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Welcome to the OPM Tribal Programs Training for Tribal Employees Webcast. You will be
viewing the module on the Initial Enrollment Opportunity for Tribal Employees in the FEHB
Program. If you have questions, please contact your
tribal employer or human resources benefits officer directly.
The purpose of this presentation is to provide basic information about the benefits offered
to you as a tribal employee, and assist you in making informed choices about these benefits
during the Initial Enrollment Opportunity. We will discuss all the aspects of FEHB enrollment
for a tribal employee, including:
What is the Initial Enrollment Opportunity? - Slides 4-11
What happens once you enroll in the FEHB Program? - Slides 12-16
Things to remember when enrolling in the FEHB Program? -Slides 17-23
Resources - Slides 24-28 This presentation assumes that your tribal
employer has chosen to participate in the FEHB Program. Check with your tribal employer
to see if they have chosen to participate.
So what is the initial enrollment opportunity or “IEO”? Your tribal employer has chosen
to participate in the FEHB Program. The FEHB Program offers a wide variety of plans to
help you meet your health care needs. This presentation will walk you through the
decisions you have to make during the Initial Enrollment Opportunity.
The Initial Enrollment Opportunity is when your tribal employer begins participation
in the FEHB Program and offers FEHB to its eligible tribal employees.
During this time period you must elect to either:
• Enroll in the FEHB Program, or • Not enroll in the FEHB Program.
Please check with your tribal employer for the dates of your Initial Enrollment Opportunity.
So now we’ll talk a little bit about what should you do during the initial enrollment
opportunity. During the Initial Enrollment Opportunity, you should follow these steps
to help you choose a plan and enroll in the FEHB Program:
1. Review the plans available to you in your geographic location;
2. Select an FEHB plan that best suits your needs;
3. Indicate your choice by completing the Health Benefits Election Form Standard Form
(SF) 2809; and 4. Submit your completed SF 2809 to your tribal
employer. Slides 7-11 will provide you with details
about how to complete each of these steps.
Let’s talk a little bit about Step 1. Every employee has the opportunity to choose the
FEHB plan that best suits his/her individual needs. Your tribal employer cannot tell you
which plan to choose. On average, each person can choose from at
least 10 FEHB plans. Not every plan is available to every employee. For example, Health Maintenance
Organizations (HMO) only provide coverage in certain geographic or service areas so
their enrollment is limited to employees living or working in those locations.
Currently, the FEHB Program offers 91 different plans, including Fee-for-Service plans, HMOs,
Consumer Driven Health Plans, and High Deductible Health Plans. Some plans offer more than one
option. For instance you might see different options such as high, standard, or basic options.
OPM has tools available to help you choose the best FEHB plan for you. You can compare
up to four plans using OPM’s plan comparison tool which is available on our website.
You can also use the PlanSmartChoice comparison tool to compare FEHB plans. This tool assists
you in deciding which health plan best meets your needs and estimates your total health
care costs before selecting a plan. The FEHB Guide for Tribal Employees lists
the plans available in each state, the premiums available, selected benefits, FEHB plan consumer
satisfaction survey results, and links to other health plan quality indicators.
Moving onto the second step, “choose the best FEHB plan for you.” When you think
about which FEHB plan is best for you, ask yourself these questions:
1. What health expenses do you and your family expect? Do you need surgery? What are your
medication needs? 2. A second question you might ask - Which
available plan has the best coverage for these expenses?
3. What are your priorities? -Lowest overall cost? Consider the premium
and your out-of-pocket expenses such as the deductible (the amount you must first pay
before your plan begins to pay benefits) look at the copays and coinsurance (the amounts
you pay as your share in the cost of covered services).
-You might want to look at which plan provides the most freedom to see providers?
• With an HMO you must use their providers; • With a nationwide Fee-for-Service (FFS)
Preferred Provider Organization (PPO) network – the network may be larger; also you can
go to a provider that is not part of the PPO network. You may pay more in this situation,
however. -You might also want to consider which plan
has the least paperwork? -Or the greatest protection for unforeseen
medical expenses? You may want a plan that does not have a deductible.
