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U.S. Office of Personnel Management

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Insurance FAQs Health

Changes in Health Coverage

If I am a Member of Congress or designated congressional staff, why am I no longer able to continue my current health plan coverage? View more

Section 1312 of the Affordable Care Act requires that Members of Congress and designated Congressional staff must obtain coverage by health plans created under the Affordable Care Act or coverage offered via an Affordable Insurance Exchange (Exchanges). For more information, please contact your agency’s benefits officer. The Senate Benefits Section can be reached Monday – Friday from 9:00am – 5:30pm EST at (202) 224-1093. The House of Representatives Office of Payroll and Benefits can be reached Monday – Friday from 8:30am – 5:30pm EST at 202-225-1435.
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What is SHOP? View more

The Small Business Health Options Program (SHOP) is a new program under the Affordable Care Act (ACA) that simplifies the process of buying health insurance for small businesses. House of Representatives and Senate offices will provide health coverage to Members of Congress and designated staff through the DC SHOP. When open enrollment begins on November 11, 2013, Members of Congress and designated staff can select coverage through the DC SHOP
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What options do I have if I have lost FEHB coverage because I turned age 26? View more
Upon turning age 26 and losing FEHB coverage, you may:
- Enroll in TCC. Please see Temporary Continuation of Coverage for more information: http://www.opm.gov/healthcare-insurance/healthcare/temporary-continuation-of-coverage/
- Purchase insurance on the Marketplace. Please visit Healthcare.gov for more information: http://www.healthcare.gov
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Will Members of Congress and designated congressional staff receive a Government contribution for their health insurance? View more

Yes, so long as they purchase a health benefits plan via the DC SHOP, or an appropriate SHOP as determined by the OPM Director.
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Where can I get more information on age 26 and other health care reform initiatives that affect FEHB? View more

For more information, please visit Health Care Reform. * Note: Under provisions of the Affordable Care Act effective January 2014, you must have minimum essential health coverage or you may have to make a payment when filing your Federal income tax return. For more information, please visit www.IRS.gov.
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When will determinations about health benefits coverage eligibility be made for Members of Congress and designated congressional staff? View more

For plan year 2014, designations must be made prior to November 2013. For all subsequent plan years, designations must be made prior to the October before the plan year begins. Designations will be effective for the entire plan year during which the staff member works for the Member of Congress.
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What happens if I am a Member of Congress or designated congressional staff and my SHOP plan is no longer offered in the next coverage year? View more

If your plan is no longer offered in the next coverage year, you must enroll in a different plan during the open enrollment to continue coverage. If you do not enroll in a different plan during open enrollment, you will lose SHOP coverage and your Government contribution.
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As a Member of Congress or designated congressional staff, why do I have to go to two websites to determine my monthly premium (DC Health Link website and the OPM webpage with the Premium Contribution Calculator)? View more

You must visit two websites because the FEHB Government contribution formula was not incorporated into the initial design of the DC Health Link website for the Small Business Market. DC SHOP (like other states) uses a contribution formula based on practice in the private group market and FEHB uses a statutory contribution formula different from the private market.
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When I turn age 26, am I eligible for a 31-day extension of coverage? View more

Yes. You will have a 31-day temporary extension of coverage at no cost after coverage ends. For more information about the 31-day extension of coverage, please view the Extension of Coverage section in the FEHB Handbook.
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Which congressional staff will remain eligible for their current FEHB plan coverage? View more

Affordable Care Act, Section 1312, defines congressional staff as all full-time and part-time employees employed by the official office of a Member of Congress. Therefore, staff who do not work for the official office of a Member will remain eligible for their current FEHB plan coverage.
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Are Members of Congress who are in U.S. Territories eligible to enroll for coverage under the DC SHOP? View more

Like other Members of Congress and congressional staff, representatives from U.S. Territories and their designated staff must enroll for coverage under the DC SHOP in order to receive a Government contribution. The DC SHOP offers health plan options with access to in-network medical providers across the nation and overseas. There will be plans offered by at least one health insurance issuer in all territories.
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As a Member of Congress or designated congressional staff, how long does my enrollment in SHOP last? View more

One year, unless an employment change occurs, such as a separation, break in service, or move to another agency with FEHB eligibility. Once you enroll in a SHOP plan, your plan enrollment will automatically renew for the next calendar year if you take no action during open enrollment.
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What options do I have if I do not have (have lost) FEHB coverage? View more
Upon separating from Federal employment and losing FEHB coverage, you have several options. You may:
- Enroll in TCC. Please see Temporary Continuation of Coverage for more information.
- Purchase insurance on the Marketplace. Please visit www.healthcare.gov for more information.
* Note: Under provisions of the ACA effective January 2014, you must have minimum essential health coverage or you may have to make a payment when filing your Federal income tax return. For more information, please visit www.irs.gov.
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As a Member of Congress or designated congressional staff, how are premiums collected for my new DC SHOP coverage? View more

Premiums will be collected through payroll deductions.
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If I am a Member of Congress or designated congressional staff that does not live in Washington, DC, am I still eligible to sign up for coverage in the DC SHOP? View more

Yes. It is very important that you evaluate the availability of each plan’s provider network in the area where you expect to use health care services prior to selecting your health plan. Some DC SHOP plans may only offer benefits coverage for in-network providers.
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