3 FAM 3600
BENEFITS
3 FAM 3610
FEDERAL BENEFITS: health, dental, vision, flexible
spending accounts, and long term care insurance
(CT:PER-950; 07-09-2019)
(Office of Origin: HR/ER/WLD)
3 FAM 3611 AUTHORITies
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. The legal authorities for the Federal Employees
Health Benefits (FEHB) Program are found in:
5 U.S. Code Chapter 89; or
5 CFR Part 890
b. In addition, the U.S. Office of Personnel Management
(OPM) has published the FEHB Handbook, which sets out policies and procedures
of the FEHB Program and provides additional guidance to those enrolled in the
FEHB Program and their employing offices.
3 FAM 3612 APPLICABILITY
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. The administrative responsibilities and internal
procedures described in this subchapter apply to Foreign Service and to Civil
Service employees of the Department of State eligible under 5 CFR Part 890.
b. These regulations address only certain aspects of
the Federal Employees Health Benefits (FEHB) Program. More comprehensive
information is available through the authorities referred to in 3 FAM 3611.
3 FAM 3613 RESPONSIBILITIES
3 FAM 3613.1 Office of Personnel
Management (OPM)
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. The U.S. Office of Personnel Management (OPM) is
responsible for the U.S. government-wide administration of the Federal
Employees Health Benefits (FEHB) Program.
b. Further information can be found on the OPM website.
3 FAM 3613.2 Department Benefits
Officer
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
The Department of States designated Benefits Officer is
located within the Bureau of Human Resources, Office of Employee Relations
(HR/ER). The Benefits Officer is responsible for the coordination of the FEHB
Program and is the OPM contact for agency-wide insurance matters.
3 FAM 3613.3 HR Service Center
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. The HR Service Center, (843) 308-5539, or (866)
300-7419 (Toll Free), or HRSC@state.gov serves as the primary resource for all
Department direct hire employees for employee benefit information, enrollment
and general inquiries. The HR Service Center is responsible for:
(1) Certifying each employees FEHB Program insurance
status, eligibility, and effective dates of benefits actions, including
decisions on belated enrollment and change-of-enrollment requests;
(2) Explaining the FEHB Program and its benefits to
employees; and
(3) Reviewing a submitted Form SF-2809, Health
Benefits Election Form, for completeness, consistency, accuracy and the
appropriateness of the action.
b. The HR Service Center performs these functions under
guidance received from OPM and instructions issued by the Department's Benefits
Officer.
3 FAM 3613.4 Bureau Human
Resources Specialist or Post Management Officer
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
A bureau HR specialist or post management officer should
refer to the FEHB Handbook, which can be found on the OPM website, when
advising employees regarding FEHB Program benefits.
3 FAM 3613.5 Payroll Office
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
The payroll office (CGFS/GC/PSP) is responsible for the
transmission of employee and employer contributions for the FEHB Program to
OPM.
3 FAM 3614 plan options
3 FAM 3614.1 General
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. The Federal Employees Health Benefits (FEHB) Program
offers different types of health plans that have different approaches to health
care coverage:
(1) Fee-for-Service (FFS) plans, Preferred Provider
Organization (PPO) and Non-Preferred Provider Organization (non-PPO);
(2) Health Maintenance Organizations (HMO);
(3) Health Maintenance Plan Offering a Point of
Service (POS) Product;
(4) Consumer-Driven Health Plan (CDHP); and
(5) High-Deductible Health Plan (HDHP).
b. The individual FEHB plan brochures contain
information regarding negotiated plan benefits, exclusions, claims procedures,
services provided, and appeal-of-service provisions. Comprehensive guidance is
available on the OPM website.
3 FAM 3614.2 Fee-for-Service (FFS)
Plans
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
A Fee-For-Service (FFS) plan Non-Preferred Provider
Organization (non-PPO) is a traditional type of insurance in which the health
plan will either pay the medical provider directly or reimburse the employee
after an insurance claim is filed for each covered medical expense. When
needing medical attention, employees can visit the doctor or hospital of their
choice. This approach may be more expensive and require extra paperwork on
behalf of the employee.
A Fee-For-Service (FFS) plan with a Preferred Provider
Organization (PPO) is an option that allows employees to see medical providers
who reduce their charges to the plan and allow them to pay less out of pocket.
