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Healthcare Reference Materials

Glossary

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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.

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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.

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Family Members

Your spouse (including a same-sex 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.

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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.

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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.

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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
The person to whom an employee is legally married.

Note – Whether an individual is the spouse of employee will be determined by the law of the state in which the couple married, and will not change based on the employee’s state of residence.
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.

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