Health Benefits for Members of Congress and
Certain Congressional Staff
Annie L. Mach
Analyst in Health Care Financing
Ada S. Cornell
Information Research Specialist
November 4, 2013February 18, 2014
Congressional Research Service
7-5700
www.crs.gov
R43194
CRS Report for Congress
Prepared for Members and Committees of Congress
Health Benefits for Members of Congress and Certain Congressional Staff
Summary
The federal government, as an employer, offers health benefits to its employees, including
Members of Congress and congressional staff. TraditionallyPrior to 2014, Members and staff have had access
to to
many of the same health benefits as other federal employees. For example, Members and staff
have beenwere eligible to voluntarily enroll in employer-sponsored health insurance through the
Federal Federal
Employees Health Benefits Program (FEHBP), and they cancould choose to participate in
other other
health benefit programs, such as the Federal Flexible Spending Account Program
(FSAFEDS).
Section 1312(d)(3)(D) of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as
amended) generally specifies that the only health plans that the federal government may make
available to Members and certain congressional staff (with respect to their service as Members or
staff) are either created under ACA or offered through an exchange. A final rule issued by the
Office of Personnel Management (OPM) amends FEHBP eligibility regulations to comply with
Section 1312(d)(3)(D) of ACA. Under the final rule, beginning January 1, 2014, Members and
designated congressional staff willare no longer be able to purchase FEHBP plans as active
employees;
however, if they enroll in a health plan offered through a small business health
options program
(SHOP) exchange, they will remain eligible for an employer contribution toward
coverage.
Additionally, the final rule allows Members and designated congressional staff who are
eligible eligible
for retirement to enroll in a FEHBP plan upon retirement.
This report summarizes the provisions of the final rule and describes how it affects current and
retired Members and congressional staff. OPM has indicated that Members and congressional
staff will beare still eligible for other health benefits related to federal employment, and these additional
health benefits are outlined in this report. These health benefits include FSAFEDS, the Federal
Employees Dental and Vision Insurance Program (FEDVIP), the Federal Long Term Care
Insurance Program (FLTCIP), the Office of the Attending Physician, and treatment in military
facilities. This report also discusses Members’ and staff’s eligibility for Medicare, which does not
appear to be affected by the final rule.
For information about the health benefits received by other federal employees (i.e., those who are
not affected by the aforementioned final rule), see CRS Report RS21974, Federal Employees
Health Benefits Program (FEHBP): Available Health Insurance Options, by Annie L. Mach and
Ada S. Cornell.
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Health Benefits for Members of Congress and Certain Congressional Staff
Contents
Introduction...................................................................................................................................... 1
Health Insurance Coverage .............................................................................................................. 2
Coverage for Annuitants (Retirees) ........................................................................................... 3
Election of Coverage and Plan Choices .................................................................................... 4
Employer Contributions ............................................................................................................ 5
Cost of Coverage ....................................................................................................................... 5
Other Health Benefits Related to Federal Employment .................................................................. 6
Federal Flexible Spending Account Program ............................................................................ 6
Federal Employees Dental and Vision Insurance Program ....................................................... 7
Federal Long Term Care Insurance Program............................................................................. 7
Office of the Attending Physician ............................................................................................. 7
Military Treatment Facilities ..................................................................................................... 8
Medicare .......................................................................................................................................... 8
Tables
Table A-1. Monthly Self-Only Premiums for Selected Gold Level Health Insurance Plans
Available Through the District of Columbia’s SHOP Exchange ................................................ 11
Appendixes
Appendix. Selected Premiums in the D.C. SHOP Exchange ......................................................... 10
Contacts
Author Contact Information........................................................................................................... 12
Congressional Research Service
Health Benefits for Members of Congress and Certain Congressional Staff
Introduction
Many private- and public-sector firms offer employer-subsidized health benefits to their
employees as part of an employee’s compensation package. Among large employers in the United
States (those with 200 or more employees), 99% offered health insurance coverage to their
employees in 2013.1 On average, large employers subsidized 81% of the cost of self-only
coverage and 74% of the cost of family coverage.2 Twenty-eight percent of large employers that
offer health benefits to their employees offer retiree coverage. Among firms with 5,000 or more
workers, 48% offer retiree coverage.3
The federal government, as an employer, also offers health benefits to its employees and
annuitants (retirees). The federal government offers employer-subsidized health insurance
through the Federal Employees Health Benefits Program (FEHBP). Prior to 2014, Members of
Congress and congressional staff arewere eligible to participate in FEHBP in the same way that most
other federal employees and annuitants are eligible to participate.4 That is, Members and staff can
could purchase a health plan offered under FEHBP, receive an employer contribution toward the
coverage, and carry the coverage into retirement (provided they arewere eligible to do so).
