+-----------------------------------------+----------------------------+
| **FEHB Program Carrier Letter**         | **U.S. Office of Personnel |
|                                         | Management**               |
| **All Carriers**                        |                            |
|                                         | **Office of Insurance      |
|                                         | Programs**                 |
+-----------------------------------------+----------------------------+
| **Letter No. 1999-013** **Date:** March |                            |
| 16, 1999                                |                            |
|                                         |                            |
| Fee-for-service \[ 12 \]                |                            |
| Experience-rated HMO \[ 12 \]           |                            |
| Community-rated \[ 11 \]                |                            |
+-----------------------------------------+----------------------------+

**SUBJECT:** Table 1 \-- Reporting Under The FEHB Program

By Carrier Letter 98-012 we notified you that we discontinued Table 2
Summary of Open Season Transactions and we asked you to only report
disenrollment data for that reporting period.

We have now revised Table 1 Enrollment Report to incorporate
disenrollment data. Please use the enclosed form beginning with your
April 15, 1999, submission and continue to use the form each year until
we notify you otherwise.

For more information about Table 1, contact Mike Hodges at 202/606-0745.

Sincerely,

(signed)

Frank D. Titus

Assistant Director

for Insurance Programs

Enclosure

**TABLE 1. SUMMARY OF FEHBP ENROLLMENT**

FREQUENCY: Annual

Cut-off date: March 31

Due date: April 15

Purpose: Summarizes the number of enrollees and dependents by type of
enrollment for a specific code.

Instructions: If your plan has multiple codes, submit a separate report
for each code.

**Employees** \-- means [active]{.underline} employees covered by
FEHBP. For the purposes of this table, all enrollees in payroll offices
not listed below are employees.

**Annuitants** -- means [retired]{.underline} employees and other
annuitants covered by FEHBP. For the purposes of this table, all
enrollees in the following payroll offices are annuitants:

10 01 5697

16 00 9919

19 00 0001

20 74 9901

23 90 0001

24 00 0002\*\*

24 03 9901

24 04 9901

24 05 9901

24 06 9901

24 07 9901

24 02 9901

24 17 9901

24 21 9901

24 57 9901

24 90 0002\*\*

28 00 3334

57 38 0101

64 90 9901

69 02 5356

95 56 0057

(formerly, 11 23 9902)

95 56 0058

(formerly, 11 93 9901)

95 56 0059

(formerly, 11 93 9902)

99 00 4860

99 00 4861

99 00 4862

99 00 4863

99 99 0001

\*\* 24 90 0002 and 24 00 0002 are OPM's payroll office numbers for CSRS
and FERS annuitants.

**Contracts** -- report the number of enrollees (employee and annuitant
contract holders) in your plan at the end of the reporting period.

**Persons Covered** -- report the number of members (enrollees plus
[all]{.underline} of their covered dependents) in your plan at the end
of the reporting period.

If you cannot provide an exact figure for dependents, estimate.

Check the box and tell us how you arrived at your estimate.

**Disenrollments** -- report the total number of contracts who
transferred out of your plan into another plan or dropped health
benefits entirely. Please note we are interested in gross disenrollments
-- not net.

# Revised March 1999 

TABLE 1. SUMMARY OF FEHBP ENROLLMENT

MARCH 31, \_\_\_\_\_\_\_\_ \[Enter year of report\]

+---+----------------------+-------------+---------------+-------------+
| P |                      |             | Plan code:    |             |
| l |                      |             |               |             |
| a |                      |             |               |             |
| n |                      |             |               |             |
| n |                      |             |               |             |
| a |                      |             |               |             |
| m |                      |             |               |             |
| e |                      |             |               |             |
| : |                      |             |               |             |
+---+----------------------+-------------+---------------+-------------+
| T |                      | Number of:  |               |             |
| y |                      |             |               |             |
| p |                      |             |               |             |
| e |                      |             |               |             |
| o |                      |             |               |             |
| f |                      |             |               |             |
| e |                      |             |               |             |
| n |                      |             |               |             |
| r |                      |             |               |             |
| o |                      |             |               |             |
| l |                      |             |               |             |
| l |                      |             |               |             |
| m |                      |             |               |             |
| e |                      |             |               |             |
| n |                      |             |               |             |
| t |                      |             |               |             |
+---+----------------------+-------------+---------------+-------------+
|   |                      | Contracts   | Persons       | Dis         |
|   |                      |             | covered       | enrollments |
|   |                      |             |               |             |
|   |                      |             | (contracts +  |             |
|   |                      |             | dependents)   |             |
+---+----------------------+-------------+---------------+-------------+
| * |                      |             |               |             |
| * |                      |             |               |             |
| [ |                      |             |               |             |
| E |                      |             |               |             |
| m |                      |             |               |             |
| p |                      |             |               |             |
| l |                      |             |               |             |
| o |                      |             |               |             |
| y |                      |             |               |             |
| e |                      |             |               |             |
| e |                      |             |               |             |
| s |                      |             |               |             |
| ] |                      |             |               |             |
| { |                      |             |               |             |
| . |                      |             |               |             |
| s |                      |             |               |             |
| m |                      |             |               |             |
| a |                      |             |               |             |
| l |                      |             |               |             |
| l |                      |             |               |             |
| c |                      |             |               |             |
| a |                      |             |               |             |
| p |                      |             |               |             |
| s |                      |             |               |             |
| } |                      |             |               |             |
| * |                      |             |               |             |
| * |                      |             |               |             |
+---+----------------------+-------------+---------------+-------------+
|   | High option          |             |               |             |
+---+----------------------+-------------+---------------+-------------+

  ------------------------------ ---------- ------------------- -------------- ---------------- --------------
                                            xx1 Self only . . .                                 
                                            . . . . . . . . .                                   

                                            xx2 Self and                                        
                                            family. . . . . . .                                 
                                            .                                                   

                                 Standard                                                       
                                 option                                                         

                                            xx4 Self only . . .                                 
                                            . . . . . . . . .                                   

                                            xx5 Self and family                                 
                                            . . . . . . .                                       

  TOTAL. . . . . . . . . . . . .                                                                
  . . . . . . . . . . . . . .                                                                   

  **[Annuitants]{.smallcaps}**                                                                  

                                 High                                                           
                                 option                                                         

                                            xx1 Self only . . .                                 
                                            . . . . . . . . .                                   

                                            xx2 Self and family                                 
                                            . . . . . . .                                       

                                 Standard                                                       
                                 option                                                         

                                            xx4 Self only . . .                                 
                                            . . . . . . . . .                                   

                                            xx5 Self and family                                 
                                            . . . . . . .                                       

  TOTAL . . . . . . . . . . . .                                                                 
  . . . . . . . . . . . . . . .                                                                 
  ------------------------------ ---------- ------------------- -------------- ---------------- --------------

Where xx is your plan's two-character identification code.

>  Dependent counts are actual. \[check if applies\]
>
>  Dependent counts are estimates. \[check if applies\]
>
> Describe your method of estimating the number of
> dependents:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Signature of responsible person Date Telephone number*

**[Be sure the PLAN CODE is on the top of the report and that you have
signed the report and included your phone number. MAIL THIS REPORT TO:
Office of Insurance Programs, Attention: Enrollment Reports, PO Box 707,
Washington DC 20044. FAX this form to 202/606-0036 or call mike hodges
at 202/606--0745]{.smallcaps}** **[for information about this
form.]{.smallcaps}**

Revised March 1999