Federal Employees Health Benefits (FEHB) Program

What is FEHB?

The Federal Employees Health Benefits (FEHB) Program is a nationwide health insurance program administered by the Office of Personnel Management (OPM). It provides eligible federal employees, retirees, and their families with a choice of more than 30 privatesector health insurance plans. The program is one of the largest employersponsored health insurance programs in the United States, covering more than 8 million individuals.

Eligibility

FEHB is open to:

• Fulltime Federal employees (including temporary and seasonal) who are appointed under civil service or excepted service statutes.
• Federal retirees, including those who were covered while employed.
• Family members: spouse, children (including adopted and stepchildren), and, in some cases, domestic partners.

Parttime employees may be eligible if they work at least 20 hours per week on a regular basis, though they must meet additional criteria set by their agency.

Plan Types & Options

FEHB plans fall into three broad categories:

1. Prime Plans Traditional feeforservice plans that pay a set amount for each covered service. Most familiar to the public.
2. ConsumerDriven Plans (CDPs) Include Health Savings Accounts (HSAs) or Health Reimbursement Arrangements (HRAs). They pair a highdeductible health plan with a taxfree savings vehicle.
3. Managed Care Plans Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs) that use a network of doctors and hospitals to control costs.

Each plan is offered by a private insurance carrier and may differ in:

• Premium amounts
• Deductibles and outofpocket limits
• Provider networks
• Coverage of prescription drugs, dental, vision, and mental health services

Enrollment & Changes

Annual Open Season

Each year, typically in November, OPM conducts an Open Season that allows participants to:

• Enroll for the first time
• Switch to a different FEHB plan
• Change the number of family members covered
• Cancel coverage (if you are still employed and have other employersponsored coverage)

Qualifying Life Events (QLEs)

Outside the Open Season, you may make changes if you experience a QLE, such as marriage, divorce, birth or adoption of a child, loss of other coverage, or a change in employment status. You generally have 60 days from the event to request a change.

Costs & Premiums

Premiums are shared between the employee (or retiree) and the Federal government. The government typically pays 72% of the premium for the employees share and 75% for retiree share, leaving the employee to cover the remainder.

Factors affecting your outofpocket premium include:

• Plan type (HMOs often have lower premiums than PPOs)
• Number of people covered
• Geographic location (premiums vary by region)
• Whether you choose a highdeductible plan with an HSA

In addition to premiums, you may be responsible for deductibles, copayments, and coinsurance. The Affordable Care Act (ACA) limits annual outofpocket costs for most plans.

Benefits Covered

All FEHB plans must meet minimum federal standards and provide coverage for:

• Hospital and outpatient services
• Preventive care (including immunizations and screenings)
• Mental health and substanceuse disorder services
• Prescription drugs (subject to a formulary)
• Maternity and newborn care
• Rehabilitative services (physical, occupational, speech therapy)
• Laboratory and radiology services

Many plans also offer optional benefits such as dental, vision, chiropractic, and alternative therapies, either bundled or as addon riders.

How to Choose the Right Plan

Choosing a plan depends on personal health needs, financial situation, and preferences for provider choice. Follow these steps:

1. Assess your health usage. If you expect frequent doctor visits or have chronic conditions, a plan with a lower deductible and broader network may save money.
2. Calculate total cost. Add premium, expected deductible, and typical copays. Use OPMs costcomparison tools to estimate annual expenses.
3. Check provider networks. Verify that your primary care physician, specialists, and preferred hospitals are innetwork.
4. Review drug coverage. Ensure that your regularly prescribed medications are on the plans formulary.
5. Consider flexibility. If you travel often or want the ability to see outofnetwork doctors, a PPO may be preferable to an HMO.
6. Think longterm. For retirees, a highdeductible plan paired with an HSA can be taxadvantageous, especially if you expect lower medical expenses.

Common Questions

Can I have both FEHB and a private plan?

Yes, but you must designate one plan as primary. Coordination of benefits rules determine which plan pays first.

What happens if I leave federal service?

Most employees become eligible for FEHB continuation (often called continuation coverage) as long as they were enrolled for at least 6 months before separation and have not been out of coverage for more than 63 days.

Are preexisting conditions covered?

All FEHB plans must cover preexisting conditions. There is no waiting period.

Do I need to enroll in Medicare when I become eligible?

Federal retirees who are not yet enrolled in Medicare can keep FEHB coverage, but most choose to enroll in Medicare Part A (hospital) at age 65. Medicare Part B (medical) is optional; however, many retirees enroll because it works together with FEHB to reduce outofpocket costs.

How do I get my claim forms?

Claims are typically processed electronically by the plans carrier. If you need a paper form, contact your plans customer service department; the contact information is listed in your enrollment packet or on the carriers website.

Helpful Resources

• OPM FEHB Homepage Official site for enrollment, plan comparison, and policy updates.
• Federal Employees Health Benefits Review Council (FEHRC) Provides independent plan ratings and consumer guides.
• HealthCare.gov General information about health insurance and the ACA, useful for understanding coverage standards.
• OPM Forms Library Locate enrollment forms, changeofstatus forms, and continuation coverage paperwork.
• Contact your agencys Human Resources office for personalized assistance.