However, Section 1312(d)(3)(D) of the Patient Protection and Affordable Care Act (ACA; P.L.
111-148, as amended) states,
(i) Requirement.—Notwithstanding any other provision of law, after the effective date of this
subtitle, the only health plans that the Federal Government may make available to Members
of Congress and congressional staff with respect to their service as a Member of Congress or
congressional staff shall be health plans that are—
(I) created under this Act (or an amendment made by this Act); or
(II) offered through an Exchange established under this Act (or an amendment made by this
Act).
(ii) Definitions.—In this section:
(I) Member of Congress.—The term ‘‘“Member of Congress’’” means any member of the
House of Representatives or the Senate.
(II) Congressional Staff.—The term ‘‘congressional staff’’” means all full-time and part-time
employees employed by the official office of a Member of Congress, whether in
Washington, DC or outside of Washington, DC.
The Office of Personnel Management (OPM) issued a final rule that amends FEHBP eligibility to
comply with Section 1312(d)(3)(D) of ACA on October 2, 2013.5 Under the rule, Members and
1
Kaiser Family Foundation and the Health Research & Educational Trust, Employer Health Benefits, 2013 Annual
Survey, Menlo Park, CA, August 2013, http://kff.org/private-insurance/report/2013-employer-health-benefits/.
2
Ibid.
3
Ibid.
4
For more information about how FEHBP works for most federal employees, see CRS Report RS21974, Federal
Employees Health Benefits Program (FEHBP): Available Health Insurance Options, by Annie L. Mach.
5
Office of Personnel Management, “Federal Employees Health Benefits Program: Members of Congress and
(continued...)
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Health Benefits for Members of Congress and Certain Congressional Staff
certain congressional staff will no longer be and Ada S.
Cornell.
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Health Benefits for Members of Congress and Certain Congressional Staff
The Office of Personnel Management (OPM) issued a final rule that amends FEHBP eligibility to
comply with Section 1312(d)(3)(D) of ACA on October 2, 2013.5 Under the rule, Members and
certain congressional staff were no longer able to purchase a health plan offered under FEHBP
beginning January 1, 2014; however, if they enroll in a health plan offered through an appropriate
small business health options program (SHOP) exchange,6 they will remain eligible for an
employer employer
contribution toward coverage. Additionally, Members and staff who obtain coverage
through a
SHOP exchange under this arrangement may purchase a FEHBP plan upon retirement
from the
federal government, provided they otherwise meet the criteria to do so.7 This report
summarizes summarizes
the provisions of the final rule and discusses how they affect current and retired
Members and
congressional staff.
OPM has indicated that the final rule only pertains to Members’ and staff’s access to health
insurance plans offered by the federal government under FEHBP.8 This report also describes other
health benefits available to Members and staff for which eligibility is not affected by the final
rule, including the Federal Flexible Spending Account Program (FSAFEDS); the Federal
Employees Dental and Vision Insurance Program (FEDVIP); the Federal Long Term Care
Insurance Program (FLTCIP); the Office of the Attending Physician; and treatment in military
facilities.
While some of the health benefits described in this report may also be available to federal
employees who are not Members or congressional staff, this report does not focus on their health
benefits and does not provide a comprehensive picture of the health benefits available to them.
For information about what is available to federal employees who are not current Members or
congressional staff, see CRS Report RS21974, Federal Employees Health Benefits Program
(FEHBP): Available Health Insurance Options, by Annie L. Mach and Ada S. Cornell.
Health Insurance Coverage
Beginning January 1, 2014, Members of Congress and certain congressional staff must obtain
health insurance coverage through a SHOP exchange in order to receive a government
contribution toward the coverage. Section 1312(d)(3)(D) of ACA defines the terms “Members of
Congress” and “congressional staff” as follows:
The term ‘‘“Member of Congress’’” means any member of the House of Representatives or the
Senate.
