Civil Service Federal Employees Federal Employees Federal Employees

Retirement Group Life Health Benefits Retirement

System Insurance Program System

United States

Office of Personnel Management

Retirement and Insurance Service

Benefits Administration Letter

Number: 97-406 Date: October 9, 1997 

Subject: Federal Employees Health Benefits (FEHB) Program: Conducting the 1997

Open Season 

GENERAL

 

 FEHB Guides

Last year we made several significant changes to the Guide to Federal Employees

Health Benefits Plans. The changes to this year's FEHB Guide have been minimal. 

We are continuing to designate plans as either 1) Managed Fee-for-Service (FFS)

plans, 2) Health Maintenance Organization (HMO) plans, or 3) plans offering a Point

of Service (POS) product. The 1997 Customer Satisfaction Survey results, with stars

to designate top-rated plans, will be incorporated with the comparison chart

information, and the plans' accreditation status, if any, from the National Committee

for Quality Assurance (NCQA) will also be shown -- either full, one-year, provisional,

or denied.

This year we added a column to indicate whether a plan has its own website from

which employees may obtain additional information from the plan. Plan websites will

be accessible directly from our website (http://www.opm.gov/insure). Our website will

be enhanced for greater ease of use and will contain additional information over last

year. The FEHB Guide will again be available for downloading, as will all health plan

brochures. In addition, a feature designed specifically for the website will enable users

to identify the plans available to them and to focus on information important to them in

selecting a plan.

 Counseling Employees

Agencies are responsible for counseling employees who ask for help on health benefits

matters. Counseling should be limited to answering questions about the FEHB

Program and the application of the FEHB law and regulations to particular

circumstances.
Benefits Administration Letter 97-406 2

Since the amount of enrollment information in the FEHB Guides may not be sufficient

for the needs of some employees, counselors should refer them to their plan brochures

if the requested information is available there.

Counselors also should try to answer specific questions on benefits by referring to the

applicable brochure. If the question cannot be answered from the brochure, the

counselor should tell the employee to contact the health plan. However, employees

should not be referred to the plans if their questions concern any subjects other than

benefits or conversion contracts.

 Plan Terminations

In BAL 97-403, we notified agency headquarters insurance officers of the names of

plans that are dropping out of the FEHB Program, or that are dropping a service area

with a separate enrollment code, at the end of 1997. We strongly recommend that

agencies distribute the list of terminating plans and enrollment codes to all employees

so they can check to see whether their plan or enrollment code will continue to be valid

in 1998.

An employee whose plan or enrollment code will not participate in the Program next

year must enroll in another plan to continue FEHB coverage in 1998. You should

monitor employees who are covered by these terminating plans/codes and follow up

with those who have not submitted a change of enrollment before the end of open

season.

 Annuitant Inquiries

Some annuitants may contact their former employing offices asking for an SF 2809

(Health Benefits Registration Form).

 CSRS and FERS - The Office of Personnel Management (OPM) does not use the

SF 2809 to register open season changes for Civil Service Retirement System or

Federal Employee Retirement System annuitants. These annuitants should be directed

to call our toll-free service, Open Season Express. Instructions for using Open Season

Express are included in the open season package sent to each enrolled CSRS and FERS

annuitant before open season. If an annuitant loses or does not receive the package,

he/she can get one by calling our Retirement Information Office at 88-US-OPM-RET

(888-767-6738).

The hearing-impaired who have access to a TDD machine may call our Retirement

Information Office TDD number: 202-606-0551.

When communicating with OPM -- for any reason -- annuitants should always provide

their CSA/CSF retirement claim number and/or their Social Security Number.

 Other retirement systems - These annuitants should be instructed to contact their
Benefits Administration Letter 97-406 3

retirement system for the proper registration form.

 OWCP - Former employees receiving benefits from the Office of Workers'

Compensation should contact the OWCP office that maintains their FEHB records. 

CARRIER ACCESS

 Health Fairs

We strongly encourage agencies to hold open season health fairs or to permit

representatives of FEHB carriers to address groups of employees on their plans'

benefits, methods of obtaining services, and similar matters.

Since the number of carrier representatives knowledgeable about the benefit provisions

and claims procedures of the plans they represent is often limited, we encourage

agencies to stagger health fairs, beginning prior to the actual start of open season.

When holding health fairs, remember:

 The purpose of the fair is to inform, not promote. You should explicitly

discourage carriers from distributing trinkets, holding raffles, or engaging in

similar activities that divert attention from the primary goal.

 Carrier representatives are expected to confine their presentations to benefit

provisions and claims procedures of the FEHB plan they represent. Questions

that do not pertain to benefits or claims should be referred to the agency's

insurance official. 

 Other Companies

Agencies are frequently contacted by insurance companies that do not participate in the

FEHB Program but that wish to sell dental insurance or other types of "supplemental"

policies to Federal employees. These companies sometimes send marketing material to

agencies and ask the agencies to distribute it; they may ask to be invited to the agency's

health fairs; they may even show up at health fairs uninvited.

We strongly discourage agencies from assisting in the marketing efforts of these

companies, including companies FEHB carriers may have contracted with for

particular benefits. To ensure the integrity of the FEHB Program, agencies should

limit access to their premises to those health plans that actually participate in the FEHB

Program; i.e., those plans listed in the FEHB Guide.

