Office of Personnel Management

Retirement and Insurance Group

1920 1954 1959 1986 

 

Benefits Administration Letter

Number: 96-410 Date: October 16, 1966 

SUBJECT: FEHB Open Season: Conducting the 1996 Open Season

___________________________________________________________________________

GENERAL

______________________________________________________

 Changes in As explained in BAL 96-402, we have made several 

 FEHB Guides significant changes to this year's FEHB Guides.

The first was to change our designations of participating 

plans and place them in three separate categories: 

managed fee-for-service plans, either open to all 

employees or restricted to specific groups; health 

maintenance organizations (HMOs), previously called 

prepaid plans; and plans offering a point of service (POS) 

product. POS plans may be either FFS plans or HMOs.

In an HMO with a POS product, the POS product acts 

like an FFS plan: The HMO's enrollees may use non-plan 

providers, but services will cost them more than if they 

used plan providers.

In an FFS plan with a POS product, the POS product acts 

like an HMO: Enrollees will get a better benefit if they 

agree to let their medical care be managed by a planaffiliated gatekeeper physician. 

HMOs with a POS product will be listed separately from 

HMOs without a POS product. Employees who do not 

find their HMO in the regular State list should look in the 

State list of POS plans. FFS plans with a POS product 

will be listed in the State in which their POS product 

operates as well as the regular FFS plan section.

Also, we merged the 1996 Customer Satisfaction Survey 

results with the comparison chart information, so all the 
Benefits Administration Letter 96-410 2.

information people need to compare plans is in one place. 

The survey data reported in the Guides has been 

expanded to include response rates to specific items, as 

well as the broad categories reported in the past. Those 

plans that scored significantly higher than the average are highlighted

by a star in the new "top rated plans" column. 

In addition, we included for the first time the accreditation status

granted by the National Committee for Quality Assurance (NCQA), a

nationally-recognized leader in evaluating managed care plans such as

HMOs. We've included an explanation of the NCQA accreditation

process and defined the four categories of accreditation status--full,

one-year, provisional, and denied.

Last, but not least, we gave the FEHB Guides a major facelift for 1996. 

We've made the Guides two-color, we're using better paper to enhance

readability, and we've added artwork to highlight the information

readers need to know. 

____________________________________________________

 Counseling Agencies are responsible for counseling employees who

 Employees 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.

Since the amount of enrollment information in the FEHB

Guides may not be sufficient for the purposes of

particular employees, counselors should refer employees

to their plan brochure if the requested information is

available there.

Counselors also should try to answer any specific

question 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. Employees should not, however,

be referred to a plan if the question concerns any subject

other than benefits or a conversion contract.

______________________________________________________
Benefits Administration Letter 96-410 3.

 Plan In BAL 96-404, we notified agency headquarters

 Terminations Insurance Officers of the names of the plans that are dropping out of

the FEHB Program or dropping an enrollment area with a separate

enrollment code at the end of 1996. Agencies must notify affected

employees of the termination of their health plans' FEHB participation.

We strongly recommend that agencies distribute the lists

of terminating plans and terminating enrollment areas to

all enrollees, so they can check to see whether their plan

will be participating in the FEHB Program and their

enrollment code is valid in 1997.

An employee whose plan will not participate in the Program or who

lives (or works) in an enrollment area that has a separate enrollment

code the plan will be dropping after December 31, 1996, must enroll in

a different plan to continue FEHB coverage next year. You should

monitor employees who are enrolled in these terminating plans/codes

and follow up with those who have not submitted a change of

enrollment before the end of open season.

______________________________________________________

 Annuitant Some annuitants may contact their former employing

 Inquiries offices asking for an SF 2809 (Health Benefits Registration Form).

CSRS and FERS - OPM does not use SF 2809 to register open

season changes for Civil Service Retirement System and Federal

Employees Retirement System annuitants. These annuitants should use

the individualized OPM 2809-EZ1 pre-printed with their name,

address, and retirement claim number. The 2809-EZ1 is included in

the open season package sent to each enrolled CSRS and FERS

annuitant before open season begins. If an annuitant loses or does not

receive the package or form, he/she can get one from OPM by calling

202-606-0500, or by writing to:
Benefits Administration Letter 96-410 4.

Office of Personnel Management

Open Season Task Force

P.O. Box 809

Washington, DC 20044-0809

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

OPM's Retirement Information Office TDD number: 202-606-0551.

When communicating with OPM, annuitants always should provide

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

number.

Other retirement systems - These annuitants should be told to contact

their retirement system for the proper registration form.

OWCP - Former employees receiving benefits from the Office of

Workers' Compensation Programs should contact the OWCP office

that maintains their FEHB records.

___________________________________________________________________________

CARRIER ACCESS

______________________________________________________

 Health Fairs We strongly encourage agencies to hold health fairs or to permit

representatives of FEHB carriers to address groups of employees on

their plan's benefits, methods of obtaining services, and similar matters.

Carrier representatives must 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.

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

should explicitly discourage carriers from distributing

trinkets, holding raffles, or engaging in similar activities

that divert attention from the primary goal.
Benefits Administration Letter 96-410 5.

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. You should

coordinate with local plans to ensure the availability of

marketing materials.

______________________________________________________

 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 may 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 private companies, including companies FEHB carriers

may have contracted with. 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 The following changes in registration may be made

 Actions during open season:

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

enroll.

 2. 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 11 and

December 9, 1996.
Benefits Administration Letter 96-410 6.

 However, these changes will likely have different effective dates 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 The employing office must receive an open season

 Registration change on SF 2809 no later than close of business on December 9,

1996, for the change 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 9.

______________________________________________________

 Belated An employing office has the authority to accept a late

 Registration 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.
Benefits Administration Letter 96-410 7.

 Effective Dates From not enrolled to enrolled - Effective the first day of the first pay

period which begins on or after January 1, 1997, and which follows a

pay period in any part of which the employee was in pay status.

However, 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, 1997, 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, 1997. 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 also must 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 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
Benefits Administration Letter 96-410 8.

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 to be

picked up 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, 1997, and the effective date of the open season change will

count toward the 1996 deductible of the plan from which he/she is

changing.

___________________________________________________________________________

AGENCY ACTIONS

______________________________________________________

 Prompt It is imperative that agencies process open season

 Processing 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 Employees often become concerned when they do not

 of Employee receive their identification card(s) from a new plan

 Coverage 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
Benefits Administration Letter 96-410 9. 

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 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 card(s) from the plan.

Employees who make open season changes electronically via

Employee Express and who do not receive new ID cards by the

effective date of the change may obtain a letter confirming their

coverage by calling the Employee Express Help Desk at (912) 757-

3030, or by requesting the assistance of their personnel office. 

______________________________________________________

 Reconciliation After open season is completed, agencies will receive

 Requests requests from carriers to reconcile 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