4. Is there a Preferred Provider Organization (PPO) or an HMO network? Are there providers
near you? 5. And lastly, a really important questions
is how much are the premiums? You must get information on the premium you will pay from
your tribal employer. Please see the FEHB Tribal FastFacts: Selecting
a Health Plan During the Initial Enrollment Opportunity for Tribal Employees at www.opm.gov/insure/health/tribes/ffchooseaplan.pdf
for additional guidance on choosing a plan.
For your final decision, you must review the plan brochure.
The third step is completing the SF 2809. You must use the SF 2809 to enroll in the
FEHB Program. You must complete the form, sign it, and submit it to your tribal employer.
You can also use the SF 2809 to elect NOT to enroll by completing Part E. You may disregard
the section at the top right column of the instructions on page 3, Employees Who Elect
Not to Enroll or Who Cancel their Enrollment, as this concerns Federal retirement and does
not apply to tribal employees. An election NOT to enroll is important so
that your tribal employer will have documentation of your intentions. If you fail to complete
SF 2809 to either enroll or not enroll in an FEHB plan, the tribal employer must assume
that you have declined to enroll. You will also use this form to change your
enrollment from one plan or option or type of enrollment to another or to cancel your
FEHB enrollment. For more information on how to complete the
SF 2809, please see the SF 2809 Guidance for Tribal Employees.
The fourth step is submitting the SF 2809 to your tribal employer. The tribal employer
must give you a copy of your completed SF 2809, signed by you and your tribal employer,
or the Tribal Insurance Processing System (TIPS) confirmation page. Your copy of the
SF 2809 or the TIPS confirmation page is acceptable proof of enrollment in an FEHB plan until
you receive an identification card from your plan.
Your tribal employer must also file a copy of SF 2809 in your personnel folder.
The next section we’ll discuss is what “what happens once you enroll in the FEHB Program?”
This section provides information on what happens once you enroll in the FEHB Program.
So first let’s talk a little bit about coverage. To find out when you can begin using your
FEHB benefits, please contact your tribal employer. They will tell you when your coverage
starts. The FEHB plan will process your health care
information and send you a health care identification card. If you do not receive an ID card or
need to check the status of your health care enrollment, contact the FEHB plan or your
tribal employer. You can find the phone number to your plan in the FEHB health plan brochure
or the FEHB Guide for Tribal Employees at www.opm.gov/insure/health/tribes/2012tribeguide.pdf.
Next I’ll cover a little bit about paying premiums. Premiums may be deducted from your
paycheck. The amount deducted depends upon the plan that you choose, how often you get
paid, and the amount your tribal employer pays as its share. Your tribal employer will
let you know how much you will pay for each available FEHB Plan.
If your tribal employer offers premium conversion, you can use pre-tax dollars to pay your share
of the premium. Please check with your tribal employer to see if this option is available.
So you might be wondering, “when is my next opportunity to change FEHB plans.” If you
participate in premium conversion, opportunities to enroll, change plans or options, change
your type of enrollment, or cancel your FEHB enrollment are limited to Open Season and
Qualifying Life Events (QLE). If you do not participate in premium conversions,
opportunities to enroll, change plans or options, or change to a Self and Family enrollment
are limited to Open Season and QLEs. However, you can cancel your FEHB enrollment or switch
to a Self Only FEHB enrollment at any time. The annual Open Season is held from the Monday
of the second full workweek in November through Monday of the second full workweek in December.
During Open Season you may enroll, change plans, options, or type of enrollment (Self
Only versus Self and Family), or cancel your FEHB enrollment.
Eligible tribal employees who did not enroll during an earlier opportunity may enroll during
the annual Open Season.
You also may make a change upon experiencing an FEHB-specific QLE. The QLE determines what
type of enrollment change is permitted. The enrollment change must be consistent with
the QLE. Usually, you can make changes beginning 31 days before the event to 60 days after
the event. Examples of QLEs include:
• Marriage or divorce • Birth or adoption of a child
• Last eligible child becoming age 26 The QLEs are based on both FEHB regulations
and IRS requirements. For more information on QLEs look at the Tables
of Permissible Changes in the SF 2809 which is available on our tribal programs website.
The next section we will discuss is “things to remember when enrolling in the FEHB Program.”
This section discusses which family members are eligible or not eligible for coverage
if you have a Self and Family enrollment. It also explains dual enrollments and when
a dual enrollment is or is not allowed.
