Healthcare & Insurance Tribal Employers

Introduction

• Federal Employees Health Benefits (FEHB) law enacted September 28, 1959
• FEHB Program administered by the Office of Personnel Management (OPM)
• Minimum of 15 choices available in the FEHB Program in any given geographical location
• Over 8 million covered lives
• Over $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

Tribal Employer's Responsibilities

• Determine tribal employer/employee contributions toward FEHB premium
• Provide FEHB information and guidance to tribal employees
• Enroll tribal employees in health insurance plan of their choice
• Deduct premiums from employee pay

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
  • Fifteen 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
• Three enrollment types:
  • Self Only
  • Self Plus One
  • Self and Family
• Do not need to reenroll each year

Family Member Eligibility

• Spouse
• Children under age 26
• Includes:
  • Married children
  • Adopted children
  • Stepchildren
  • Foster Children (as long as all requirements are met)

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 the first day of January, the year following the Open Season
• 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 you 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