Introduction

The Federal Employees Health Benefits Program (FEHBP) provides you with protection against the expenses of illness and accidental injuries. The FEHBP provides some of the following benefits:

• Guaranteed medical insurance protection for you and your family,
• Major catastrophic illness protection,
• Coverage without medical examination, without waiting periods, and without restrictions because of your age or physical condition (preexisting conditions are covered; for example, pregnancy),
• Premium-sharing to reduce your cost of the plan,
• Continued protection after you retire, and
• A choice of plans to provide the protection you need and want.

Eligibility

Any permanent or term employee is eligible to enroll in the FEHBP. Participation is voluntary, but NASA encourages you to enroll for this coverage. If you are a new employee, you have 60 days from the date of your appointment to enroll. If you choose not to enroll, then you still may enroll later during the "open season" that is described below.

Temporary employees who have more than 1 year continuous service are eligible to enroll; however, they must pay the full cost of the premium for their share and the Government's share.

Open Season

Open season is once a year. You will receive information during November and December. Generally, the effective date for enrollments and changes is the beginning of the first pay period in January. Open season is your chance to enroll or change your coverage.

Most of the plans are open to all employees; however, some plans require that you receive your health care in a particular geographic location or clinic. Other plans sponsored by unions and employee organizations are available only if you are or you become a member of the sponsoring organization. They also require a modest associate membership fee to be eligible.

Types of Plans

There are two basic types of plans under the Federal Employees Health Benefits Program:

• Fee-for-Service Plans - Fee-for-Service plans repay you or your health care provider for covered services. If you enroll in one of these plans, you may choose your own physician, hospital, and other health care providers. For example, Blue Cross/Blue Shield Service Benefit Plan is a fee-for-service plan.
  
• Prepaid Plans - Prepaid Plans are the Comprehensive Medical Plans/Health Maintenance Organizations (CMPs/HMOs). These plans provide or arrange for health care by appointed plan physicians, hospitals, and other providers in particular locations. These plans are available to all eligible employees within the plans’ enrollment (local) area. CMPs/HMOs pay all providers through salaries or other payment arrangements. You pay any required co-payments. The following are the types of prepaid plans:

• Group Practice Plans provide care through staff physicians or a group of physicians. These physicians practice at one or more medical centers operated by the plans.
• Individual Practice Plans provide care through participating plan physicians and usually require you to choose a primary physician. These physicians practice in their own offices.

The plans arrange hospital and other care not available in centers and offices when necessary.

Pre-admission Certification

All fee-for-service plans (Blue Cross, GEHA, Mail Handlers, etc.) require you, your doctor or the hospital to contact your local plan before admission to the hospital. For an emergency admission, you need to contact your plan within 2 business days of the emergency. You need to follow these new procedures because of a $500 penalty. The plan applies the penalty by deducting $500 from your hospital benefits.

Enrollment

Each plan has two types of enrollment: self only and self and family.

• Self-only enrollment provides benefits just for you -- the enrolled employee.
• Self and family enrollment provides benefits for:

-- you,
-- your spouse,
-- your unmarried dependent children under 22 years old, and
-- disabled children who are 22 years old or older may be eligible for coverage.

You will need adequate medical proof of a mental or physical handicap that existed before the child’s 22nd birthday. Children whose marriage ends in divorce or annulment before they reach age 22 may again be eligible for coverage. It is your responsibility to notify your carrier as well as your Employee Benefits Counselors when you add a new family member.

Children covered by your enrollment include: your natural children, legally adopted children, stepchildren, foster and grandchildren. Stepchildren, foster children and grandchildren must live with you in a regular parent-child relationship. There are also other requirements for foster children and grandchildren. Ask your Employee Benefits Counselors for details about these requirements.

A newly eligible family member (such as a newborn child or a new spouse) has automatic coverage under your self and family enrollment. In addition, some former spouses may qualify to enroll in a health benefit plan. No other person is a member of your family for health benefits purposes even though they live with you and you are their main means of support.

If you have self-only coverage, you must elect, or change to, a self and family enrollment to cover a newly eligible family member. If you and your spouse are both Federal employees, you may have only one family enrollment. The law prohibits dual enrollment.

