Agency
A department or independent establishment (e.g., the U.S. Postal Service) of the
executive branch of the United States Government, including Government-owned or controlled
corporations, the legislative and the judicial branches of the United States Government
and entities under their supervision, the District of Columbia Government (for certain
eligible employees), and Gallaudet College. The term agency refers to the whole
organization, as distinguished from its subdivisions and field establishments.
In the executive branch, the Department of Defense, Department of the Army, Department
of the Navy, and Department of the Air Force are considered to be separate agencies.
Annuitant
A former employee entitled to an annuity under a retirement system established for
employees. This includes the retirement system of a nonappropriated fund instrumentality
of the Department of Defense or the Coast Guard. Compensationers
are considered annuitants for health benefits purposes.
Cancel
Your election on an enrollment request that you no
longer want to be enrolled in the Federal Employees Health Benefits Program.
Carrier
A legal entity that offers a health benefits plan
approved by the Office of Personnel Management.
Compensation
Compensation under subchapter I of chapter 81 of title 5, United States Code (Workers'
Compensation), which is payable because of an on-the-job injury or disease.
Compensationer
An employee or former employee who is entitled to workers' compensation and whom the
Department of Labor determines is unable to return to duty. Compensationers
are considered annuitants for health benefits purposes.
Consumer-Driven Health Plan
A type of health benefits plan that requires member responsibility for certain up-front medical costs; an employer-funded account that may be used to pay these up-front costs; and catastrophic coverage with a high deductible. Full coverage is provided for in-network preventive care.
Contributions
Amounts which each agency is required to pay from its salary appropriations or other
available funds as the Government's share of the cost of the health benefits coverage of
its enrolled employees. The Government contribution toward the cost of health benefits for
most annuitants is paid from annual appropriations by Congress for this purpose.
Conversion Contract
An individual, nongroup policy offered by a carrier to enrollees
whose FEHB coverage terminates.
Coordination of
Benefits
When you are covered by more than one type of insurance that covers the same health
care expenses, one pays its benefits in full as the primary payer and others pays a
reduced benefit as a secondary or third payer. When the primary payer doesn't cover a
particular service but the secondary payer does, the secondary payer will pay up to its
benefit limit as if it were the primary payer.
Court Order
Any judgment or property settlement issued by, or approved by, any court of any State,
the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Northern Mariana
Islands, or the Virgin Islands, and any Indian tribal court in connection with, or
incident to, the divorce, annulment of marriage, or legal separation of a Federal employee
or retiree.
CSRS
The Civil Service Retirement System.
Current Continuous
Employment
For purposes of health benefits coverage for temporary employees, "current"
means beginning with the present and counting back 1 full year (365 calendar days).
"Continuous" means employment with no break in service of more than 5 days. A
break in service occurs when you are off the employment rolls. A break in service of 1 to
4 days does not interrupt the 1 year of current continuous employment and is counted
toward the service requirement. Days on which a part-time employee is not scheduled to
work are not breaks in service. "Employment" means full-time or part-time
service that is not excluded by law
or regulations applicable to the FEHB Program.
Days
Whenever, in this Handbook, a period of time is stated as a number of days, or as a
number of days from an event, the period is computed in calendar days, excluding the day
of the event.
Dual Enrollment
Coverage under more than one FEHB enrollment at the same time; dual enrollment is
prohibited under FEHB law.
Elect not to Enroll
Upon your first eligibility, your request
not to be enrolled in the Federal Employees Health Benefits Program.
Eligible
Not excluded from coverage
under the Federal Employees Health Benefits Program by the law or the regulations.
Employee
An individual appointed or elected to a position in or under the executive,
legislative, or judicial branch of the United States Government, as defined at 5 U.S.C.
8901. This includes Government-owned or controlled corporations, the District of Columbia
government (for certain eligible employees), and Gallaudet College.
Employee Organization
An association or other organization of Federal or postal employees that sponsors a
health benefits plan approved by the Office of Personnel Management.
Employing Office
The agency office (or retirement system office) that has responsibility for health
benefits actions.
Enroll
Election to join a health benefits plan under the Federal Employees Health Benefits
Program. Your election must be submitted to your employing office on a Health Benefits
Election Form (SF 2809) or other enrollment request.
Enrollee
The individual in whose name the health plan enrollment is carried. The term includes
employees, annuitants, survivor annuitants, former employees, former spouses, or children
who are enrolled after completing a valid election form or other enrollment request or
who have continued an enrollment as an annuitant or survivor annuitant.
Enrollment Change
Your election of a different plan or option, or a different type of coverage (self only
or self and family), submitted to your employing office on a Health Benefits Election Form
(SF 2809) or other enrollment request.
Enrollment Code
A three-digit code assigned to a health plan and option. The first two digits identify
the health plan; the third digit identifies the option (high or standard) and type of
enrollment (self only or Self and family).