Employees who visit a PPO will not have to file for services rendered by PPO
providers, which usually saves the employees money. Generally, enrolling in
FFS plans does not guarantee that a PPO will be available in your area.
Employees may review plan brochures on OPM's website.
3 FAM 3614.3 Health Maintenance
Organizations (HMO)
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. A Health Maintenance Organization (HMO) is a health
plan that provides care through a network of physicians and hospitals in
particular geographic service areas. HMOs coordinate the health care services
employees receive and free enrollees from completing paperwork or being billed
for covered services. Eligibility to enroll in an HMO is determined by where
you live or, for some plans where you work. Some HMOs are affiliated with or
have arrangements with HMOs in other service areas for non-emergency care for
those who travel or are away from home for extended periods. Plans that offer
reciprocity discuss this in their brochure. HMOs limit employees' out of
pocket costs to the relatively low amounts shown in the benefit brochures.
b. Generally, employees must choose a doctor or medical
group to be their primary-care physician (PCP). The PCP provides general
medical care. In many HMOs, employees must obtain an authorization or a
"referral" from their PCP to see other providers. The referral
ensures that employees are able to see the right provider for the care most appropriate
to their conditions.
3 FAM 3614.4 High-Deductible and
Consumer-Driven Health Plans with a Health Savings Account or Health
Reimbursement Arrangement
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. A High-Deductible Health Plan (HDHP) is a health
plan product that combines a Health Savings Account (HSA) or a Health
Reimbursement Arrangement (HRA), traditional medical coverage and a
tax-advantaged way to help save for future medical expenses while providing flexibility
and discretion over how employees use health care dollars. HDHPs also protect
employees against catastrophic out-of-pocket expenses for covered services.
Depending on the HDHP, employees may have a choice of using in-network or
out-of-network providers. Using in-network providers will save employees
money. With the exception of preventive care, the annual deductible must be
met before plan benefits are paid. The HDHP gives employees a greater
flexibility and discretion over how they use their health care benefits.
b. When employees enroll in an HDHP, their health plan
establishes for them either a health savings account (HSA) or a health
reimbursement arrangement (HRA). The plan automatically deposits the monthly
premium pass through into the HSA. The plan credits an amount into the HRA.
c. An HSA allows employees to pay for current health
expenses and save for future qualified medical expenses on a pre-tax basis.
Funds deposited into an HSA are not taxed, the balance in the HSA grows tax-free,
and that amount is available on a tax-free basis to pay medical costs.
d. Employees who are enrolled in an HDHP may be
eligible for an HSA. HSAs are subject to a number of rules and limitations
established by the Department of Treasury. For more information, contact the
U.S. Department of the Treasury, Health Savings Account.
e. A consumer-driven plan like an HDHP provides
employees with greater flexibility in making health care expenditures. The
typical plan has common features including member responsibility for certain
up-front medical costs, an employer-funded account that employees may use to
pay these up-front costs, and catastrophic coverage with a high deductible.
Employees and their families receive full coverage of in-network preventive care.
3 FAM 3614.5 FEHB Plan Selection
Initiated by Employee
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
Each eligible employee who wishes to participate in the
FEHB Program must decide which FEHB plan is best suited for the employee and
their dependents within the designated time limit set by OPM. Individual
health plan brochures and FEHB comparison charts can be viewed on the OPM website. The HR Service Center, bureau HR
specialists, and post management officers are prohibited from recommending or
showing favoritism toward a particular FEHB plan or in any way trying to
influence an employees final selection of an FEHB plan that best meets his or
her needs.
3 FAM 3615 types of enrollment AND ELIGIBILITY
TO ENROLL OR CHANGE ENROLLMENT
3 FAM 3615.1 Self-Only Enrollment
(CT:PER-752; 10-31-2014)
(State only)
(Applies to Foreign Service and Civil Service Employees)
Self-only enrollment provides coverage for the employee.
