June 14, 2011 - General information on FEHB and FEGLI presented at the NCAI Mid-Year conference in Milwaukee, WI.
Introduction
- Federal Employees Health Benefits (FEHB) law enacted September 28, 1959
- FEHB Program administered by the Office of Personnel Management (OPM)
- 207 choices available in the FEHB Program for 2011
- About 8 million covered lives
- About $40 billion in annual premiums
OPM Responsibilities
- Administer contracts with carriers
- Negotiate benefits and rates
- Approve plan‘s FEHB brochures
- Audit plans
- Publish FEHB regulations and informational material
- Prepare Open Season materials
- Maintain OPM and FEHB websites
- Provide guidance to agencies and plans
- Resolve disputed health benefits claims
Carrier Responsibilities
- Furnish a plan identification card to each enrollee
- Process claims and/or provide services to enrollee and covered family members
- Maintain provider networks
- Reconsider disputed claims
- Print and distribute plan brochures
Federal Agency Responsibilities
- Enroll agency employees in health insurance plan of their choice
- Deduct premiums from employee pay
- Add employer contribution to employee share of premium and forward to health insurance trust fund held at Treasury.
- Notify OPM on number of employees enrolled in each plan and amount of premium deposited at Treasury.
- Reconcile enrollments with FEHB carriers
Picking a Health Plan
- What types of plans are offered?
- Fee-for-Service (FFS) with Preferred Provider Organization (PPO)
- Health Maintenance Organization (HMO)
- Which plan is best?
- Highly individual answer
- Employees must make an informed choice
FFS Plans
- Nationwide
- Ten choices open to all employees
- Others open only to specific groups, such as postal workers
- Fewer costs are incurred if PPO providers are used
- Some paperwork if PPO provider is not used
HMOs
- Enrollee must “live” or “work” in HMO‘s enrollment area to enroll (plan may be changed if enrollee or a family member moves)
- Plans operate in a specific geographic area (service area)
- Generally members must use the network and get referrals from primary care doctor
- Out-of-pocket costs are generally limited to copays
- Little, if any, paperwork
FEHB Program Features
- No waiting periods
- No pre-existing condition limitations
Enrollment
- Coverage is effective on first day of pay period after enrollment request is received
- Two enrollment types:
- Self Only
- Self and Family
- Do not need to reenroll each year
Family Member Eligibility
- Spouse (as defined in Defense of Marriage Act)
- Children under age 26
- Includes:
- Married children
- Adopted children
- Stepchildren
- Children who have, or are eligible for, employer-provided health insurance
Family Members not Eligible
- Grandchildren, unless foster child requirements are met
- Parents
- Siblings
- In-laws
Open Season
- Held annually from mid-November to mid-December
- Enrollments and changes become effective on first day of first full pay period in January
- During Open Season can:
- Enroll
- Cancel enrollment
- Change type of enrollment
- Change from one plan or option to another
Additional Opportunities to Enroll or Change Enrollment
- When experience a Qualifying Life Event
- Common QLEs include:
- Change in Family Status
- Enrollee or family member loses coverage under other insurance coverage
- Enrollee enrolled in an HMO moves from plan‘s service area
2011 Premiums (Nationwide FFS)
Plan | Enrollment Option | Total Monthly Premium |
BC/BS Basic |
Self Only |
$453.48 |
Self and Family |
$1061.97 |
BC/BS Standard |
Self Only |
$578.61 |
Self and Family |
$1306.89 |
2011 Premiums (Nationwide FFS)
Plan | Enrollment Option | Total Monthly Premium |
GEHA High |
Self Only |
$567.62 |
Self and Family |
$1290.97 |
GEHA Standard |
Self Only |
$346.62 |
Self and Family |
$788.28 |
2011 Premiums (Nationwide FFS)
Plan | Enrollment Option | Total Monthly Premium |
MailHandlers Value |
Self Only |
$285.91 |
Self and Family |
$681.63 |
MailHandlers Standard |
Self Only |
$611.20 |
Self and Family |
$1398.76 |
The Federal Employees’ Group Life Insurance (FEGLI) Program
Introduction
- Federal Employees’ Group Life Insurance (FEGLI) Program law enacted August 29, 1954
- FEGLI Program administered by the Office of Personnel Management (OPM)
- The Civil Service Commission (precursor to OPM) contracted with the Metropolitan Life Insurance Company (MetLife)
- FEGLI is term insurance; it accrues no cash value
- An enrollee cannot borrow against coverage
OPM Responsibilities
- Administers the FEGLI contract between OPM and MetLife
- Prescribes regulations
- Sets premium rates through its Office of Actuaries
- Receives employee premiums from participating tribes for deposit into U.S. Treasury
- Decides when to have an Open Season
- Provides guidance to agency HR staff
OFEGLI Responsibilities
- An administrative unit of MetLife; it is not a government agency
- Pays claims
- Arranges for conversions
- Provides technical guidance on designations/trusts
- Evaluates requests:
- to enroll based on medical information (SF 2822)
- to receive living benefits
- to receive living benefits
Tribal Organization / Paymaster Responsibilities
- All administrative functions related to FEGLI enrollments, including enrollments for:
- new employees, open season, QLEs
- maintain enrollment files, designation of beneficiary, assignment, court orders, etc.)
- withhold enrollee premiums from member pay and send to OPM
- issue conversion rights to member when coverage terminates because of separation or at the end of 12 months LWOP,
- certify coverage to OFEGLI upon death of an employee or family member
Types of Insurance
- Benefits/coverage are not negotiated; they are in law
- Two types of insurance:
- Three types of Optional insurance:
- Option A (Standard)
- Option B (Additional)
- Option C (Family)
Basic Insurance
- Basic Insurance Amount (BIA) — employee’s annual rate of pay rounded up to nearest $1,000, plus $2,000
- Benefits are payable, regardless of cause or location of death
Option A
- Standard Optional Insurance
- Amount payable is $10,000
- Also pays up to $10,000 Accidental Death & Dismemberment (AD&D) benefits at no additional cost
Option B
- Additional Optional insurance
- Multiples of 1-5X times salary (after salary is rounded up to next $1,000)
- No minimum or maximum FEGLI amounts
Option C
- Family Optional insurance
- Elect 1-5X multiples
- Each multiple equals:
- $5,000 for the death of a spouse
- $2,500 for the death of each eligible child (under age 22 or disabled dependent)
Optional Insurance
- Employee needs Basic Insurance to elect any Optional insurance
- 60 days to elect any optional coverage
- Employee pays full cost
Additional Opportunities to Elect Coverage
- Open season — infrequent, held when OPM decides
- Physical exam — apply by submitting satisfactory medical evidence to OFEGLI
- Life event — marriage, divorce, death of a spouse, acquiring an eligible child
Designation of Beneficiary
- Not required
- Necessary IF insured wants:
- payment made to someone who doesn’t fall in the order of precedence
- payment made in a different order
- different percentages
FEGLI Rates
Rates are set by OPM, not MetLife.
Biweekly Rates (per $1,000 insurance)
Basic | Optional (A, B, C) |
$0.15 |
Age-based; 5-year age band |
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