ADMINISTRATIVE DIGEST No. 96-01 Date: Wed, 08 Nov 1995 11:15:09 -0500 From: "Cynthia S. Wylie" To: "Water Resources Division Employees" Subject: Health Benefits Open Season ADMINISTRATIVE DIGEST No. 96-01 November 13, 1995 HEALTH BENEFITS OPEN SEASON The Health Benefits Open Season for the 1996 contract year is being held from November 13 through December 11, 1995. During this period, employees who are not enrolled in a health benefits plan may enroll in one. In addition, employees and retirees who are currently enrolled may change from one plan or option to another, and they may change from Self Only to Self and Family coverage, either in their old plan or in a new one. Temporary employees who have completed a year of continuous service will be eligible to enroll in a health benefits plan or make a change from one health plan to another. Employees who wish to remain in their present health plan are not required to take any action. To enroll or to make any of the changes listed above, the employee must complete Standard Form 2809 (Health Benefits Registration Form) and return it to the servicing personnel office. Enrollment in a health plan or a change in coverage made during the open season (except a change to Self Only within the same plan) will be effective at the beginning of the first full pay period in January 1996 (01-07-96). If you change plans, any covered expenses incurred between January 1, 1996, and January 6, 1996, will count toward the 1995 deductible of the plan you are changing from. Changes to Self Only within the same plan may be made at any time and are not open season changes; they are effective the first day of the pay period following their receipt in the servicing personnel office. Plans Available to All Eligible Employees. The Governmentwide Service Benefit Plan (Blue Cross-Blue Shield), and the following employee organization plans are available to all eligible employees: the Alliance Health Benefit Plan, the American Postal Workers Union Health Benefit Plan, the Government Employees Hospital Association Benefit Plan, the Mail Handlers Health Benefit Plan, the National Association of Letter Carriers Health Benefit Plan, and the Postmasters Health Benefit Plan. Please note that the employee organization plans charge a membership fee when enrolling in the health plan. Comprehensive Health Plans. In addition to the plans available to all employees, those in certain geographic areas may choose a comprehensive plan which covers that area. Several comprehensive plans have dropped out of the Federal Employees Health Benefits Program this year, and employees enrolled in these plans should have already been notified by the plans. Any employee currently enrolled in a comprehensive health plan which is no longer participating in the Federal Employees Health Benefits (FEHB) Program in 1996 must select a new plan during this open season. You should also note that the policy for establishing prepaid plan service and enrollment areas is being liberalized. Starting in 1995, some plans had enrollment areas larger than their service areas. Some plans may also accept enrollments from persons who work in the enrollment area, as well as from 2 those who live in the enrollment area. The specific requirements may vary from plan to plan and will be stated on the front of each prepaid plan's brochure. Distribution of Materials. The 1996 Enrollment Information Guide and Plan Comparison Chart (RI 70-1) will be available in the servicing personnel office for review. Because of the number being provided by the Office of Personnel Management this year, there will be no general distribution of this booklet. This guide contains enrollment and general information, a comparison chart showing the major benefits of all plans, and biweekly and monthly rates for each plan for 1996. This year the Office of Personnel Management is providing a 1996 Enrollment Information Guide and Plan Comparison Chart (RI 70-10) for the visually impaired. This chart is available through your servicing personnel office upon request. There will be no general distribution of individual plan brochures. Employees enrolled in the employee organization, Governmentwide, and comprehensive plans will receive a brochure for that plan directly from the carrier. Brochures for all plans will be available for employees to review from the servicing personnel office in limited quantities during the open season. If, after examining the comparison chart, you decide that you are interested in enrolling in or changing to a particular plan, you should contact your servicing personnel office to arrange to review the brochure of the plan(s) in which you are interested. Please note that the Office of Personnel Management has permitted health plans to advertise non-FEHB benefits in the individual plan brochures. These benefits are shown in the brochure on a page clearly marked "Non-FEHB Benefits Available to Plan Members." It is important to note that any benefits shown on this page are not part of the FEHB contract and therefore are not guaranteed. This means that the plan may change or even discontinue the benefits at any time. The costs of these benefits are not included in the FEHB premium. Any charges for these services do not count toward FEHB deductibles, out-of-pocket maximums, or catastrophic protection. These benefits are not subject to the disputed claims procedure. Completing Standard Form 2809. Standard Form 2809, Health Benefits Registration Form, was revised effective August 1992, to make several minor editorial and technical clarifications. This is the only usable edition of the form. This form is available through GSA channels and may be obtained by using FEDSTRIP/MILSTRIP procedures, National Stock Number (NSN) 7540-01-231-6227, at an approximate cost of $9.16 per hundred. Below are some specific instructions for completing SF 2809: 1. Complete Part C by recording the name of your present health plan in Block 1 and the three-character enrollment code of the plan in Block 2; write the number "1" (which designates the event as open season) in Block 3; and write November 13, 1995 (the date open season begins) in Block 4. 3 2. Cancellations and changes from Family to Self Only within the same plan are not open season changes. If you are cancelling your coverage, complete Part E and be sure to read "Cancellation of Enrollment." If you are changing to Self Only within the same plan, complete only Blocks 1 and 2 of Part C; the remaining blocks in Part C should be left blank. Note that changes to Self Only within the same plan are effective on the first day of the first pay period after the servicing personnel office receives the SF 2809; cancellations are effective the last day of the pay period when the servicing personnel office receives the SF 2809. 