.......3What Is Premium Conversion? ...........................3What Types of Plans Are Plans .............................5Health Maintenance Organizations (HMOs) .................6Point of Service ................................7What Types of Enrollment Are Available? ....................7Self Only ...................................7Self and Family ................................7Which Family Members Are Covered Under My Enrollment? ..........8When Does My Family Member Lose Coverage? .................) Coverage? ................................10Benefits (FEHB) Enrollment? ..........................11i When Can I Enroll in Federal Employees Health Benefits (FEHB) orChange My FEHB Are the Major Events That Permit Enrollment or Change inCan I Change My Enrollment if My Physician Stops ParticipatingWhat Happens When I Have Federal Employees Health Benefits (FEHB)Can I Continue My Federal Employees Health Benefits (FEHB) CoverageCan My Family Members Continue Federal Employees Health BenefitsEnrollment? ....................................13When Does My Enrollment Become Effective? .................14What Is an Enrollment Request? .........................14With My Plan? ..................................15When Will I Get an Identification Card? .....................15Coverage and Medicare? .............................15After I Retire? ...................................16When Does My Enrollment Continue Automatically? ..............17Transfer ...................................17Leave Without Service ...............................17Workers’ Compensation ...........................18What Happens to My Family’s Coverage When I Die? .............18Can I Cancel My Enrollment? ..........................18When Will My Enrollment End? .........................19Do I Get an Extension of Coverage After My Enrollment Ends? ........20Can I Continue FEHB Coverage After I Separate From Service? ........20How Do I Elect Temporary Continuation of Coverage? .............21(FEHB) Coverage? ................................21ii How Do My Family Members Elect Temporary Continuation of Coverage? ..

21I’m Leaving Federal Employment.Can I Get a Certificate of MyWill the Office of Personnel Management (OPM) Process or PayWhat Are My Rights and Responsibilities as a Federal EmployeesWhat About Premiums for Temporary Continuation of Coverage? .......22When Does My Temporary Continuation of Coverage Become Effective? ...

22Can I Convert to an Individual Policy? ......................23How Do I Apply for an Individual Policy? ....................23What Happens if I Miss the Deadline? ......................23Can My Family Members Convert to an Individual Policy? ...........24When Does the Individual Policy Become Effective? ..............24FEHB Coverage? .................................24Where Can I Get Information on How My Plan Processes Claims? .......24My Claim? ....................................25What Can I Do if My Plan Won’t Pay a Claim? .................25Health Benefits (FEHB) Enrollee? ........................25What Are the Five Steps to Safer Health Care?..................27Table of Permissible Changes in Enrollment ........................................................31Former Spouse Under Spouse Equity Provisions .................33Temporary Continuation of Coverage Enrollees .................35iii What is the Federal Employees Health Benefits (FEHB) Program? The FEHB Program is the largest employer-sponsored group health insurance program in the world, covering almost 9 million people including employees, annuitants, and their family members, as well Maintenance Organizations (HMOs), and plans offering a Point of Service (POS) product.Can I Enroll? Do I Have to Join? You can enroll in FEHB if you are: ?a permanent Federal employee with a regularly scheduled tour of duty; ?a temporary employee with an appointment for longer ?a temporary employee with an appointment limited to one You are not eligible to enroll if you are an intermittent another event permitting enrollment occurs.1What Does the Federal Employees Health Benefits How Do I Stay Informed About ?Group-rated premiums and benefits; ?A Government contribution toward the cost of your plan; ?Your choice of plans and options; ?Annual enrollment opportunities (called open season); ?Guaranteed coverage that your plan can’t cancel; ?No waiting periods, medical examinations or restrictions ?Catastrophic protection against unusually large medical ?Salary deduction for premiums; ?Temporary continuation of FEHB coverage or conversion ?Continued group coverage are receiving Workers’ Compensation; ?Continued group coverage for your family after you die.Before you enroll, your human resources office will give Guide to Federal Employees Use that to decide which health plans from your human resources office.

Read the brochures carefully to find out what each plan covers, its rules, its plan will send you an updated brochure every year that specifies how it changes for the upcoming year.If you want You can download Guides and plan brochures from our web site at www.opm.gov/insure.You can also compare health plans, link to plan web sites, and get information on plan changes online during open season.Our web site has the most current information available to you.2Do I Pay for Federal Employees Health Benefits (FEHB) What Is Premium Conversion? You share the cost of your health benefits coverage with the Premiums and the Government contribution change yearly.

Guide to Federal Employees Health Benefits Plans www.opm.gov/insure).

If you are a part-time employee, your share of the premiums enrolled under temporary continuation of coverage, the Premium conversion is a method of reducing your taxable income by the amount of your FEHB insurance premium.benefits rather than in cash.The effect is that your taxable income is reduced.