3 FAM 3615.2 Self and Family
(CT:PER-831; 09-29-2016)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. Self and Family enrollment provides coverage for the
employee and eligible family members. All eligible family members are
automatically covered, even if they are not listed on the Health Benefits
Election Form (SF 2809) or via Employee Express (EEX). Eligible family members
include spouse (including legally married same-sex spouses and valid common law
marriages), and children under the age of 26. Children aged 26 and over who
are incapable of self-support also may be eligible to remain covered under a
Self and Family enrollment.
b. In order for a disabled child aged 26 and over to
retain coverage, the employee must obtain a Certificate of Incapacity from the
Department of State providing adequate medical documentation of a mental or
physical handicap that existed before the childs 26th birthday. The employee
must provide medical documentation to the Office of Medical Services before a Certificate
of Incapacity can be issued. Consult the FEHB Handbook for guidance.
c. To obtain FEHB coverage for a newly eligible family
member, an employee must have Self and Family enrollment. See FEHB Handbook
for guidance.
3 FAM 3615.3 Self Plus One
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
Self Plus One provides benefits for an employee and one
eligible family member designated by the employee to be covered.
3 FAM 3615.4 Children Covered
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. For the purposes of FEHB coverage, the term
"children" includes, up to age 26:
(1) An employees legally adopted children;
(2) Recognized natural children; and
(3) Stepchildren.
b. Foster children (including grandchildren) may also
be included up to the age of 26 if they live with the employee in a
parent-child relationship.
3 FAM 3616 RECONSIDERATION AND FILING
CLAIMS FOR PAYMENT OR SERVICE
3 FAM 3616.1 Reconsideration of
Denial of Health Insurance or Change of Enrollment
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. An employee may request reconsideration of the
Departments initial decision denying health insurance coverage or change of
enrollment.
b. Requests for reconsideration must be made in writing
and should be addressed to the Department of State Health Benefits Officer
within 30 days from the date of the initial decision.
c. The time limit may be extended when the employee
shows that the employee was not notified of the time limit and was not
otherwise aware of it, or that the employee was unable, due to reasons beyond
the employee's control, to make the request within the time limit.
d. Requests for reconsideration must include the
following information:
(1) Claimants name and address;
(2) Date of birth;
(3) Social Security Number;
(4) Reason(s) for the request;
(5) Name of health insurance carrier; and
(6) A copy of the written initial decision.
e. For additional information on filing a request for
reconsideration, contact the HR Service Center at HRSC@state.gov.
3 FAM 3616.2 Filing Claims for
Payment or Service
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
Each health benefits carrier resolves claims filed under
the plan. For more information, employees should refer to 5 CFR 890.105.
3 FAM 3617 FEDERAL LONG TERM CARE
INSURANCE PROGRAM AUTHORITIES
(CT:PER-752; 10-31-2014)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. The legal authorities for the Federal Long Term Care
Insurance Program are found in Public Law 106-265, The Long Term Care Security
Act, 5 U.S.C. 9001 et seq., as amended, and 5 CFR 875.
b. More detailed information regarding the Federal Long
Term Care Insurance Program can be found on the OPM website.
3 FAM 3617.1 Federal Long Term
Care Insurance Program (FLTCIP)
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
The Federal Long Term Care Insurance Program (FLTCIP), is
a smart way for employees to protect their income and assets and remain
financially independent should they need long term care services at home, in a
nursing home, or at another long term care facility. Most health insurance
programs, including the Federal Employees Health Benefits (FEHB) Program,
provide little or no coverage for long term care services, which can be very
expensive. OPM sponsors a long term care insurance program for eligible employees,
annuitants, current spouses of eligible employees and annuitants, the parents,
parents-in-law, and step-parents of living eligible employees, adult children
(at least 18 years old, including adopted and step-children) of living eligible
employees, and annuitants and domestic partners (both opposite sex and
same-sex) of eligible employees and annuitants.
a. To apply for the FLTCIP, domestic partners must
check a box on the FLTCIP application
certifying that documentation of the domestic partnership has been submitted to
the HR Service Center at HRSC@state.gov or
sent via fax to 843-202-3807 for processing. A copy of the certification form
will be placed in the employees eOPF.
b. Before submitting an application for coverage under
the FLTCIP, an eligible domestic partner needs to provide documentation, in
addition to the Declaration of Domestic Partnership form that the employee and
the employee's partner meet the definition of domestic partnership. Refer to 5
CFR 875.101 for guidance on domestic partnership.
c. To enroll, all employees must contact a FLTCIP consultant at the FLTCIP webpage or call 1-800-582-3337 or TTY
1-800-843-3557 for further information.