The term ‘‘congressional staff’’ means all full-time and part-time employees employed by
the official office of a Member of Congress, whether in Washington, DC or outside of
Washington, DC.
(...continued)
5
Office of Personnel Management, “Federal Employees Health Benefits Program: Members of Congress and
Congressional Staff,” 78 Federal Register 60653, October 2, 2013, http://www.gpo.gov/fdsys/pkg/FR-2013-10-02/pdf/
2013-23565.pdf
6
For more information about SHOP exchanges, see CRS Report R42663, Health Insurance Exchanges Under the
Patient Protection and Affordable Care Act (ACA), by Bernadette Fernandez and Annie L. Mach.
7
Neither ACA nor the proposed rule requires Members and staff to enroll in a health plan offered through a SHOP
exchange; rather, SHOP plans are the only plans that will be made available to them with respect to their federal
service.
8
Office of Personnel Management, “Federal Employees Health Benefits Program: Members of Congress and
Congressional Staff,” 78 Federal Register 60653, October 2, 2013, page 60655, http://www.gpo.gov/fdsys/pkg/FR2013-10-02/pdf/2013-23565.pdf
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The term “congressional staff” means all full-time and part-time employees employed by the
official office of a Member of Congress, whether in Washington, DC or outside of
Washington, DC.
The final rule delegates to the employing office of the Member the responsibility to make the
determination as to whether a congressional staff member meets the statutory definition of being
employed by an “official office.” OPM indicates that it will not interfere in the process by which
a Member or his or her designee determines the designations of his or her staff. Additionally,
OPM notes, “Nothing in this regulation limits a Member’s authority to delegate to the House or
Senate Administrative Offices the Member’s decision about the proper designation of his or her
staff.”9
The employing office of a Member (or its designee) mustwas required to designate its staff prior to November
November 2013 for the plan year effective January 1, 2014; for subsequent plans years, the
designations must
be made prior to October of the preceding year (or at the time of hiring for
individuals whose
employment begins during the year).10 The designation will be made annually,
and individuals
will maintain their designations for the entire FEHBP plan year, so long as they
continue to be
employed by the same Member.11 Congressional staff who do not receive a
designation of being
employed by an official office retain the ability to enroll in a health plan
offered under FEHBP.
Coverage for Annuitants (Retirees)
OPM indicates that Members and congressional staff designated as working for an official office
of a Member (hereafterhereinafter “staff” or “designated staff”) who purchase coverage through an exchange
exchange will have the ability to enroll in plans offered through FEHBP when they become
annuitants,
provided they meet the eligibility criteria to do so under 5 U.S.C. Section 8905.12 The eligibility
eligibility criteria are generally the same criteria that all other federal employees must meet to continue
continue FEHBP coverage in retirement. The criteria are (1) eligibility for retirement from the federal
federal government,13 and (2) continuous enrollment in a health plan offered under FEHBP (or in
the case
of Members and staff, offered through an exchange) for the five years of service immediately
immediately prior to retirement. To be clear, OPM has indicated that Members’ and staff’s SHOP exchange
exchange coverage counts toward the five-year requirement.
OPM indicates that the final rule does not apply to Members or staff who become annuitants
before December 31, 2013. If these annuitants are enrolled in a plan under FEHBP, nothing would
prohibit them from continuing their coverage under a FEHBP plan.
9
Office of Personnel Management, “Federal Employees Health Benefits Program: Members of Congress and
Congressional Staff,” 78 Federal Register 60653, October 2, 2013, page 60653.
10
5 CFR § 890.102(c)(9)(ii).
11
Ibid.
12
The final rule allows Members and staff to transfer to coverage offered under FEHBP on becoming annuitants, but
the proposed rule did not. Under the proposed rule, Members and staff were unable to return to FEHBP upon becoming
annuitants; instead, they could continue to receive the government contribution toward an exchange plan on becoming
annuitants. In the preamble to the final rule, OPM notes (page 60654), “Section 1312 only addresses the health benefits
plans that the federal government may offer Members of Congress and congressional staff employed by the official
office of a member of Congress while they are employed in those positions. This provision neither amended any of the
sections of Chapter 89 relating to annuitant health benefits nor otherwise indicated that the provision applies to
annuitants. Because we agree with the central premise of these comments, we have deleted the proposed language in §
890.501(h)(1) and (2) referring to annuitants.”
