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FEHB Handbook

Introduction Page 2 of 2

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AGENCY RESPONSIBILITIES

• Headquarters Benefits Officer
• Field Installation Responsibilities
• Information and Counseling
• Contacts Between Employees and Carriers
• Employing Office Questions

Headquarters Benefits Officer

The head of each agency must designate a person to serve as the headquarters benefits officer (Benefits Officer) for the agency. The agency head must notify OPM in writing of the designee's name or any change in the designation. The Benefits Officer is OPM's contact for agencywide insurance matters.

Agency heads can send their notification to Office of Personnel Management, Retirement and Insurance Service, Agency Services Division, P.O. Box 57, Washington DC 20044 or fax the notification to 202-606-1108.

Field Installation Responsibilities

The head of each agency must arrange for the designation of employees at the employing office level. This person will be responsible for explaining the FEHB Program to employees and other eligible persons. He/she will determine individual eligibility for enrollment, effective dates of health benefits actions, and other related matters.

An agency may also delegate responsibility for counseling and advising employees and maintaining records to decentralized local operating offices or field installations or provide the services in some other way.

Information and Counseling

Each agency has a responsibility to provide health insurance information and counseling to its employees. Agencies must become especially familiar with the participation requirements for continuing FEHB coverage into retirement and make this information available to employees, especially those considering retirement. OPM encourages agencies to develop counseling programs that meet the needs of their own employees. While these services must be provided, agencies are using many different approaches. Specific information on resources within your agency should be available to you at your work site.

Contacts between Employees and Carriers

Authorized agency insurance officials should develop contacts with carrier representatives to assist their employees. These contacts must be limited to agency personnel who have FEHB Program responsibilities and to those employees enrolled in the carrier's plan, except during an Open Season. An agency may allow carrier representatives on agency premises to help enrollees with claim or service problems.

A carrier representative may give information only about the plan's benefit provisions and claim procedures. Carrier representatives must be qualified to explain and assist with problems involving the plan's benefit structure and claims  procedures and they must confine themselves to these matters. If you have any other questions, such as questions on the law, the regulations, or the FEHB Program in general, you should ask authorized agency insurance officials.

Carrier representatives may address groups of employees during Open Seasons about their plan's benefits structure, methods of obtaining services, and similar matters. An agency may allow the use of its facilities or services for the distribution of OPM-authorized, carrier-supplied information on health benefits plans. An agency must treat employee organization carriers in accordance with current policies on labor-management relations in the Federal service, found in chapter 71 of title 5, United States Code.

Distribution of materials is limited to official brochures and other carrier-supplied information on a health insurance plan that the carrier certifies are in compliance with OPM's supplemental literature guidelines.

Employing Office Questions

Employing office questions concerning the FEHB Program must be directed to the headquarters Benefits Officer. This person may refer questions to OPM's Insurance Policy and Information Division. Questions about the benefits or claims procedure of a specific plan should be directed to a local office of that plan.

Other Agency Responsibilities

Agencies also are responsible for:

• providing eligible persons with information on their rights and responsibilities under the FEHB Program and ensuring that they have free choice among all plans in which they are eligible to enroll;
• determining the eligibility or ineligibility of, and enrolling employees, former employees, former spouses, and children (including decisions on belated enrollment and change of enrollment requests);
• reviewing enrollment reconsideration requests;
• ensuring that election forms are properly completed, including the enrollee's social security number;
• processing health benefits actions and determining proper effective dates;
• determining capability of self-support of children over age 22;
• stocking and distributing health benefits forms and literature;
• maintaining a controlled system of transmitting health benefits enrollment information to carriers;
• remitting and accounting for withholdings and contributions;
• maintaining and certifying necessary records;
• working with carriers to reconcile enrollment records.

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CARRIER RESPONSIBILITIES

Each carrier is responsible for:

• adjudicating claims of, and providing health benefits to, enrollees and covered family members in accordance with its contract with OPM;
• typesetting, printing, and distributing brochures;
• furnishing each person enrolled in its health plan an identification card or other evidence of enrollment;
• contacting and working with agency payroll offices to reconcile enrollment records;
• acting on enrollee requests for reconsideration of disputed claims;
• maintaining financial and statistical records and reporting on the operation of its plan;
• developing and maintaining effective communication and control techniques to ensure that its subcontractors and local offices comply with regulations and OPM instructions.

