Federal Employees
Health Benefits (FEHB)
Program
Background
3
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
4
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
7
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
9
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-ofpocket 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
12
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
22
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 26
Married 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
36
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
37
How Do Tribal
Employees Pay?
• Salary deduction
• Premium conversion
38
Roles
39
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
40
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
42
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 tribalprograms@opm.gov
– 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 tribalprograms@opm.gov
– 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: tribalprograms@opm.gov
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Questions?
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