Costs

You and the Government share the cost of your enrollment. The Government pays an average of 60% of the premium. You pay the remainder of the cost through salary withholdings.

Changes in Enrollment

You may change your enrollment during the annual open season each year or within 31 days before to 60 days after a change in marital status. See the Table of Permissible Changes in Enrollment of Employees on page 6 of the SF2809 for additional life events that allow you to make a change in coverage.

Continuation of Enrollment

Your enrollment will continue if:

• You transfer to another Government agency;
• You are on leave without pay (up to 365 days) and pay your part of the premium (co-op employees are allowed to continue as long as they remain in the co-op program);
• You enter on active duty or active duty for training in the military for 30 days or less (for example, the reserves);
• You are receiving pay for an injury on the job (worker’s compensation) and meet the requirements described for retirement; or
• You are retired and meet the requirements described below.

If You Retire…

Your enrollment may continue upon retirement from NASA. You receive the same benefits and pay the same premiums as when you were working; however, you need to meet the following requirements:

• You retire on an immediate annuity. That is, an annuity which begins no later than 1 month after your separation. If you are retiring under FERS, an immediate annuity includes one based on the minimum retirement age and 10 years of service (MRA & 10), even though you may postpone receipt of the annuity, and
• You have at least 5 years of continuous coverage under the FEHBP immediately before your retirement, or for all service since your first chance to enroll.
• Your coverage can be under your own enrollment or as a family member under your spouse's enrollment.

If You Die…

The following requirements must be met for your survivors to continue their enrollment in the health plan:

• You had self and family enrollment at the time of death,
• At least one family member has a right to a survivor annuity,
• If there is only one eligible family member, their enrollment will automatically change to self only.

Temporary Extension of Coverage and Conversion

Employee or family member loses coverage

Your coverage continues temporarily for 31 days after your enrollment ends for any reason except voluntary cancellation. In addition, confinement in a hospital on the 31st day of the extension, allows benefits to continue during confinement for a maximum of 60 more days.

The 31-day temporary extension is free, and applies also to any family member who loses coverage -- unless you voluntarily cancel or change from self and family to self only. A change to self only is a cancellation for the covered family members. The family members lose rights to temporary extension of coverage. A family member who loses coverage because you cancel or change to a self only enrollment also loses their conversion right.

Except for reasons given above, if you or a family member have lost coverage (divorce, becoming age 22, etc.), you and your family have a right to convert. Conversion is to a nongroup health benefits contract offered by the carrier of your plan -- no requirement for a medical examination. This is especially important to remember when a child reaches age 22 and loses coverage. You or your child need to contact your Employee Benefits Counselors for further information.

Temporary Continuation of Coverage

Separating employees, former spouses and children who would otherwise lose coverage may be eligible to continue coverage. This continuation is in addition to the 31-day temporary extension of coverage (above).

If you separate from NASA (not retire) you will be able to continue your health insurance coverage for up to 18 months. Spouses who lose coverage because of divorce and children who lose coverage upon marriage or turning age 22 may have continuous coverage for up to 36 months.

If you are eligible to continue your coverage, you need to contact your Employee Benefits Counselors within 60 days of your separation from NASA, divorce, etc. The Employee or Benefits Services Representative will help you to complete the necessary forms. They will also give you any other information you need to help you decide. You pay the full enrollment costs -- both NASA’s share (approximately 60%) and your share -- plus a 2 percent administrative charge.

If you retire, you have permanent coverage and you pay the same group rates as an employee. You are also eligible to make changes during Open Seasons.

Termination of Enrollment

Your enrollment automatically ends if you separate or have more than 365 days of leave without pay. If you retire, transfer, or have a compensable disability then you may continue enrollment.

Guidance on Choosing Your Federal Health Plan

There are five key considerations in selecting an appropriate health plan:

• To protect you and your family from a financial hardship as a result of catastrophic medical care;
• To receive prompt payment or service upon submission of a claim for payment or medical care;
• To cover the expected expenses for medical care that may arise during the coming year;
• To cover special medical needs that you may reasonably expect; and
• To pay a reasonable amount of money, depending upon the level of protection you want or need.