3 FAM 3618 FLEXIBLE SPENDING ACCOUNTS
FOR federal employees (fsafeds)
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. The Flexible Spending Account Program (FSAFEDS)
allows eligible employees to save money for health care expenses with a Health
Care or Limited Expense Health Care FSA. This is similar to a savings account
that helps employees pay for items that typically aren't covered by their FEHB
plan, the FEDVIP Program, or other health insurance coverage. FSAFEDS also
offers the Dependent Care FSA, an account that assists with the costs of providing
care for children under 13 and/or relatives living in an employee's home who
are physically or mentally incapable of self-care. The Federal Flexible
Benefits Plan (FedFlex) enables eligible employees to pay for certain benefits
with pre-tax dollars. FSAFEDS offers three different flexible spending
accounts (FSA):
(1) A health care flexible spending account;
(2) A dependent care flexible spending account; and
(3) A limited-expense health care flexible spending
account.
NOTE: The FSA is a tax-qualified
program based on the guidelines in sections 105,125, and 129 of the Internal
Revenue code.
b. An open season is held each year at the same time as
the Federal Employees Health Benefits Program Open Season (November-December)
during which employees may enroll in an FSA for the following year. An
employees yearly election to participate will not roll over to the next year.
An FSA election is 100 percent voluntary.
c. A health care FSA pays for uncovered or
unreimbursed portions of qualified medical costs. A dependent care FSA allows
you to pay eligible expenses for dependent care with pre-tax dollars. The
limited expense health care FSA is designed for employees enrolled in, or
covered by, a high-deductible health plan with an HSA. Eligible expenses for
Limited Expense Health Care FSAs are limited to dental and vision care expenses
for employees, their spouse, tax dependents, and adult children through the end
of the calendar year in which they turn age 26 that are not covered or
reimbursed by the Federal Employees Health Benefits Program, the Federal
Employees Dental and Vision Insurance Program, or other insurance programs.
d. All employee contributions to FSAs are made from
pre-tax earnings. There are no U.S. government contributions to the FSAFEDS
program.
e. OPM has placed the responsibility for implementing
and managing FSAs with WageWorks, the administrator of the program.
f. For further information, visit www.FSAFEDS.com or
call 1-877-372-3337.
3 FAM 3619 FEDERAL EMPLOYEE DENTAL AND
VISION INSURANCE PROGRAM (FEDVIP)
(CT:PER-950; 07-09-2019)
(State only)
(Applies to Foreign Service and Civil Service Employees)
a. Dental and vision insurance benefits are available
to eligible employees, annuitants, and their eligible family members.
b. Eligible family members include a spouse, including
legally married same-sex spouse, unmarried dependent children under age 22, to
include legally adopted children, stepchildren and foster children who live
with the employee in a regular parent-child relationship, and recognized
natural children who meet certain dependency requirements. Under certain
circumstances, an employee may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.
c. The Federal Employees Dental and Vision Program
(FEDVIP) offers three types of enrollment:
(1) Self Only;
(2) Self and Family; or
(3) Self Plus One.
d. Dental and vision insurance benefits are available
to eligible employees and their eligible family members on an enrollee-pay-all
basis. This program allows dental and vision insurance to be purchased on a
group basis which means competitive premiums and no pre-existing condition
limitations. Premiums for enrolled Federal and Postal employees are withheld
from salary on a pre-tax basis.
e. New and newly eligible employees can enroll within
60 days after they become eligible. Enrollment otherwise takes place during the
annual Federal Benefits Open Season in November and December.
f. In order to enroll in FEDVIP, employees must be
eligible to enroll in the FEHB Program, whether or not they are actually
enrolled, and their positions must not be excluded by law or regulation.
Annuitants do not have to be eligible for or enrolled in the FEHB Program to
enroll in FEDVIP.
g. For enrollment/premium questions regarding dental
and vision insurance, please contact BENEFEDS at 877-888-372-3337. To enroll
in FEDVIP, employees must visit BENEFEDS online.