Civil Service 

Retirement 

System 

Federal Employees’ 

Group Life 

Insurance Program 

Federal Employees 

Health Benefits 

Program 

Federal Employees 

Retirement 

System 

Long Term 

Care Insurance 

Program 

United States 

Office of 

Personnel Management 

The Federal Government’s Human Resources Agency

Retirement and Insurance Service 

Benefits Administration Letter 

Number: 02-301 Date: January 4, 2002 

SUBJECT: HB-PC - ANNUAL REPORTING REQUIREMENT 

\ 

The Internal Revenue Code requires that administrators of cafeteria plans file an annual information return 

on the Form 5500 – Annual Return/Report of Employee Benefit Plan – with an attached Schedule F – 

Fringe Benefit Plan Annual Information Return. To fulfill our Form 5500 reporting responsibilities as the 

administrator of Health Benefits Premium Conversion (HB-PC), we will need input from all agencies of 

the Executive Branch of the Federal government that have participating employees. 

Our Form 5500 submission to the IRS for tax year 2001 will be based on the information that Executive 

Branch agencies provide to us on the attached Input for Form 5500. If an agency has adopted HB-PC for 

the benefit of its employees, but is not part of the Executive Branch, it will not submit an Input for Form 

5500 to OPM, but must file its own Form 5500 directly with the IRS. 

As the tax year 2001 Form 5500 for HB-PC must be submitted to the IRS by July 31, 2002, we will need 

Executive Branch agencies to complete the Input for Form 5500 and fax it back to us no later than June 1, 

2002; our fax number is 202-606-7944. If an agency performs payroll cross-servicing functions, it must 

include on its Input for Form 5500 information for its own agency as well as for all client Executive 

Branch agencies. Likewise, if an agency’s payroll functions are cross-serviced, it will not submit an Input 

for Form 5500 to OPM. 

If you have any questions about the matters discussed in this letter, we would prefer that you email them to us 

at finance@opm.gov, so that we may retain a record of them. You may also call us on 

(202) 606-0606. 

 

 Robert A. Yuran, Chief 

 Financial Policy Staff 

 Retirement and Insurance Service 

Attachment
 

Health Benefits Premium Conversion (HB-PC) 

INPUT FOR FORM 5500 

for Executive Branch Agencies 

For the plan year ending on December 31, 2001 

***Fax completed form to (202) 606-7944 no later than June 1, 2002*** 

Agency: Payroll Office Number: 

Note: if your payroll functions are cross-serviced, do not complete this report; it will be 

completed for you by your cross-servicer. 

***In completing this report, it is important that you follow the instructions on the reverse*** 

1. Number of employees 

2. Number of employees eligible to participate in HB-PC 

3. Number of employees who participated in HB-PC 

4. Total FEHB withholdings and contributions for HB-PC participants $ 

5. If you cross-service the payroll functions of other Executive Branch agencies, attach a list 

of those agencies as an addendum to this report. 

Name of preparer: Telephone: 

Title of preparer: E-mail: 

Signature of preparer: Date signed: 
 

INSTRUCTIONS FOR COMPLETING THE INPUT FOR FORM 5500 

Line 1: Number of Employees 

 Enter the total number of employees you paid on the last pay day in calendar year (CY) 2001. 

 Include ALL employees -- full-time, part-time, intermittent, etc. 

Line 2: Number of Employees Eligible to Participate in HB-PC 

 Enter the total number of employees enrolled in the FEHB Program on the last pay day in CY 

2001. Include in this number those for whom FEHB deductions were made and those for whom 

you made no FEHB deductions (e.g., those on LWOP). 

Line 3: Number of Employees who Participated in HB-PC

 Enter the sum of: 

 The number of HB-PC participants on the last pay day in CY 2001

 Plus: the number of employees with pre-tax FEHB deductions, who subsequently waived 

participation in HB-PC during CY 2001 

 Plus: the number of HB-PC participants who terminated or cancelled their FEHB 

coverage during CY 2001.

Line 4: Total FEHB Withholdings and Contributions for HB-PC Participants 

 Enter the total amount of FEHB withholdings and contributions remitted to OPM for all HB-PC 

 participants during CY 2001.