How Obamacare affects your FEHBP plan


The Affordable Care Act — Obamacare — is already affecting the Federal Employees Health Benefits Program. In this column, I’ll fill you in on some of the new requirements imposed on FEHBP.

Implemented in 2011 is the requirement that allows children up to age 26, regardless of their marital status, to remain on or be added to the self-and-family option of a parent’s plan. The child does not have to reside with that parent, be financially dependent on the parent, or be a student. Coverage doesn’t extend to a child’s spouse or children.

With one exception, when coverage ends under a parent’s plan, the child may continue that coverage on a self-only enrollment for up to 18 months under the Temporary Continuation of Coverage provision of the law. If the child does that, he or she must pay the entire premium, plus 2 percent to cover administrative costs. The exception: An unmarried child who was disabled before age 26 can continue to be covered under the parent’s self-and-family plan.

The law now requires plans to offer certain preventive care and screening. FEHBP plans have long covered many of these. And since 2011, the Office of Personnel Management has required that plans waive cost-sharing when its enrollees use in-network providers for this care.

The law also now requires plans to provide applicants and enrollees with a summary of benefits and coverage, plus a glossary of terms. The purpose is to give consumers straightforward information about their benefits. While the OPM had already gone a long way toward making it possible for federal employees and retirees to understand what their benefits are and to compare plans, the stricter requirements were imposed on FEHBP plans this year.

Historically, FEHBP plans haven’t imposed lifetime dollar limits on any health condition or kind of service. Beginning in 2013, the law requires this of all plans.

This year, OPM requires FEHBP plans to comply with the requirement that enrollees be allowed to participate in clinical trials. This opens up an area of medical care and scientific investigation where coverage by FEHBP plans had been sparse.

The law that established FEHBP more than 50 years ago prohibited plans from excluding coverage of pre-existing conditions on any enrollee, regardless of age. Beginning in 2014, the Affordable Care Act will bar such exclusions under all plans for any enrollee under age 19.

Since 2011, large group plans, including those in FEHBP, have been required to provide rebates if the ratio of the amount of revenue expended on clinical claims and health quality costs is less than 85 percent, after adjustment for taxes and regulatory fees. Any rebates will be deposited in the FEHBP program’s reserve and used to reduce the cost of that plan’s premiums the following year.

If you are enrolled in a flexible spending account (FSA) or health savings account (HSA), you may have already felt the effects of the Affordable Care Act’s restrictions. Since 2011, the law hasn’t allowed over-the-counter medicines to be covered unless they are prescribed by a physician. The only exception to that rule is insulin. However, other eligible items that aren’t medicine or drugs, such as bandages, won’t require a prescription.

FSAs and HSAs may be used to pay for the qualified expenses of any children who are under 26 and covered by your self-and-family plan, regardless of their financial dependence on you. But beginning this year, the law lowered the maximum annual contributions you can make to these accounts from $5,000 to $2,500. From now on, the contributions threshold will be indexed to inflation.


About Author

Reg Jones was head of retirement and insurance policy at the Office of Personnel Management. Email your retirement-related questions to

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