Enrollment Request
A properly completed health benefits enrollment form (SF 2809) or an alternative method
acceptable to both your employing office and OPM. Alternative methods must be capable of
transmitting to the health benefits plans the information they need to accept an
enrollment, change of enrollment, or cancellation. Electronic signatures, including the
use of Personal Identification Numbers (PIN), have the same validity as a written
signature.
Extension of Coverage
Automatic continuation of your health benefits coverage for 31 days after FEHB
eligibility terminates, except by your cancellation of
coverage.
Family Members
Your spouse and unmarried dependent children under age 22. Such child includes:
- A legitimate child
- An adopted child
- A stepchild, foster child, or recognized natural
child who lives with you in a regular parent-child relationship
- A recognized natural child for whom a judicial determination of support has been
obtained, or to whose support the enrollee makes regular and substantial contributions.
A child age 22 or over is covered if he/she is incapable of self-support because of
mental or physical disability that existed before the child reached age 22.
Certain restrictions apply to coverage of family members under former spouses'
enrollments, under temporary continuation of coverage (TCC) and spouse equity provisions.
No other person is considered a family member for health benefits purposes.
Fee-for-Service Plan
A traditional type of insurance that lets you use any doctor or hospital, but you
usually must pay a deductible and coinsurance. These plans are called fee-for-service
because doctors and other providers are paid for each service, such as an office visit, or
test. They help control costs by managing some aspects of patient care. Most FEHB fee-for-service plans also provide access to preferred provider organizations (PPOs).
FEHB
The Federal Employees Health Benefits law or program.
FERS
The Federal Employees Retirement System.
First Opportunity to Enroll
The first time that you were employed in a position in which you were eligible to
enroll in the FEHB Program and were entitled to a Government contribution towards
premiums. You are considered to have enrolled at the first opportunity if you were covered
at that time by the FEHB enrollment of another employee or annuitant.
Former Spouse
A person whose marriage to a Federal employee or annuitant ended in divorce or
annulment of the marriage. This term does not refer to widows or widowers.
Foster Child
A child who lives with the enrollee in a regular parent-child relationship and is
expected to be raised to adulthood by the enrollee.
Fund
The Employees Health Benefits Fund.
Gross Misconduct
For purposes of qualifying for temporary continuation of coverage (TCC), a flagrant and
extreme transgression of law or established rule of action for which you are separated
from service and for which a judicial or administrative finding of gross misconduct has
been made.
Health Benefits Plan
A group insurance policy or contract, medical or hospital service agreement, membership
or subscription contract, or similar group arrangement provided by a carrier
for the purpose of providing, paying for, or reimbursing expenses for, health services.
Health Maintenance Organization (HMO)
A type of health benefits plan that provides care through a network of doctors and
hospitals in particular geographic or service areas. HMOs coordinate the health care
services you receive. Your eligibility to enroll in an HMO is determined by where you live
or, for some plans, where you work. Some FEHB HMOs have agreements with providers in other
service areas for non-emergency care if you travel or are away from home for extended
periods.
High Deductible Health Plan (HDHP)
A type of health benefits plan that offers catastrophic risk protection with higher deductibles, health savings accounts and health reimbursement accounts, and lower premiums.
Immediate Annuity
- An annuity that begins no later than one month after the end of the pay period during
which you are separated from service; or
- An annuity under 5 CFR 842.204(a)(1) for which the starting date has been postponed.
Impaired Relationship
An irrepairable rift between an HMO's medical providers and the enrollee and/or family
members, which jeopardizes the furnishing of adequate medical care.
Incapable of Self Support
Dependent on the enrollee because of a physical or mental disability which occurred
before the child reached age 22.
Interim Appointment
The employment status of a person whose appeal of a personnel action to the Merit
Systems Protection Board results in an initial decision granting relief, pending final
action on a petition for review by a party to the appeal or OPM.
Interlocutory Divorce
An intermediate divorce; one that has not become finalized. The spouse is still
considered to be an eligible family member under an FEHB enrollment. An interlocutory
divorce is considered to be a change in family status that allows the enrollee to change
his/her enrollment.
Intermittent Employee
A non-full time employee without a regularly scheduled tour of duty.
Law
Chapter 89 of title 5, United States Code.
Medically Underserved Area
Any of the 50 States of the United States where OPM determines that 25 percent or more
of the residents are located in primary medical care manpower shortage areas designated
under section 332 of the Public Health Service Act (42 U.S.C. 254e).
Medicare Managed Care Plan
A managed care plan such as an HMO or PPO that contracts with Medicare to enroll Medicare beneficiaries. Services must be
obtained from the managed care plan's network of doctors and hospitals to receive full plan benefits.
The managed care plan may charge a monthly premium and require copayments.
Official Personnel Folder
Your personnel records that are maintained by your employing office.