13
For information about retirement eligibility, see CRS Report RL30631, Retirement Benefits for Members of
Congress, by Katelin P. Isaacs.
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OPM indicates that the final rule does not apply to Members or staff who became annuitants
before December 31, 2013. If these annuitants were enrolled in a plan under FEHBP, nothing
would prohibit them from continuing their coverage under a FEHBP plan.
Election of Coverage and Plan Choices
Under the final rule, all Members of Congress, including representatives of the U.S. Territories,
and their designated staff must purchase “health plans offered by an appropriate SHOP as
determined by the Director [of OPM] ... ” in order to receive an employer contribution toward the
coverage.14 OPM has indicated that Members and staff must use the District of Columbia’s SHOP
exchange (DC Health Link).15
The open enrollment period for Members and staff beginswas November 11, 2013, and ends
through December 9,
2013.16 Members and staff will bewere able to select a plan from 112 options offered in
the gold tier on
the DC SHOP exchange.17 Coverage will beginbegan on January 1, 2014, for those
Members and staff who select
selected a plan during the open enrollment period. (For Members and staff
currently previously covered by
a plan offered under FEHBP, their coverage will terminateunder that plan terminated December 31,
2013.)
Members and staff will be able tocan select individual coverage or family coverage. OPM notes that,
“Under
FEHB rules, eligible dependents are limited to your spouse, your children (including stepchildren and adopted children) and foster children. Regardless of the dependent relationships
listed on the DC Health Link webpage when enrolling, these are the only dependents you may
enroll.”18 OPM indicates that enrollment in a SHOP plan will last for one year, unless an
employment change occurs (such as a move to a different federal agency). Once Members and
staff enroll in a SHOP plan, enrollment in the plan will automatically renew for the next calendar
year if the enrollee does not take action during the open enrollment period.
SHOP coverage will terminateterminates once Members and staff separate from federal service, but
Members Members
and staff may have the option to enroll in a FEHBP plan under Temporary Continuation
of of
Coverage (TCC) in such situations.19 TCC is also available to FEHBP enrollees and is similar
to to
COBRA coverage offered to individuals in the private sector. Members, staff, and their
dependents who lose their SHOP coverage because of a qualifying event, such as job loss (except
for gross misconduct), may be eligible for TCC. TCC enrollees may initially enroll in any FEBHP
plan and may also change plans during open season, but they must pay the full premium for the
plan they select (that is, both the employee and government shares of the premium) plus a 2%
FEHBP
14
5 CFR § 890.102(c).
In addressing the question as to whether individual who reside outside the D.C. region will be able to obtain a health
plan through the D.C. SHOP exchange that provides in-network coverage outside the D.C. region, OPM notes that the
DC SHOP offers health plans that have “in-network access to medical providers across the nation and overseas.” OPM,
Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?cid=
6bf9dd32-d3b9-4fc7-9416-431e535f933a&page=1.
16
The open enrollment period coincides with the FEHBP open enrollment period. OPM, Insurance FAQs: Members of
Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?cid=6bf9dd32-d3b9-4fc7-9416431e535f933a&page=2.
17
The D.C. SHOP exchange also offers plans in the other metal tiers – bronze, silver, and platinum – but OPM has
indicated that Members and designated staff must purchase plans offered in the gold tier in order to retain the employer
contribution. The plans offered in the gold tier must have an actuarial value around 80%. This means that, on average,
the plan is responsible for 80% of the cost of all covered benefits and the enrollee is responsible for 20%.
18
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a&page=2.
19
Ibid.
15
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Health Benefits for Members of Congress and Certain Congressional Staff
plan and may also change plans during open season, but they must pay the full premium for the
plan they select (that is, both the employee and government shares of the premium) plus a 2%
administrative charge. In general, TCC coverage is available to separating employees and their
families for up to 18 months after the date of separation.