You save on: ?Federal income tax, ?Social Security tax, ?Medicare tax, and ?State and local income tax (in most States and localities).Premium conversion has no effect on: ?statutory pay provisions, ?the General Schedule, ?the amount of your health insurance premium, ?the Government contribution towards your FEHB ?your base pay for retirement, life insurance, or the Thrift 3 What Is Premium Conversion? (continued) You are automatically enrolled in premium conversion effective the first pay period on or after October 1, 2000, if Employees Health Benefits (FEHB) Program.If the Executive Branch does not employ you, or an Executive in premium conversion if your employer offers it.The Federal Judiciary, the U.S.Postal Service, and some You may only waive participation in premium ?At the initial premium conversion effective date; ?During an open season; ?When you are first hired or hired as a reemployed ?When you leave Federal service and are rehired in a ?When you have a qualifying life event (whether or not You can cancel your waiver and participate in premium ?When you have a qualifying life event; or ?During an open season.Retirees and persons paying FEHB premiums directly (not A qualifying life event includes: ?Addition of a dependent; ?Birth or adoption of a child; ?Changes in entitlement to Medicare or Medicaid for you, ?Change in work site; 4 ?Change in your employment status or that of your spouse or dependent from either full-time to part-time, or the ?Death of your spouse or dependent; ?Divorce or annulment; ?Loss of a dependent; ?Marriage; ?Significant change in the health coverage of you or your ?Start or end of an unpaid leave of absence by you or your ?Start or end of your spouse’s employment.

What Types of Plans Are The types of plans that participate in the Federal Employees Health Benefits (FEHB) Program are: Available? Fee-for-Service Plans the service.When you need medical attention, you visit the doctor or hospital of your choice.

After receiving medical Fee-for-service plans include: ?Plans open to everyone eligible to enroll under the FEHB 5What Types of Plans Are ?Plans sponsored by unions and employee organizations and restricted to employees in certain occupational groups and/or agencies.Available? (continued) Generally, a sponsoring organization will require you to pay (OPM).?Preferred Provider Organizations (PPO).A PPO is a fee-for-service option that allows you to see certain when you use a non-PPO provider.When you visit a PPO you usually won’t have to file claims or paperwork.PPO benefits for all services received within that hospital.For instance, the PPO agreement may not cover lab work Health Maintenance Organizations (HMOs) An HMO is a health plan that provides care through a where you work.Some HMOs have agreements with providers in other service areas for non-emergency care if you travel or are away from home for extended periods, called “reciprocity”.

Plans that offer such reciprocity discuss Special Features.?network
federal civilian employee benefits ebis
.HMOs charge a copayment for primary

?Most HMOs ask you to choose a doctor or medical group to be your primary care physician (PCP).Your PCP 6What Types of Plans Are Available? (continued) What Types of Enrollment Are provides your general medical care.In many HMOs, you ?Care you receive from a provider not in the HMO’s Point of Service Some fee-for-service plans and health maintenance go out of network.

If you don’t use network providers, you must pay higher out-of-pocket costs, including deductibles, coinsurance, and copayments.The Federal Employees Health Benefits (FEHB) Program offers two types of enrollment: Self Only A self only enrollment covers only you as the enrollee.If Self and Family A self and family enrollment covers you and all of your 7What Types of Enrollment Are Available? (continued) Which Family Members Are A new family member is automatically covered under your marriage license or birth certificate) to verify the family member’s eligibility.

Your plan is not entitled to a new eligibility.The family members covered under your self and family enrollment are: ?Your spouse; ?Your unmarried dependent children under age 22.In ?Your legally adopted child; ?Your recognized natural child, if you live together in a parent-child relationship, or the child is judicial determination of support; ?Your stepchild, if you live together in a parent-child relationship; and ?Your foster child, if you live together in a ?Your unmarried dependent child age 22 or over who is the reason the child isn’t capable of self-support.

The Federal Employees Health Benefits (FEHB) Handbook provides more detailed guidance on coverage requirements, ).8When Does My Family Member Lose Coverage? When Can I Change From a Your spouse immediately loses coverage under your self Your child immediately loses coverage under your self and ?Your child reaches age 22, unless he/she is incapable of ?Your child marries; ?Your disabled child age 22 or over marries or becomes ?Your stepchild or foster child stops living with you in a FEHB coverage under Spouse Equity provisions.Your family members also lose coverage if you change from Neither your human resources office nor your plan will You should immediately tell your plan when a family If you participate in premium conversion, you may change changing to a self only enrollment would be consistent with that qualifying life event.If you adopt a child, a change from self and family to self only coverage would not be consistent with that qualifying life event.9When Can I Change From a Self and Family Enrollment To (continued) Can My Former Spouse If you have waived participation in premium conversion, Your former spouse may be eligible to continue FEHB ?was divorced from you during your Federal employment ?was covered as a family member under an enrollment at ?is entitled to a portion of your annuity or to a former ?does not remarry before age 55.You or your former spouse must apply to your human Benefits for Former Spouses under the Federal Employees or see the FEHB Handbook at .

If your former spouse is not eligible to enroll under Spouse 10Can Someone Be Covered Under More Than One Federal same time.A human resources office may authorize a dual ?Protect children who would otherwise lose coverage as ?Allow an employee under age 22 covered under a parent’s more than one FEHB enrollment.When your human For more information on dual enrollments, contact your human resources office or see the FEHB Handbook at .

