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Tribal Employers General Information

Introduction

  • Federal Employees Health Benefits (FEHB) law enacted September 28, 1959
  • FEHB Program administered by the Office of Personnel Management (OPM)
  • Minimum of 13 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
    • 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
  • 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 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 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

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:
    • Basic
    • Optional
  • 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)
BasicOptional (A, B, C)
$0.15 Age-based; 5-year age band

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