Employer Contributions
Members and staff will beare able to receive an employer contribution toward coverage purchased
through the D.C. SHOP exchange. The employer contribution will beis calculated using the
statutory statutory
formula for health plans offered under FEHBP.20 The percentage of premiums paid by
the federal
government is calculated separately for individual and family coverage, but each uses
the same
formula. According to the formula, the employer contribution is set at 72% of the
weighted weighted
average of all FEHBP plan premiums, not to exceed 75% of any given plan’s
premium.21 In 2014,
the maximum government contribution for full-time employees is $426.14
per month for self-onlyselfonly coverage and $948.18 per month for self and family coverage. The
employer contribution to
a plan for a part-time worker is generally prorated.22 OPM indicates that
Members’ and staff’s
contributions to premiums will beare collected by payroll deduction and the
contributions will beare tax
preferred, as they are for FEHBP enrollees.23
Cost of Coverage
Plans offered under large group coverage arrangements typically offer the same premium to all
enrollees. This is the case for plans offered under FEHBP—the premium for any particular plan
for self or family coverage is the same for any individual who enrolls in the plan, regardless of
the individual’s characteristics (e.g., age) or health status. In contrast, plans offered in the small
group market, such as those that will be available through SHOP exchanges, are allowed to vary
premiums based on an individual’s age, geographic location, and whether the individual uses
tobacco products. This means that two individuals who have different characteristics (i.e., one is
25 years old and the other is 56 years old) who select the same plan in an exchange could be
charged different premiums because of the rating allowances, unlike FEHBP where they would be
charged the same premium.
Plans offered through D.C.’s SHOP exchange will only vary premiums based on an enrollee’s
age.24
Table A-1 in the Appendix illustrates how age-rating could affect the cost of coverage for
Members and staff who obtain coverage through the D.C. SHOP exchange.
20
5 CFR § 890.501(h).
5 U.S.C. §8906.
22
Part-time workers (working 16 to 32 hours a week) hired on or after April 8, 1979, are entitled to a partial
government contribution in proportion to the number of hours they are scheduled to work in a pay period. Part-time
workers hired before April 8, 1979, who have continued to serve on a part-time basis without a break in service are
eligible for the full government contribution. Additionally, part-time employees who work less than 16 hours or more
than 32 hours per week are entitled to the full government contribution. The amount of the prorated government
contribution for a part-time employee is the ratio of scheduled part-time work hours to full-time hours (usually 80 hours
per biweekly pay period) multiplied by the government contribution for full-time employees enrolled in that plan. The
part-time employee pays the difference between the total premium and the prorated government contribution.
23
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a&page=2.
24
Under ACA, state may also allow insurers to vary premiums by geographic rating area and whether or not an
enrollee uses tobacco products; however, D.C. only has one geographic rating area and has decided not to allow
insurers to vary premiums based on tobacco use.(continued...)
21
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Other Health Benefits Related to
Federal Federal
Employment
Section 1312(d)(3)(D) of ACA and the final rule only affect the health insurance coverage the
federal government may make available to Members and certain congressional staff as part of
their federal employment. Members and staff (hereinafter, “staff” refers to all congressional staff),
as well as other federal employees, have access to other health benefits, and their access to these
benefits does not appear to be affected by Section 1312(d)(3)(D) and the final rule.25 Some of
these health benefits are available to all federal employees and annuitants, while others are only
available to active employees or Members.
Federal Flexible Spending Account Program
OPM administers a Flexible Spending Account (FSA) program, FSAFEDS. Current federal
employees (including Members and congressional staff) who are eligible for FEHBP are also
eligible to participate in FSAFEDS, whether enrolled in FEHBP or not. There are three options
within FSAFEDS:
•
The Health Care Flexible Spending Account (HCFSA) reimburses eligible
health care expenses that are not covered or reimbursed by other insurance
coverage, including copayments, over-the-counter drugs, eyeglasses, dental care,
and infertility treatments. Employees can choose to deposit between $250 and
$2,500 each year.
•
The Dependent Care Flexible Spending Account (DCFSA) reimburses eligible
non-medical child day care and elder care expenses. A $5,000 limit applies.
•
The Limited Expense HCFSA (LEX HCFSA) is for those enrolled in a highdeductible health plan (HDHP) with a Health Savings Account, and it reimburses
only eligible dental and vision expenses that are not covered or reimbursed by
other insurance coverage.