The Enrollment Information Guide, Plan Comparison Chart will help you to learn about the various plans. Do not depend on the guide alone to select your plan. The Comparison Chart and individual plan brochures are available from your Human Resources Office or on the OPM website. Use the comparison chart as a rough guide to rule out plans. If you notice that a plan does not offer the coverage you want (e.g., mail-order prescription drugs), then forget that plan.

Catastrophic coverage is probably the single most important reason for having a health plan. The comparison chart can be misleading about catastrophic coverage. Some plans do not cover all important costs. Use individual plan brochures for complete information. Read the plan brochures carefully to determine if the plan will cover what you and your family need.

Even though there are really no ‘bad’ Federal Employee Health Benefits plans, you should be sure that the plan you choose meets your needs as well as your family's needs. Having the right health plan is important if you expect major changes -- in your health, financial situation, or in major medical expenses.

Some special considerations to aid your selection are the catastrophic limit, psychiatric care, prescription drugs, skilled nursing care, home care, hospice care, dental care, or chiropractic care. Beware of choosing a plan specifically because it covers one need well. Make sure it also covers other major medical expenses. Sometimes the expense for one type of care (e.g., dental care) is minor compared to expenses for another type of care (e.g., major surgery). Contact your Employee Benefits Counselors for further assistance.

High Option versus Low Option

You should understand the differences between a high option and a low or standard option. Just because you pay higher costs doesn't mean that you will have better or more coverage. The main differences are in the deductible ($50 or $100) and in the coinsurance (80% instead of 75%).

You choose your own plan! Only you know your family medical history and the chances of something happening to you or your family members. Only you can determine what coverage you truly need and how much you can afford to pay for that coverage. Only you know your complete financial situation. Do not switch plans simply for the sake of switching or because other employees are switching to what they think is the cheapest or best plan available! Stay with your plan if:

• You feel comfortable with your plan;
• You have no major problems getting repaid or obtaining any services;
• You think the payments you pay are reasonable; and
• You believe that nothing has happened, or is expected to happen that might change your health coverage needs.

Special Features of Fee-for-Service Plans (Blue Cross, GEHA, Alliance, etc.)

• You may seek treatment anywhere in the United States.
• Plans cover prescription drugs. Most offer an inexpensive prescription-by-mail service.
• You may select your own doctor.
• Most plans offer special coverage, such as hospice care, home health care, dental care, and discount drugs by mail.
• You must save bills and receipts and keep decent records in order to get repayment.
• You or your provider must file claim forms for repayment.
• You should discuss fees with your doctor.
• You should check bills from doctors and hospitals for correct charges.
• You need advanced approval before a non-emergency admission to a hospital or you suffer a penalty ($500).

Special Features of Health Maintenance Organizations (Aetna, HMO Blue, Pacificare)

• You do not need to spend your own funds and then wait for reimbursement.
• Plans tend to stress preventive examinations and health education -- routine physical examinations, well baby care, and immunizations.
• Plans save you the inconvenience of submitting claim forms. There is a minimal charge for office visits and prescriptions.
• Plans assure you access to a group of doctors.
• Plans prevent the doctor charging you more than the plan will repay.
• Plans require you to go to one of their office locations, or choose doctors who work for their plan.
• Many plans use mid-level professionals (such as nurse practitioners and physician assistants).
• You are in the hospital less frequently and usually for a shorter time.
• Plans pay most surgical and related hospital costs.
• Plans decide whether you need surgery, referral to a specialist, or therapy.

Effective Dates

• Enrollments and changes in enrollment (except cancellations and open season changes) become effective on the first day of the first pay period after the one in which (1) the employing office receives the registration form (Standard Form 2809), and that (2) follows a pay period during any part of which the employee was in a pay status. The pay status requirement does not apply to a change from Self and Family to Self Only or a change from Self Only to Self and Family due to the birth of a child or addition of a child as a family member.
• A cancellation becomes effective on the last day of the pay period in which the cancellation is received.