2. Federal Employees Health Benefits (FEHB) Program

3. Background 3

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? 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) 5

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

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

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 8

9. FEHB Program Benefits 9

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 10

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. 11

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 12

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 13

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

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 15

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

17. Choosing a Health Plan 17

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

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

20. FFS 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 20

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 21

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 22

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 23

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

25. Eligibility 25

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 26

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 27

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 28

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

30. Enrolling in an FEHB Plan 30

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 31

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) 32

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 www.opm.gov/forms/pdf_fil/sf2809.pdf 33

34. SF 2809 34

35. Premium Costs 35

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 36

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 37

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

39. Roles 39

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 40

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 41

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 42

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 43

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 44

45. How Do I Join the FEHB Program? 45

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

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 47

48. Signed Agreement Email tribalprograms@opm.govtribalprograms@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 48

49. Resources 49

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

51. Questions? 51