Let’s talk a little bit about types of FEHB enrollment. FEHB statute Title 5 United States
Code 8905(a) only allows two types of enrollment: Self Only or Self and Family.
A Self Only enrollment provides benefits for the tribal employee only. You may enroll for
Self Only even if you have a family. Under a Self Only enrollment, your family is not
eligible for FEHB coverage. A Self and Family enrollment provides benefits
for you and your eligible family members. All eligible family members are automatically
covered, even if you do not list them on the Health Benefits Election Form, SF 2809. You
cannot exclude or remove any eligible family member.
Your FEHB enrollment will not cover anyone who is not an eligible family member, even
if that person is listed on the SF 2809. The premium for a Self and Family enrollment
is the same regardless of the number of eligible family members.
Let’s talk a little bit about eligible family members. The FEHB law defines family members
as a spouse (including a valid common law marriage) and a child under age 26. Public
Law 104-199, Defense of Marriage Act (DOMA), states, “the word ‘marriage’ means only
a legal union between one man and one woman as husband and wife, and the word ‘spouse’
refers only to a person of the opposite sex who is a husband or a wife.” Same-sex partners
are not eligible family members. Foster children are covered if the tribal
employee certifies that all of the following are true:
• The child must live with tribal employee in regular parent-child relationship
• The tribal employee must be primary source of financial support
• The tribal employee must expect to raise child to adulthood
• And the tribal employee must provide written certification to tribal employer (a sample
certification is in the FEHB Handbook) For more information on family member eligibility,
please contact your tribal employer.
Right now you might be wondering, “who are not eligible members.” If you are divorced
or your marriage has been annulled, your former spouse may not continue to receive FEHB benefits
under your Self and Family enrollment. This is the case even when the court has ordered
you to provide coverage for your former spouse. However, your former spouse may be eligible
for Temporary of Continuation Coverage (TCC). For more information on TCC, please visit
the tribal programs website. Once your child reaches age 26, he/she is
no longer eligible for benefits under your FEHB Self and Family enrollment, unless he/she
is disabled and incapable of self-support. However, your child would be eligible for
TCC. You must tell your FEHB plan immediately when
family members lose coverage for any reason including divorce, annulment, or when your
child turns age 26. Regardless of whether or not the following
family members are dependent upon the tribal employee, they are not eligible family members
in the FEHB Program: • Grandchildren (unless they meet the foster
child requirements), • Parents or parents-in-law,
• Siblings (unless they meet the foster care requirements),
• Same-sex partners, domestic partners, or spouses,
• Boyfriends, girlfriends, or fiancés (even if they live with the tribal employee).
Contact your tribal employer for more information.
The next topic is dual FEHB enrollments. A dual enrollment exists when a person is enrolled
or covered under more than one FEHB plan. FEHB law prohibits a person from being covered
under more than one FEHB enrollment. This includes FEHB enrollment via another tribal
employer or a Federal government agency. An example of a dual enrollment is when two
tribal employees enroll in FEHB. The wife has a Self and Family enrollment. The husband
has a Self Only enrollment. The husband is covered under his Self Only and his wife’s
Self and Family enrollment. This is a dual enrollment and is NOT permitted in the FEHB
Program. If a dual enrollment occurs, the tribal employer
must void or cancel one of the enrollments. There are very few exceptions to this prohibition.
Dual enrollment must be authorized by your tribal employer and will only be allowed when
you or an eligible family member would otherwise lose coverage.
There are some termination events I would like to talk about now. The events I will
talk about now are the most common reasons why a tribal employee’s FEHB enrollment
would terminate. For additional information, see FEHB regulations at 5 CFR 890.304 and
the Tribal FEHB Handbook Chapter 7 on Termination and Conversion.
The first is separating from employment (including retirement)
The second is beginning leave without pay or military service and electing not to continue
FEHB A tribal employee who begins leave without
pay must elect to: • continue FEHB for up to 365 days and be
responsible for his/her share of the premium, or
• have his/her FEHB terminate at the end of the last pay period for which premiums
were withheld. It is important to note that if the tribal
employee does not make an election, coverage terminates at the end of the last pay period
for which premiums were withheld. In either case, the tribal employee may enroll
when he/she returns to pay status. More detailed information is in the Tribal FEHB Handbook
Chapter 6, Leave Without Pay and Insufficient Pay.