Related Topics:

• Identification Cards
• Claims Kit
• Enrollee Responsibilities
• Health Insurance Questions

Identification Cards

Your plan carrier will mail your identification cards directly to you. You will receive a new identification card if you change the type of enrollment within your plan or if your name changes.  You will not receive a new identification card if you retire or change payroll or employing offices without changing your enrollment.

If you want a duplicate identification card, you must request the card from your carrier. Include in the request your date of birth, social security number, and any additional identifying number the plan may use. This number can usually be found on your current identification card.

Claim Kits

Some carriers provide claim kits as a convenient way for you to maintain claims expense records. Generally, carriers issue the kits to their enrollees at the same time they issue identification cards. Employing offices wanting information copies of these kits may obtain them from the nearest office of the plan.

Enrollee Responsibilities

Your responsibilities include:

• being aware of your plan's benefit package and premium charges;
• being aware of your plan's exclusions and limitations;
• reviewing the benefit and rate changes made to your plan during Open Season;
• during Open Season, determining whether your plan will still meet your needs in the upcoming year;
• filing the appropriate forms with your employing office on a timely basis to enroll, change, or cancel enrollment;
• ensuring that the proper deduction has been recorded on your earnings and leave statement;
• examining plan provider directories or checking directly with a health care provider to see if that provider participates or will continue to participate in any plan networks or preferred provider arrangements;
• being aware of and following plan precertification and preauthorization requirements;
• filing claims on a timely basis with the necessary documentation;
• being aware of requirements for continuing your enrollment into retirement;
• promptly asking your employing office for information about temporary continuation of coverage if a family member ceases to be eligible under your enrollment;
• promptly requesting conversion to an individual contract when FEHB eligibility ends;
• notifying the carrier of your plan when your address changes;
• notifying the carrier of your plan when a new family member is added to yourself and family enrollment.

Health Insurance Questions

If you are a current employee, a former employee or family member covered under temporary continuation of coverage (TCC), a compensationer, or a former spouse of a current employee, you must direct questions about the FEHB Program to your servicing employing office. If you are an annuitant or a former spouse whose divorce occurred after the enrollee left Federal service, you can direct your questions to OPM's Retirement Information Office at 1-88USOPMRET (1-888-767-6738) or (202) 606-0500 from the metropolitan Washington area, or you can write to OPM's Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045.

Questions from agency personnel offices and field installations must be directed to the agency headquarters Benefits Officer.

Designated headquarters Benefits Officers can direct their questions to OPM, Retirement and Insurance Service, Office of Insurance Programs, Insurance Policy and Information Division, Washington, DC 20415. Questions also may be sent through the e-mail address on the OPM web site.

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CUSTOMER SERVICE STANDARDS

Our customers include Federal employees and retirees, or their survisors, who are eligible to enroll in the FEHB Program. This is our commitment to our health benefits customers:

• Your choice of health benefits plans will compare favorably for value and selection with the private sector.
• When you use the FEHB Guide and plan benefit brochures, you will find they are clear, factual and give you the information you need.
• When you change plans or options, your new plan will issue your identification card within 15 calendar days after it gets your enrollment form from your agency or retirement system.
• Your fee-for-service plan should pay your claims within 20 work days; if more information is needed, it should pay within 60 calendar days.
• If you ask us to review a claim dispute with your plan, our decision will be fair and easy to understand, and we will send it to you within 60 calendar days. If you need to do more before we can review a claim dispute, we will tell you within 14 work days what you still need to do.
• When you write to us about other matters, we will respond within 30 calendar days after we get your letter. If we need time to give you a complete response, we will let you know.

page: 1 2

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Handbook Contents

• Introduction
• Cost of Insurance
• Health Plans
• Eligibility for Health Benefits
• Enrollment
• Leave Without Pay Status and Insufficient Pay
• Termination, Conversion, and Temporary Continuation of Coverage
• Annuitants and Compensationers
• Military Service
• Family Members
• Former Spouses

Appendices

• Forms and Brochures
• Glossary
• Table of Permissible Changes
• Chapter 89 of title 5, United States Code
• Part 890 of title 5, Code of Federal Regulations

Other

• Search the Handbook
• Handbook Changes