**Federal Employees Health Benefits Program Overview**

2. Federal Employees Health Benefits (FEHB) Program

3. Background

4. Did You Know? • Became effective in 1960 • Largest employer-sponsored group health insurance program in the world • Over 8 million covered lives • FEHB annually provides over $40 billion in health care benefits 4

5. Who Can Join? 5 • Urban Indian Organizations carrying out programs under title V of the Indian Health Care Improvement Act (IHCIA) • Tribes and tribal organizations carrying out programs under the Indian Self-Determination and Education Assistance Act (ISDEAA)

6. FEHB Features • No pre-existing condition limitations • No waiting periods - immediate coverage upon enrollment • Enrollee out-of-pocket maximum

7. FEHB Features (cont.) 95 available plans Plans contract with doctors and hospitals (provider network) No broker fees Disputed claims process

8. FEHB Features (cont.) Continuing Coverage • 31-day extension of FEHB benefits (at no additional cost to member) • Temporary Continuation of Coverage (TCC) • Conversion to individual contract with your plan

9. FEHB Program Benefits

10. FEHB Benefits Snapshot • All plans cover: • Preventive care and immunizations • Medical care • Diagnostic treatment services • Maternity care • Treatment therapy such as chemotherapy, radiation therapy, and kidney dialysis • Inpatient hospital • Surgical and anesthesia services

11. FEHB Benefits Snapshot (cont.) • Emergency and ambulance service • Prescription drugs • Mental health and substance abuse treatment • Catastrophic cost protection through out-of-pocket maximums for covered benefits The benefit information listed is only a snap shot of benefits available under the FEHB Program. Each plan’s FEHB brochure is the official statement of benefits.

12. Preventive Care • All FEHB plans cover a wide variety of preventive services with no cost sharing for enrollees • Services include: • Periodic Physical Exam • Immunizations • Mammograms • Childhood Immunizations • Well Child Care

13. Health and Wellness Most plans offer incentives for participating in the following: • Disease Management Programs for chronic conditions such as: • Asthma • Diabetes • Wellness Program • Smoking Cessation • Health Risk Assessment

14. Mental Health and Substance Abuse Parity • Comparability for mental health and medical benefits; • Same Cost-sharing such as • Deductibles • Coinsurance • Copays • Same Limitations • Covered providers • Generally Accepted Treatment

15. Tobacco Cessation • Provided at no cost • Four tobacco cessation counseling sessions for at least two quit attempts per year • All seven Food and Drug Administration (FDA) - approved tobacco cessation medications with a doctor's prescription

16. Maternity Benefits • Complete maternity care • Prenatal • Delivery • Postpartum

17. Choosing a Health Plan

18. What Types of Plans Are Offered? 18 • Fee-for-Service (FFS) with Preferred Provider Organization (PPO) • Health Maintenance Organization (HMO) • Consumer-Driven Health Plan (CDHP) • High Deductible Health Plan (HDHP)

19. How Many Choices Are Available? 19 • Plan Choices • 10 FFS • 164 HMO • 15 HDHP • 13 CDHP

20. FFS 20 Offers health coverage in which doctors and other providers receive a fee for each service All FFS plans offer nationwide and international coverage Lower costs if PPO provider is used

21. HMOs HMO is managed care HMOs operate in a specific geographic area (service/enrollment area) Generally members must use HMO network providers and get referrals from primary care doctor

22. CDHPs • Combine traditional health plan with a separate medical fund • Annual medical fund used first for covered expenses • When medical fund is exhausted, must meet deductible before traditional health insurance coverage pays

23. HDHPs • Provide coverage for high-cost medical events and a tax advantaged way to build savings for future medical expenses • Annual deductible and cost sharing • Premium contribution to Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) • Tax-free withdrawals from accumulated funds to pay for qualified out-of-pocket expenses including annual deductible

24. Ways to Compare Plans 24 • OPM’s Plan Comparison Tool • PlanSmartChoice • FEHB Guide for Tribal Employees www.opm.gov/tribalprograms

25. Eligibility

26. Tribal Employee Eligibility • Eligible • Meet Internal Revenue Service’s “definition” of common law employee • Meet FEHB requirements for type of employment • Ineligible employment types include: • Contract Employees • Intermittent Employees • Tribal Retirees • Volunteers