The accounts are funded by the employee from pre-tax salary dollars, with no government
contribution. FSA money is lost if it is not spent within 2½ months after the end of the calendar
year in which the money was allotted.26 During the annual FEHBP open season, employees may
change the amount to set aside in the upcoming year or may choose not to deposit money in their
FSA.27
25
(...continued)
enrollee uses tobacco products; however, D.C. only has one geographic rating area and has decided not to allow
insurers to vary premiums based on tobacco use.
25
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a&page=2.
26
The Treasury Department and the Internal Revenue Service (IRS) recently issued Notice 2013-71, which modifies
health FSA (e.g., HCFSA) “use it or lose it” rules. According to the Notice, plan sponsors (e.g., employers) may allow
employees to carry over up to $500 of unused amounts remaining in a health FSA into the next plan year. This
carryover option is an alternative to the 2½ month grace period; plan sponsors may not offer both. As of the date of this
report, OPM has not announced whether the carryover option will be available to federal employees who have health
FSAs.
27
Office of Personnel Management, Flexible Spending Accounts (FSAFEDS) FastFacts, http://www.opm.gov/insure/
fastfacts/fsafeds.pdf.
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change the amount to set aside in the upcoming year or may choose not to deposit money in their
FSA.27
Federal Employees Dental and Vision Insurance Program
Dental and vision benefits are available to active federal employees and annuitants (including
current and retired Members and congressional staff) through the Federal Employees Dental and
Vision Insurance Program (FEDVIP) administered by OPM. Employees and annuitants are not
required to enroll in FEHBP to enroll in FEDVIP. Enrollees are responsible for 100% of the
premiums, and employees’ salary contributions are paid with pre-tax dollars. To continue or
obtain FEDVIP coverage in retirement, an employee does not have to participate in FEDVIP prior
to retirement.
For dental coverage, enrollees have a choice of four nationwide and three regional dental plans
covering a variety of preventive and major services, as well as orthodontics for dependents under
the age of 19.28 For vision coverage, enrollees can choose from three nationwide vision plans that
cover routine eye exams and glasses or contact lenses. Plans vary in the other types of vision
services they cover, such as discounts on Lasik surgery, low vision therapy, prosthetic eyes, and
other services.29
Federal Long Term Care Insurance Program
Federal employees and annuitants (including current and retired Members and congressional
staff) are eligible to apply for long-term care coverage through the Federal Long Term Care
Insurance Program administered by OPM. Long-term care includes services and assistance for
those who can no longer perform activities of daily living, such as bathing and dressing, due to
chronic illness, injury, disability, or aging. Most health insurance plans, including plans offered
through FEHBP, do not include coverage for long-term care services. To apply for coverage under
FLTCIP, employees must answer questions about their medical history. Some medical conditions
will prevent employees from being approved for coverage. Premiums for FLTCIP may be
deducted from an individual’s salary or annuity, but they are not pre-tax contributions, and
employees pay 100% of the premiums.30
Office of the Attending Physician
Current Members are eligible to receive limited services from the Office of the Attending
Physician (OAP) in the U.S. Capitol for an annual fee. The annual fee for 2013 is $576.31
Services include routine exams, consultations, and certain diagnostic tests. The office does not
provide vision or dental care, and prescriptions can be written but not dispensed.32
28
Services include routine exams,
27
Office of Personnel Management, Flexible Spending Accounts (FSAFEDS) FastFacts, http://www.opm.gov/insure/
fastfacts/fsafeds.pdf.
28
Office of Personnel Management, FastFacts for Dental Insurance, http://www.opm.gov/insure/fastfacts/dental.pdf.
29
Ibid.
30
Individuals under age 65 can deduct long-term care insurance premiums as medical expenses if total qualified
medical expenses exceed 10% of annual adjusted gross income (AGI). Prior to 2017, individuals aged 65 and older can
deduct long term care insurance premiums as medical expenses if total qualified medical expenses exceed 7.5% of
annual AGI (beginning in 2017 the threshold increases to 10%). The amount of long-term care insurance premiums an
individual can deduct is subject to Internal Revenue Service (IRS) limits. For more information, see
http://www.ltcfeds.com/start/aboutltci_taxqual.html.
