3 FAM 3600
BENEFITS
3 FAM 3610
FEDERAL BENEFITS: health, dental, vision, flexible spending accounts, and long term care insurance
(CT:PER-1163; 11-17-2023)
(Office of Origin: GTM/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-993; 05-26-2020)
(State only)
(Applies to Foreign Service and Civil Service Employees)
The Department of State’s designated Benefits Officer is located within the Bureau of Global Talent Management, Office of Employee Relations (GTM/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 employee’s 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-1163; 11-17-2023)
(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 employee’s final selection of an FEHB plan that best meets their 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-1133; 06-06-2023)
(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 child’s 26th birthday. The employee must provide medical documentation to the Bureau 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 employee’s 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 Department’s 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) Claimant’s 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 employee’s 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 employee’s 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.