Indian Tribes General Information

June 14, 2011 - General information on FEHB and FEGLI presented at the NCAI Mid-Year conference in Milwaukee, WI.

Introduction

• Federal Employees Health Benefits (FEHB) law enacted September 28, 1959
• FEHB Program administered by the Office of Personnel Management (OPM)
• 207 choices available in the FEHB Program for 2011
• About 8 million covered lives
• About $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

Federal Agency Responsibilities

• Enroll agency employees in health insurance plan of their choice
• Deduct premiums from employee pay
• Add employer contribution to employee share of premium and forward to health insurance trust fund held at Treasury.
• Notify OPM on number of employees enrolled in each plan and amount of premium deposited at Treasury.
• Reconcile enrollments with FEHB carriers

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 (as defined in Defense of Marriage Act)
• 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 first day of first full pay period in January
• 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.

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