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Tribal Employers General Information


  • 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


  • 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


  • 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
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