1 / 51

Federal Employees Health Benefits (FEHB) Program

Federal Employees Health Benefits (FEHB) Program. Background. 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.

Download Presentation

Federal Employees Health Benefits (FEHB) Program

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Federal Employees Health Benefits (FEHB) Program

  2. 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

  4. Who Can Join? 5 • 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)

  5. FEHB Features • No pre-existing condition limitations • No waiting periods - immediate coverage upon enrollment • Enrollee out-of-pocket maximum

  6. 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

  8. 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

  10. FEHB Benefits Snapshot (cont.) • Emergency and ambulance service • Prescription drugs • Mental health and substance abuse treatment • Catastrophic cost protection through out-of-pocket 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.

  11. 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

  13. Mental Health and Substance Abuse Parity • Comparability for mental health and medical benefits; • Same Cost-sharing such as • Deductibles • Coinsurance • Copays • Same Limitations • Covered providers • Generally Accepted Treatment

  14. 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

  15. Maternity Benefits • Complete maternity care • Prenatal • Delivery • Postpartum

  16. Choosing a Health Plan

  17. What Types of Plans Are Offered? 18 • Fee-for-Service (FFS) with Preferred Provider Organization (PPO) • Health Maintenance Organization (HMO) • Consumer-Driven Health Plan (CDHP) • High Deductible Health Plan (HDHP)

  18. How Many Choices Are Available? 19 • Plan Choices • 10 FFS • 164 HMO • 15 HDHP • 13 CDHP

  19. FFS 20 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

  20. 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

  23. Ways to Compare Plans 24 • OPM’s Plan Comparison Tool • PlanSmartChoice • FEHB Guide for Tribal Employees www.opm.gov/tribalprograms

  24. Eligibility

  25. 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

  26. Tribal Employee Eligibility • All tribal employees are eligible based on common law standard • This includes: • Full-time • Part-time • Seasonal (over 6 months) • Term

  27. 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

  28. Which Family Members Are Not Eligible? • Same-sex marriages (Defense Of Marriage Act) or domestic partners • Grandchildren • Parents • Siblings • Boyfriends, girlfriends, or fiancés

  29. Enrolling in an FEHB Plan

  30. 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

  31. 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)

  32. 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

  33. SF 2809

  34. Premium Costs

  35. 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

  41. 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

  43. 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

  44. How Do I Join the FEHB Program?

  45. 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

  46. 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

  47. 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

  48. Resources

  49. Resources www.opm.gov/tribalprograms • Tribal Programs Listserv • Tribal Benefit Administration Letters (TBALs) • Tribal Desk • Phone: 202.606.2530 • Email: tribalprograms@opm.gov

More Related