OPEN SEASON CHANGES

 Permissible Actions
Benefits Administration Letter 97-406 4

The following changes in registration may be made during open season:

 An eligible employee who is not enrolled may register to enroll.

 An enrollee may change from one plan or option to another, from self only

to self and family, or make any combination of these changes.

New enrollments and enrollment changes for permissible reasons other than the open

season can be made, as usual, between November 10 and December 8, 1997. 

However, these changes will likely have different effective dates than, and should not

be mistakenly identified as, open season changes.

Whether an employee is enrolling or changing enrollment based on open season or

some other qualifying event, it is important that the correct event number be noted on

the SF 2809, so that the correct effective date will be assigned.

 Timely Registration

The employing office must receive an open season change on SF 2809 no later than

close of business on December 8, 1997, to be considered filed on time.

Changes via Employee Express must be received by the Employee Express contractor

(OPM Macon, GA) no later than midnight, December 8.

 Belated Registration

An employing office has the authority to accept a late registration if it determines that

the employee was unable to submit an SF 2809 on time because of circumstances

beyond the employee's control. While we normally encourage agencies to make

limited use of this authority, we recommend that you take a liberal view in cases where

an employee's plan is terminating its FEHB participation.

If you decide to accept an employee's late registration, write "Belated open season

enrollment/change" in the "Remarks" section of the SF 2809. Attach to copy 1 of the

SF 2809 the employee's statement explaining why he/she could not register on time.,

or add your own note if the reason was an agency problem.

If you decide that the delay in filing is not due to a cause beyond the employee's

control, do not accept the employee's late request. Notify the employee in writing that

you are not approving the late enrollment. Give the reason for your denial and include

a statement of the employee's right to request reconsideration within 30 days after the

date of your notice.

 Effective Dates

From not enrolled to enrolled - Effective the first day of the first pay period which

begins on or after January 1, 1998, and which follows a pay period in any part of
Benefits Administration Letter 97-406 5

which the employee was in pay status.

 However, the enrollment of a new employee who happens to register for the

first time during open season is effective the same as for all new employees;

i.e., the first day of the first pay period after the employing office receives the

SF 2809.

Enrollment change - Effective the first day of the first pay period which begins on or

after January 1, 1998, regardless of whether or not the employee was in pay status

during the preceding pay period.

Belated open season action - Effective retroactive to the first day of the first pay

period which begins on or after January 1, 1998. This effective date is the same as

that of an open season change filed on time.

 If the belated change is from not enrolled to enrolled, the requirement of

having been in pay status during the preceding pay period must also be met.

Cancellation - Effective the last day of the pay period in which the employing office

receives the SF 2809.

 Enrollees may cancel their health insurance at any time without waiting for

an "event" or an open season. The effective date is therefore different from the

effective date of actions related to open season.

 Cancellation

Agencies should be sure to counsel employees about the consequences of cancelling

their enrollment.

 Remember that an employee must have been covered under the FEHB

Program continuously for the five years of service immediately before

retirement (or, if less than five years, for all periods of service during which

he/she was eligible for FEHB coverage and for participation in a retirement

system) in order to continue health benefits coverage after retirement.

 If an employee is cancelling his/her enrollment in order to be picked up as a

family member by a spouse's open season enrollment, be sure to coordinate the

cancellation with the effective date of the spouse's enrollment to prevent a break

in coverage.

 Deductibles

If an employee changes plans, covered expenses incurred between January 1, 1998,

and the effective date of the open season change will count toward the 1997 deductible

of the plan from which he/she is changing.
Benefits Administration Letter 97-406 6

AGENCY ACTIONS

 Prompt Processing

It is imperative that agencies process open season enrollments and enrollment changes

promptly. Payroll offices should process enrollee and carrier copies of SF 2809 on a

daily basis.

 Gaining carriers must be notified of new enrollments so the carrier can

complete the paperwork necessary to provide coverage for the employee and

covered family members and issue identification cards to the new enrollees.

 Losing carriers must be notified as soon as possible of enrollment

terminations so they won't guarantee or provide benefits to employees or family

members after the termination.

 Verification of Employee Coverage

Employees often become concerned when they do not receive their identification cards

from a new plan within a short time after the end of open season. If an employing

office receives this type of inquiry, it should first contact the payroll office to

determine when the carrier was notified of the change. If more than a month has

passed since the SF 2809 was sent, the employing office should contact the carrier to

determine the reason for the delay and to relay the employee's request for identification

cards.

An employee may need verification of coverage under his/her plan before the carrier's

processing of the enrollment or enrollment change has been completed. Employing

offices should verify that the employee is covered under the plan and inform the

requesting party (e.g., carrier, doctor, hospital) of the effective date of the coverage. 

Employing offices should also remind employees that their copy of the SF 2809 is

acceptable as proof of enrollment until they receive their identification cards from the

plan.

Employees who make open season changes electronically via Employee Express and

who do not receive new identification cards by the effective date of the change may

obtain a letter confirming their coverage by calling the Employee Express Help Desk

on 912-757-3030, or by requesting the assistance of their personnel office.
Benefits Administration Letter 97-406 7

 Reconciliation Requests

After open season is completed, agencies will receive requests from carriers to

reconcile their enrollment records. These requests should receive the highest

priority. The reconciliation process is critical to ensure that carriers receive the

proper premium payments and that enrollees are properly reflected on plans' records.

 

 Abby L. Block, Chief

 Insurance Policy

 and Information Division