The third termination event is ending of 365 days of leave without pay or 24 months of
military service (if elected to continue FEHB) A tribal employee who enters active military
service may elect to: • have his/her FEHB terminate on the day
he/she is placed on leave of absence for military duty, or
• continue his/her FEHB for up to 24 months of active duty.
Please note that if the tribal employee does not elect termination, the FEHB continues.
In either case, the FEHB is reinstated upon reemployment, unless the tribal employee postpones
reinstatement to use extended TRICARE. More detailed information is in the Tribal FEHB
Handbook chapter 9 on Military Service.
Let’s talk a little bit more about termination events. If your employment is terminated , you
all and your eligible family members will have a 31-day extension of coverage when you
lose FEHB coverage other than by cancellation. The 31-day extension of coverage is at no
cost to the tribal employee. If your FEHB coverage terminates, you have
the right to convert to individual non-FEHB coverage with the same FEHB plan. A conversion
policy differs from FEHB plans and has different rates and benefits. The plan may not exclude
you because of a pre-existing medical condition. TCC is a feature of the Federal Employees
Health Benefits (FEHB) Program that allows certain people to temporarily continue their
FEHB coverage after regular coverage ends. If your FEHB enrollment terminates, the tribal
employer must give you a notice of your right to convert to an individual policy on the
Notice of Change in Health Benefits Enrollment Form (SF 2810). The tribal employer must provide
you with this notice immediately upon the your FEHB enrollment termination, but no later
than 60 days from the termination date. To apply for conversion, you must complete
the back of your copy of the SF 2810 and send it to your plan within 31 days from the date
of the tribal employer's notice to the tribal employee (part H of SF 2810), but no later
than 91 days from the date the FEHB enrollment terminates (Part A, item 8 of SF 2810).
The tribal employer will not issue an SF 2810 when a family member loses coverage. It is
your or your family member’s responsibility to know when the family member loses coverage.
If the family member is interested in converting to individual coverage with the FEHB plan,
he/she must request conversion within 31 days after his/her coverage as a family member
is terminated. See the Tribal FEHB Handbook chapter 7 on
Termination and Conversion. TCC is available to: (1) employees who lose
their FEHB Program coverage because they leave their Federal jobs or retire, (2) children
who lose their FEHB Program family member status because they reach age 26, and (3)
former spouses who lose their FEHB Program family member status because of divorce or
annulment. TCC allows former employees to continue their FEHB Program coverage for up
to 18 months, and former family members (meaning children and former spouses) to continue FEHB
Program coverage for up to 36 months.
Now I want to move on to the resources that OPM has made available. This section provides
a list of resources to help you learn more about the FEHB Program and to help you make
your plan selection.
Please use the following resources to assist you in a selecting a health plan that best
suits you and/or your family’s needs. The FEHB Tribal FastFacts: The Federal Employees
Health Benefits (FEHB) Program for Tribal Employees provides basic information about
the FEHB Program for tribal employees. The Quick Guide provides answers to over 30
common questions about the FEHB Program. The FEHB Program Features presentation provides
an overview of the FEHB program. You can find all of these resources at www.opm.gov/insure/health/tribes/reference/index.asp.
Let’s talk about some more resources. The FEHB plan brochures provide information
about the benefits of each plan. The SF 2809 is used to enroll, change, or
cancel enrollment in the FEHB Program. The SF 2809 Guide for Tribal Employees provides
guidance on how to complete the SF 2809.
The FEHB Guide for Tribal Employees includes summary information about the FEHB Program
and gives details intended to educate and inform you about the choices available to
you. The Guide lists the plans available in each state, premiums, selected benefits, FEHB
plan consumer satisfaction survey results, and links to other health plan quality indicators.
The Helpful FEHB Resources for Tribal Employees contains a list of resources to help you find
specific FEHB benefits information.
Last, you might me wiondering, “where can I get help?” We really hope you’ve enjoyed
the slideshow presentation. If you have any questions, please visit our website www.opm.gov/tribalprograms
or contact your tribal employer.