3. Some comprehensive plan and employee organization plan brochures instruct employees to enter on the SF 2809 additional information which is needed by the specific plan to properly process the enrollment. It is important that you supply this information to avoid unnecessary delays in processing. 4. At the top of the form or on a separate sheet, please provide your local mail stop or an office address so that the personnel office can return your copy to you. Please note that information you provide by enrolling in the FEHB Program may also be used for computer matching with Federal, State, or local agencies' files to determine whether you qualify for benefits, payments, or eligibility in the FEHB Program, Medicare, or other Government benefits programs. Timely Filing. "Employing Office" means the servicing personnel office. All employees will be filing with their local personnel office. The exception is the ST, SL, and SES employees; they will file all registration forms with the Office of Human Resources, Mail Stop 601, Reston, Virginia. Employees who are located at a distance from their servicing personnel office should make certain that their forms reach the servicing personnel office by December 11 to be timely filed. Employees who must mail changes should not wait until December 11 to file forms unless there are extenuating circumstances (for example, informational materials were not received until December 11). All employees are urged to make desired changes as early as possible in the open season. Employees Considering Cancellation. Employees considering cancelling their health benefits plans are reminded that the law allows employees to continue health benefits coverage into retirement provided they meet all of the following conditions: 1. They are retiring on an immediate annuity; 4 2. They are retiring after 5 or more years of service or under the disability provisions of the retirement law; AND 3. They have been enrolled (or covered as a family member) in a plan under the FEHB Program during the 5 years of service immediately preceding retirement or since their first opportunity to enroll. The 5-year requirement must be met on the date annuity commences. (This is a very significant consideration if you are thinking of cancelling your enrollment for any reason; it would be particularly important should you subsequently need to retire on disability.) Part-Time Employees. Employees serving on a part-time basis on or after April 8, 1979, are subject to the provisions of Public Law 95-437 (the Federal Employees Part-Time Career Act of 1978), which requires that the Government's contribution toward the cost of health benefits enrollment is prorated in direct proportion to the percentage of full-time service such employees perform. Thus, an employee who works 32 hours per week, or 80 percent of a full-time schedule, receives 80 percent of the Government's contribution toward the premium of a full-time employee. The effect of this reduction in the Government's contribution is to raise the amount of the premium part-time employees pay. The rate charts employees will receive reflect Government and employee contributions for full-time employees; therefore, part-time employees must make appropriate adjustments in the rates. The exception to Public Law 95-437 is those employees who are part-time but work less than 16 hours per week. In this instance, health benefits are not prorated. Employees in Nonpay Status. Employees are reminded that although health benefits coverage continues for up to a year while an employee is in a nonpay status, employees must pay their share of the premiums on their return to pay status. The Government will pay its share of the premiums for up to a year while the employee is in a nonpay status. Arrangements will be made through the Payroll Office for payment of premiums either through payroll deductions or a lump sum payment. Temporary Employees. Temporary employees who have completed 1 year of continuous employment, excluding any break in service of 5 days or less, are eligible to enroll in a health benefits plan. These employees must pay the full amount of the premium, with no Government contribution. Servicing personnel offices have copies of this comparison chart available for review. Temporary Continuation of Coverage (TCC). A change in regulations now allows three groups of people to maintain their Federal health benefits coverage past the normal termination. Employees who separate from Federal service are able to continue their Federal health coverage for a maximum of 1-1/2 years; children who have been covered under the employee's enrollment and stop meeting the requirements for dependent children (either due to marriage or upon reaching age 22) may continue health benefits coverage for a maximum of 3 years; and spouses who lose coverage as the result of a divorce may continue health benefits coverage for a maximum of 3 years. Your servicing personnel office should be contacted in regard to registration procedures and time limitations. 5 Important Information for All Employees. As part of their efforts to reduce costs, in recent years many carriers have added to their plans features which require employees to follow special procedures in order to obtain benefits. Some have also added copayments beyond the basic deductible, e.g., for dental benefits, diagnostic tests, and first day of hospitalization. Even if you do not make an open season change, it is very important that you read your 1996 plan brochure carefully. OPM has directed all plans in 1996 to require pre-certification for all non-emergency hospital visits. If this pre-approval is not obtained, you will not receive full benefits for hospital charges. The pre-approval of non-emergency inpatient hospital care by the insurer will reduce costly and unnecessary admissions and help assure that admissions are appropriate. Also, you should note especially requirements to obtain second opinions for certain types of surgery, requirements to use a plan's mail order prescription service for certain drugs, requirements to use preferred hospitals, and requirements to obtain authorization from the plan within 48 hours of an emergency admission. Employees are responsible for knowing their plan's requirements and for making certain that family members (including children living away from home) and personal physicians are aware of any restrictions in benefits or services. If you have been in the same plan for several years, you may not have kept up with changes your plan has made over the years. If you do not understand any provisions of your plan, you should contact your servicing personnel office or the carrier. Employee Questions. Questions regarding the above information and requests for health plan brochures should be directed to the servicing personnel office. William F. Gossman, Jr. Acting Chief, Office of Program Support Distribution: E