27. Tribal Employee Eligibility • All tribal employees are eligible based on common law standard • This includes: • Full-time • Part-time • Seasonal (over 6 months) • Term

28. Family Member Eligibility • Spouse State-recognized marriages such as: - Common law marriages - Tribal marriages • Children up to age 26 Married children, adopted, recognized natural children, foster children, and stepchildren and children over 26 who are incapable of self-support due to a disability that existed before age 26

29. Which Family Members Are Not Eligible? • Same-sex marriages (Defense Of Marriage Act) or domestic partners • Grandchildren • Parents • Siblings • Boyfriends, girlfriends, or fiancés

30. Enrolling in an FEHB Plan

31. FEHB Enrollment Types • Self Only • Self and Family (covers anyone who is an eligible family member) FEHB statute does not permit any other type of enrollment

32. When Can Tribal Employees Enroll in FEHB? • Initial Enrollment Opportunity • New tribal employee (or newly eligible to enroll) • Annual Open Season • Certain Qualifying Life Events (QLEs)

33. Standard Form (SF) 2809 Health Benefits Election Form • Tribal employees complete SF 2809 to request a health benefits action • SF 2809 is located at www.opm.gov/forms/pdf_fil/sf2809.pdf

34. SF 2809

35. Premium Costs

36. FEHB Premiums • OPM negotiates benefits & rates annually with the plans • FEHB premiums will be fully funded by the tribal employer and tribal employee contributions with no contribution from the Federal government

37. Tribal Employer Contribution • The Tribal Employer contribution must be at least as much as the Government contribution for Federal employees • Tribal employers can pay up to 100% of the premium

38. How Do Tribal Employees Pay? • Salary deduction • Premium conversion

39. Roles

40. What Does OPM Do? Administers contracts with FEHB plans Negotiates benefits and rates Resolves disputed health benefit claims Maintains FEHB tribal website www.opm.gov/tribalprograms

41. What Do Tribal Employers Do? • Provide general guidance to tribal employees • Administer Initial Enrollment Opportunity and conduct the annual Open Season • Withhold premiums • Inform tribal employees how much they will pay in premiums • Deposit the total premiums into a bank account for NFC to withdraw the premiums that are due each month

42. What Do Tribal Employers Do? (cont.) • Enter enrollment data into National Finance Center’s (NFC) online enrollment portal called Tribal Insurance Processing System (TIPS) • Work with NFC and FEHB plans to reconcile enrollments

43. What Does the National Finance Center (NFC) Do? • Receives enrollment data from tribal employers via TIPS • Transmits enrollment data to health plans • Collects total premiums due from tribal employer’s designated account • Transmits premiums to U.S. Treasury which sends them to OPM where funds are distributed to health plans • Makes enrollment reports available to tribal employers and OPM

44. What Do FEHB Plans Do? • Provide plan brochures • Furnish a plan identification card for each enrollee/family member • Maintain provider networks • Provide benefits to enrollee and covered family members • Process claims • Reconcile enrollment records • Reconsider disputed claims

45. How Do I Join the FEHB Program?

46. Notification of Interest • At least 3 months before the effective coverage date, notify OPM by either: • Emailing at tribalprograms@opm.gov • Calling the Tribal Desk: 202.606.2530 • OPM confirms the interest • Sends Expressed Interest Fact Sheet • OPM confirms eligibility • Sends application packet

47. Application Package • At least 2 months before the effective coverage date • Application Packet • Agreement • Contact Information • Billing Unit Information • Bank Account Information • Temporary Continuation of Coverage Memorandum of Understanding

48. Signed Agreement • Email tribalprograms@opm.gov • Mail to OPM U.S. Office of Personnel Management Federal Employee Insurance Operations Attn: Demi Mozian 1900 E Street NW, Room 3425 Washington, D.C. 20415 • Receive Acknowledgement Letter from OPM

49. Resources

50. Resources www.opm.gov/tribalprograms • Tribal Programs Listserv • Tribal Benefit Administration Letters (TBALs) • Tribal Desk • Phone: 202.606.2530 • Email: tribalprograms@opm.gov