Open Season
The annual time period set by OPM in which all eligible persons may elect or change
their health benefits coverage.
OPM
The Office of Personnel Management.
Option
A level of benefits provided by a health benefits plan. Some plans provide a high and a
standard option; others provide only one option.
Overseas
Outside a State of the United States and the District of Columbia.
OWCP
The Office of Workers Compensation Programs, U.S. Department of Labor, which
administers compensation benefits for Federal employees under subchapter I of chapter 81
of title 5, United States Code.
Pay Period
For former employees, former spouses, children enrolled under TCC provisions, and
annuitants not actively receiving an annuity, pay period means any regular pay
period for employees of the agency that is responsible for the health benefits actions for
the enrollee.
Plan
See Health Benefits Plan.
Preferred Provider Organization (PPO)
A fee-for-service option where you can choose plan-selected providers who have
agreements with the plan. When you use a PPO provider, you pay less money out-of-pocket
for medical services than when you use a non-PPO provider.
Premium Conversion
Federal employees can use pre-tax dollars to pay health insurance premiums to the Federal Employees Health Benefits Program under the "Premium Conversion" program. Premium conversion uses Federal tax rules to let employees deduct their share of health insurance premiums from their taxable income, thereby reducing their taxes. This plan is similar to the private sector, which has allowed their employees to deduct health insurance premiums from their taxable incomes for many years. Premium conversion for Federal employees enrolled in the FEHB Program went into effect in October 2000.
Primary Payer
When coordinating benefits, the health plan that pays benefits first and to the full
extent of its coverage.
Program
The Federal Employees Health Benefits Program.
Qualifying Court Order
A court order that awards a portion of your future annuity
or a survivor annuity to your former spouse and is determined by OPM, CIA, or the Foreign
Service, as appropriate, to meet the requirement of a qualifying court order.
Recognized Natural Child
For whom the father:
- Has acknowledged paternity in writing;
- Was ordered by a court to provide support;
- Before his death, was pronounced by a court to be the father;
- Was established as the father by a certified copy of the public record of birth or
church record of baptism, if he was the informant and named himself as the father of the
child; or
- Established paternity on public records, such as records of schools or social welfare
agencies, which show that with his knowledge he was named as the father of the child.
If paternity is not established by one of the above means, other evidence such as the
child's eligibility as a recognized natural child under other State or Federal programs or
proof that the father included the child as a dependent child on his income tax returns
may be considered.
Reconsideration
The final level of administrative review of an employing office's initial decision
about an enrollment or enrollment change to determine if the employing office followed the
law and regulations correctly.
Reemployed Annuitant
A Federal employee annuitant who has returned to active Federal service under
conditions which do not result in termination of annuity.
Regular Tour of Duty
Your work schedule that is determined in advance and expected to continue indefinitely.
It consists of a certain number of hours or other time units in a day, week, biweekly pay
period, month, or year.
Regulations
Part 890 of title 5 and part 16 of title 48, Code of Federal Regulations.
Retired Federal Employees Health Benefits Program
A program that provides health benefits coverage for Federal employees who retired
before July 1, 1960 or their survivors.
Secondary Payer
When coordinating benefits, the health plan that pays benefits only after the primary
payer has paid its full benefits. When an FEHB fee-for-service plan is the
secondary payer, it will pay the lesser of:
- its benefits in full, or
- an amount that when added to the benefits payable by the primary payer, equals 100% of
covered charges.
Self and Family
The type of FEHB enrollment that covers the enrollee and all eligible family members.
Self Only
The type of FEHB enrollment that covers only the enrollee.
Service
Civilian service which is creditable under subchapter III of chapter 83 or subchapter
II of chapter 84 of title 5, United States Code. This includes service under a
nonappropriated fund instrumentality of the Department of Defense or the Coast Guard for
an individual who elected to remain under a retirement system established for employees
described in Section 2105 (c) of title 5.
Service Area
The geographical area in which an HMO's medical providers are located.
Spouse Equity
A provision of the FEHB law that allows eligible former spouses of Federal employees
and annuitants to enroll in the FEHB Program in their own name.
Survivor Annuitant
A surviving family member of a deceased Federal employee or annuitant who is entitled
to an annuity under a retirement system established for employees.
Suspension of FEHB Enrollment
When you notify your retirement system that you are giving up your FEHB coverage to
enroll in a Medicare managed care plan, but still retain the right to reenroll in FEHB if your
enrollment in the Medicare managed care plan ends. Otherwise, if you cancel your FEHB coverage as an
annuitant, you probably may never reenroll.
Temporary
Continuation of Coverage (TCC)
A provision of the FEHB law that allows Federal employees who separate from service and
family members who lose eligibility to temporarily continue FEHB coverage.
Withholdings
Amounts deducted from your pay, annuity, or compensation for your share of the cost of
health benefits.