31
Committee on House Administration.
32
For background information on the Office of the Attending Physician, see CRS Report RS20305, The Office of
Attending Physician in the U.S. Congress, by Mildred Amer.
29
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consultations, and certain diagnostic tests. The office does not provide vision or dental care, and
prescriptions can be written but not dispensed.31
Military Treatment Facilities
Current Members are also authorized to receive medical and emergency dental care at military
treatment facilities. There is no charge for outpatient care if it is provided in the National Capital
Region.3332 For inpatient care, Members are billed at full reimbursement based on rates set by the
Department of Defense. Outside the National Capital Region, charges are at full reimbursement
rates for both inpatient and outpatient care provided to current Members of Congress. Members
pay out
of pocket for expenses not covered by insurance. Former Members and dependents are not
Dependents and former Members are
not eligible for care at military hospitals.34treatment facilities. 33
Medicare
Medicare is the nation’s health insurance program for individuals aged 65 and over and certain
disabled persons. Medicare consists of four distinct parts: Part A, or Hospital Insurance (HI); Part
B, or Supplementary Medical Insurance (SMI); Part C, or Medicare Advantage (MA); and Part D,
the prescription drug benefit.3534 Workers, including all federal employees, Members, and
congressional staff, must pay a tax on their wages for Medicare Part A.3635 Workers and their
employers each pay a tax of 1.45% of earnings.3736
Participation in Part B, Medicare Advantage, and Part D is voluntary, and each requires that
enrollees pay a monthly premium to participate.38 Medicare beneficiaries may also choose to
purchase a Medigap policy, which provides supplemental coverage in the private sector if one
enrolls in Medicare Part A and B.
With respect to Members and designated congressional staff, §Section 1312(d)(3)(D) and the final rule
rule do not appear to affect their eligibility for any Medicare programs. Additionally, OPM indicates
indicates that eligibility for Medicare willdoes not affect Members’ and staff’s ability to obtain coverage
coverage through a SHOP exchange:
SHOP coverage is not subject to the same limitation as the individual Exchange which
precludes an individual from carrying both Medicare and an individual Exchange policy.
You can continue to have Medicare coverage in addition to your employer-sponsored DC
SHOP plan.39
33
37
31
For background information on the Office of the Attending Physician, see CRS Report RS20305, The Office of
Attending Physician in the U.S. Congress, by Mildred Amer.
32
The National Capital Region includes Washington, DC, and nearby jurisdictions in Maryland and Virginia.
33
32 C.F.R. §728.77.
3534
For more detail on Medicare eligibility and benefits, see CRS Report R40425, Medicare Primer, coordinated by
Patricia A. Davis and Scott R. Talaga.
3635
This tax was established for federal employees under the Tax Equity and Fiscal Responsibility Act of 1982 (P.L. 97248, effective January 1, 1983).
3736
For a full discussion of wage taxes, see CRS Report 94-28, Social Security and Medicare Taxes and Premiums: Fact
Sheet, by Dawn Nuschler.
38
For Part B, the 2013 monthly premium is $104.90 for most Medicare beneficiaries. For Part D, the 2013 base
beneficiary premium is $31.17. Premiums vary among Medicare Advantage plans.
3937
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a&page=2.
34FAQS/topic/insure/index.aspx?cid=
(continued...)
Congressional Research Service
8
Health Benefits for Members of Congress and Certain Congressional Staff
This information indicates that Members and designated staff who become eligible for Medicare
while actively employed can have SHOP coverage and Medicare coverage concurrently. For
those Members and designated staff who carry their federally- sponsored health insurance
coverage into retirement, they will switch to a plan offered under FEHBP, and their FEHBP
coverage will interact with Medicare coverage in the ways outlined for the programs.40
40
38
(...continued)
6bf9dd32-d3b9-4fc7-9416-431e535f933a.
38
For more information about how FEHBP interacts with Medicare, see CRS Report RS21974, Federal Employees
Health Benefits Program (FEHBP): Available Health Insurance Options, by Annie L. Mach and Ada S. Cornell.
Congressional Research Service
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Health Benefits for Members of Congress and Certain Congressional Staff
Appendix. Selected Premiums in the D.C.
