General Overview
The Federal Employees Health Benefits (FEHB) Program became effective in 1960. It is the
largest employer-sponsored group health insurance program in the world, covering over 8
million Federal employees, retirees, former employees, family members, and former spouses.
Law and Regulations
Public Law 86-382, enacted September 28, 1959, created of the FEHB Program; the current
law governing the Program is chapter 89 of title 5, United States Code. The 1959 Act
became effective generally on the first day of the first pay period that began on or after
July 1, 1960. It authorized the Civil Service Commission (now the Office of Personnel
Management) to write any regulations necessary to carry out the Act. These regulations are
in part 890 of title 5 and chapter 16 of title 48, Code of Federal Regulations.
FEHB Handbook
This Handbook provides the policies and procedures of the FEHB Program and provides
additional guidance to those enrolled in the FEHB Program and their employing offices.
These policies and procedures reflect operations under title 5, United States Code.
This guidance does not cover any authority that individual agencies, such as the U.S.
Postal Service, may have under different laws.
Enrollment
As a Federal employee, you are entitled to enroll yourself and cover any eligible family
members in a health plan offered under the FEHB Program, unless your position is
excluded
from coverage by law or regulation. If you meet the requirements, you will be
eligible
to continue group coverage into retirement.
There are two types of enrollment: Self Only and Self and Family. A Self and Family
enrollment covers you, your spouse, and your unmarried dependent children under age 22.
Premiums
Each health plan carrier under the FEHB Program charges a different premium. The
Government pays up to 75% of the cost of your health benefits coverage, and you pay the
remainder, based on a formula set by law.
Who Provides the Coverage?
Over 250 health plans choices are offered under the FEHB Program. Of the available fee-for-service plans, several are open to all enrollees, while others are available
only to specific categories of employees. In addition, health maintenance organizations
(HMOs) are available in most areas of the United States; you must live or work within a
defined area to be eligible to enroll in a particular HMO.
Opportunities to Change Coverage
Each year, an Open Season is held for FEHB Program enrollees to change health plans
and/or the type of enrollment they have. Eligible employees may also enroll during this
time. Open Season runs from the Monday of the second full workweek in November through the
Monday of the second full workweek in December.
There are limited opportunities to enroll, cancel your enrollment, or change your enrollment outside of an Open Season.
Contractual Benefits
Each carrier contracts with the Office of Personnel Management to provide certain
health benefits to all persons who enroll in its participating plan. Contract negotiation
is a bilateral process, and both OPM and the carrier must approve the final contract.
Contract periods are usually one year. Individual policies or contracts are not issued to
FEHB Program enrollees.
Once benefits have been agreed upon, OPM and each carrier jointly prepare a brochure
describing each plan approved under the FEHB Program. This brochure is intended to be a
complete statement of benefits available to the enrollee, including the plan's benefits,
limitations, and exclusions.
Legal Actions
The District Courts of the United States have original jurisdiction, concurrent with
the United States Court of Federal Claims, in any civil action or claim against the United
States founded upon the law. Actions to recover on claims for health benefits must be
brought against OPM. Actions to review the legality of OPM's regulations or a decision
made by OPM must be brought against OPM. Actions to compel enrollment must be brought
against the employing office that made the enrollment decision.
Garnishment
Your plan's carrier may garnish your pay to collect debts you owe to it. Garnishment
could occur, among other reasons, if you fail to pay deductibles and copayments or if the
carrier overpaid claims in error. Federal employee retirement benefits may not be
garnished for this purpose.
Your employing office must follow the provisions of 5 CFR part 582 to process a
garnishment. These regulations protect some pay from garnishment, such as
amounts to cover health benefits premiums and Basic life insurance withholdings. However, amounts to
cover Optional life insurance withholdings are not protected. See the FEGLI Handbook for additional
information about the effect of garnishment on life insurance coverage.
OPM Responsibilities
OPM has the overall responsibility for the administration of the FEHB Program. This
includes:
- contracting for and approving or disapproving carriers for participation in the FEHB Program;
- negotiating benefit and rate changes with carriers;
- approving the certified text on benefits for the brochures;
- publishing FEHB regulations, instructions, forms, and documents;
- receiving and depositing premium withholdings and contributions, remitting premiums to carriers, and accounting for the Employees Health Benefits Fund;
- making final determinations of the applicability of the FEHB law to specific employees or groups of employees;
- studying and evaluating the operation and administration of the FEHB law and the plans offered under it, and reporting findings to Congress;
- ordering corrections of administrative errors if it would be against equity and good conscience not to do so;
- providing guidance to agencies;
- auditing carriers' operations under the law;
- resolving disputed health insurance claims between the enrollee and the carrier;
- conducting employing agency FEHB responsibilities for retired employees and survivor annuitants.
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