11When Can I Enroll in Federal Employees Health Benefits I am … When Can I Enroll? A new employee.Within 60 days after your appointment date.Moving to a position that Within 60 days after your offers FEHB coverage.My appointment date.previous position was excluded from coverage.

An eligible employee, but I am Open season, or when another not enrolled in FEHB.event permitting enrollment occurs (such as a change in family status or employment status).Enrolled in FEHB, and I want Open season, or when another to change my enrollment.

event permitting enrollment occurs (such as a change in status).If you are an eligible temporary employee, all of the enrollment and enrollment change information applies to after retirementTo enroll or change your enrollment, you must file enrollment request with your human resources office within Important: You will not be eligible for FEHB coverage after retirement unless you are enrolled before you retire and 12What Are the Major Events That Permit Enrollment or ?A change in family status:

marriage birth or adoption of a child acquisition of a foster child legal separation divorce?A change in employment status:

you are reemployed after a break in service of more

you return to pay status after your coverage terminated

your pay increases enough for premiums to be withheld

you are restored to a civilian position after serving in

you change from a temporary appointment to an you change to or from part-time career employment.?You or a family member lose Federal Employees Health Benefits (FEHB) or other coverage:

under another FEHB enrollment because the covering

under another federally-sponsored health benefits under Medicaid or similar State-sponsored program for

because your membership terminates in the employee

under a non-Federal health plan.?When one of these events occur, you may:

enroll

change your enrollment from self only to self and change your enrollment to another FEHB plan or13What Are the Major Events That Permit Enrollment or (continued) When Does My Enrollment What Is an Enrollment Request? You also may waive or cancel your waiver of premium You must give your enrollment change to your human See Generally, the effective date of your enrollment or ?completed enrollment request; and ?status.

(This pay status requirement doesn’t apply to a effective dates.You can find complete information about .You may use the Health Benefits Election form (SF 2809) to make open season changes through “Employee Express” or another electronic method, which doesn’t involve a 14Can I Change My Enrollment if My Physician Stops When Will I Get an What Happens When I Have No, this is not a qualifying event for changing your able to continue seeing your provider for up to 90 days after the notice of termination.If you are in the second or third obstetrician until the end of postpartum care.Your plan will send you an identification card once it processes your enrollment.If you need services before you enrollment verification letter as proof of enrollment.Generally, your FEHB plan and Medicare provide protection against the same kind of medical expenses.Your FEHB Medicare does not.

Some FEHB plans also provide coverage for dental and vision care.Medicare covers orthopedic and care, limited chiropractic services, and medical supplies, which some FEHB plans may not cover or only partially Whether your FEHB plan or Medicare is primary depends You can get more information about Medicare at www.medicare.gov or from the publication Medicare and You (also available on the web site).You can get more The Federal Employees Health Benefits Program and Medicare,” at .15 Can I Continue My Federal Employees Health Benefits

You may continue your FEHB enrollment after you retire if: ? you are entitled to retire on an immediate annuity under a

? you have been continuously enrolled (or covered as a (if less than 5 years).

An immediate annuity is one that begins within 30 days of separation for retirement.

An annuity you receive under the qualifies as an immediate annuity, even though you postponed receipt of your annuity after separating from

“Service” means time in a position in which you were eligihave been enrolled in the same FEHB plan.Coverage under

Your first opportunity to enroll is within 60 days after you first become eligible to enroll and receive a Government

The Office of Personnel Management (OPM) may waive the Handbook at .16When Does My Enrollment Continue Automatically? Transfer Your Federal Employees Health Benefits (FEHB) ?don’t have a break in service of more than three calendar ?are eligible for FEHB coverage in your new position.Leave Without Pay Your FEHB enrollment will continue for up to one year payments.Military Service Your FEHB enrollment will continue without change if you enter on active duty in the military service for 30 days or If you enter on active duty for more than 30 days, you may period.

Your human resources office will tell you whether you will have to pay premiums, how much the premiums will be, and how to make the premium payments.You may also choose to terminate your enrollment.You will get it back when you exercise your reemployment rights and within 60 days after you return to civilian service.

17When Does My Enrollment Continue Automatically? (continued) What Happens to My Family’s Can I Cancel My Enrollment? Workers’ Compensation Your enrollment continues while you are receiving ?OWCP determines that you are unable to return to duty; ?you meet the same requirements for continuing coverage Your surviving eligible family members may continue your ? you had a self and family enrollment; and ? one family member is entitled to a survivor annuity.Your retirement system will take appropriate action with If you participate in premium conversion, you may cancel For example, if you get married and your spouse is employed by a company that provides health insurance for (FEHB) coverage would be consistent with that qualifying life event.

If you are divorcing and have children to cover, If you have waived participation in premium conversion, Your cancellation takes effect on the last day of the pay of Coverage.

18Can I Cancel My Enrollment? (continued) When Will My Enrollment End? When you cancel your enrollment, you may not enroll again until family status)
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