FEHB Highlights: OPM, Carriers, Agencies, and Enrollees’ Responsibilities

Continuing our series on the Federal Employee Health Benefits (FEHB) program. In this piece, we review the responsibilities of OPM, carriers, agencies, employees, and family members.

OPM’s FEHB Handbook is a dense digital document that details all the technicalities around health insurance for active and retired federal workers and their family members. In this series, we’re attempting to summarize the government’s guide in more digestible chunks. In the first article, we provided a general overview of the handbook and its introduction. Now, we’re going to look at the legal responsibilities of the parties involved.

OPM Responsibilities

The Office of Personnel Management (OPM) deals mostly with insurance carriers and agencies when it comes to the FEHB program. Other than resolving disputes between enrollee and carriers, and providing FEHB services for their own employees, OPM’s only other direct involvement with enrollees is to administer FEHB plans for retirees receiving a FERS or CSRS pension, and any beneficiary who is eligible for FEHB via survivor benefits.

Learn all about FEHB plans, TriCare, FEDVIP coverage, and Medicare at our no-cost webinar

OPM mainly provides guidance to federal agencies and approves contracts for participating health insurance carriers. OPM negotiates the plan’s benefits structures and premium rates, fixes errors in health plan policies, and publishes regulatory documents, forms, and instructions. OPM receives premium payments from agencies, deposits the money in the FEHB fund, and from there, remits the premiums due to carriers. Other OPM responsibilities include:

• determining if certain FEHB rules apply to specific people, or groups of people;
• study and evaluate FEHB operations, reporting findings to Congress
• approving the text on brochures provided by carriers

Agency Responsibilities

Every federal agency must employ a Headquarters Benefits Officer and then there are FEHB “field installations,” which exist at the employing office level. These installations deal directly with federal employees. When the employing office cannot answer a fed’s questions, they are required to direct that question to the benefits officer and not contact the carrier directly. OPM’s “insurance service program” can also be reached for help. Employing offices are required to distribute brochures to employees and to provide counseling and advice. How each office decides to go about offering guidance on FEHB is open to interpretation and the handbook notes there are “many different approaches.” At the employing office level, agencies are required to review enrollment and reconsideration requests, ensure coverage election forms are filled out correctly, and also to determine their employee’s eligibility, including whether a dependent aged 26 or older can “self-support.” Other agency responsibilities at the office level are:

• Establish effective dates for coverage
• Maintain employee records
• Account for tax withholdings and contributions
• Certify certain records and documents

An agency’s Headquarters Benefit Officer is expected to work with health plan carriers to reconcile enrollment records and assist employees. Except for during the annual open season, carrier representatives are only allowed to contact agency officers, as well as individuals currently enrolled with them. When in contact with an insured person, they can only discuss plan benefit structures and claim procedures – no medical advice.

Carrier Responsibilities

The main responsibility of an FEHB plan carrier to adjudicate claims and provide medical benefits. They also must act on dispute claims and reconsideration requests submitted by agencies. Along with maintaining financial and statistic records, and ensuring subcontractors and local offices are compliant with OPM rules and regulations, carriers are also responsible for typing, printing, and distributing brochures to agencies.

The Enrollee’s Responsibilities

When it comes to the FEHB program, covered feds and their family members are responsible for being aware of their plan’s intricacies, and updating their personal information. And, well, to pay their premiums, of course. In a timely manner, they are expected to complete new enrollment forms, coverage changes, cancelations, and to file claims. They should be aware of their health insurance’s benefits, premium amounts, exclusions, limitations, and any changes that may occur during open season. Federal employees with FEHB need to make sure the correct dollar amount is being deducted from their paycheck and that they understand the requirements for enrollment. Enrollees must also notify their employing office if there’s any change of address, if they’ve recently added an eligible family member, or if a covered family member is no longer eligible for coverage.

The next article in this FEHB series will go over the cost of health insurance provided through the FEHB program. In the meantime, don’t forget to register for our FEHB Webinars!

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Until Next Time,

The information has been obtained from sources considered reliable but we do not guarantee that the foregoing material is accurate or complete. Any opinions are those of Serving Those Who Serve writers  and not necessarily those of RJFS or Raymond James. Any information is not a complete summary or statement of all available data necessary for making an investment decision and does not constitute a recommendation. Investing involves risk and you may incur a profit or loss regardless of strategy suggested. Every investor’s situation is unique and you should consider your investment goals, risk tolerance, and time horizon before making any investment or financial decision. Prior to making an investment decision, please consult with your financial advisor about your individual situation. While we are familiar with the tax provisions of the issues presented herein, as Financial Advisors of RJFS, we are not qualified to render advice on tax or legal matters. You should discuss tax or legal matters with the appropriate professional. **

FEHB Highlights: OPM, Carrier, Agency, and Enrollee Responsibilities