SHOP SHOP
Exchange
Table A-1 shows the monthly premiums for self-only coverage from selected gold level health
plans available to individuals (age 27, 40, and 55) through the D.C. SHOP exchange (D.C. Health
Link) beginning January 2014.4139 Table A-1 also shows the potential federal government
contribution to that coverage. The federal government contribution was calculated using the
statutory formula for FEHBP—the government’s contribution is 72% of the weighted average of
all FEHBP plans not to exceed 75% of any given plan’s premium. The maximum monthly federal
government contribution in 2014 for self-only coverage under FEHBP is $426.14 (i.e., $426.14 is
72% of the weighted average of all self-only FEHBP plans for 2014).
The information in Table A-1 is illustrative only; it does not provide comprehensive information
about all of the plan options that may be available to Members and designated staff through the
D.C. SHOP exchange. Individuals interested in a more comprehensive examination of the plans
available through D.C.’s SHOP exchange should visit www.dchealthlink.com.
4139
The D.C. SHOP exchange also offers plans in the other metal tiers—bronze, silver, and platinum—but OPM has
indicated that Members and designated staff must purchase plans offered in the gold tier in order to retain the employer
contribution. Plans offered in the gold tier must have an actuarial value around 80%. This means that, on average, the
plan is responsible for 80% of the cost of all covered benefits and the enrollee is responsible for 20%.
Congressional Research Service
10
Table A-1. Monthly Self-Only Premiums for Selected Gold Level Health Insurance Plans Available Through the District of
Columbia’s SHOP Exchange
Individuals Aged 27
Individuals Aged 40
Individuals Aged 55
Total
Premium
Gov’t.
Contribution
Employee
Contribution
Total
Premium
Gov’t.
Contribution
Employee
Contribution
Total
Premium
Gov’t.
Contribution
Employee
Contribution
Low
$324.16
$243.12
$81.04
$434.74
$326.06
$108.69
$772.72
$426.14
$346.58
High
$403.13
$302.35
$100.78
$540.65
$405.49
$135.16
$960.98
$426.14
$534.84
Low
$242.29
$181.72
$60.57
$324.94
$243.71
$81.24
$577.57
$426.14
$151.43
High
$314.03
$235.52
$78.51
$421.15
$315.86
$105.29
$748.57
$426.14
$322.43
Low
$272.72
$204.54
$68.18
$365.75
$274.31
$91.44
$650.10
$426.14
$223.96
High
$329.07
$246.80
$82.27
$441.32
$330.99
$110.33
$784.43
$426.14
$358.29
Low
$226.27
$169.70
$56.57
$303.46
$227.60
$75.87
$539.38
$404.54
$134.85
High
$256.30
$192.23
$64.08
$343.73
$257.80
$85.93
$610.95
$426.14
$184.81
Low
$226.78
$170.09
$56.70
$303.75
$227.81
$75.94
$539.01
$404.26
$134.75
High
$267.96
$200.97
$66.99
$358.98
$269.24
$89.75
$637.17
$426.14
$211.03
Low
$256.85
$192.64
$64.21
$344.47
$258.35
$86.12
$612.27
$426.14
$186.13
High
$311.92
$233.94
$77.98
$418.32
$313.74
$104.58
$743.54
$426.14
$317.40
Low
$240.05
$180.04
$60.01
$321.94
$241.46
$80.49
$572.22
$426.14
$146.08
High
$295.14
$221.36
$73.79
$395.82
$296.87
$98.96
$703.55
$426.14
$277.41
Aetna – PPO
Aetna – HMO
CareFirst – PPO
CareFirst – HMO
Kaiser – HMO
United – PPO
United – HMO
Source: The premium information was obtained at http://disb.dc.gov/sites/default/files/dc/sites/disb/publication/attachments/FINALRates72313.pdf.
Notes: The “low” premium is for the lowest cost plan offered in the category; the “high” premium is for the highest cost plan offered in the category.
CRS-11
Health Benefits for Members of Congress and Certain Congressional Staff
Author Contact Information
Annie L. Mach
Analyst in Health Care Financing
amach@crs.loc.gov, 7-7825
Congressional Research Service
Ada S. Cornell
Information Research Specialist
acornell@crs.loc.gov, 7-3742
12