.
Health Benefits for Members of Congress and
CertainDesignated Congressional Staff
Annie L. Mach
Analyst in Health Care Financing
Ada S. Cornell
Information Research Specialist
February 18, 2014June 17, 2015
Congressional Research Service
7-5700
www.crs.gov
R43194
CRS Report for Congress
Prepared for Members and Committees of Congressc11173008
Health Benefits for Members of Congress and CertainDesignated Congressional Staff
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Summary
The federal government, as an employer, offers health benefits to its employees, including
Members of Congress and congressional staff. Prior to 2014, Members and staff had access to
many of the same health benefits as other federal employees. For example, Members and staff
were eligible to voluntarily enroll in employer-sponsored health insurance through the Federal
Employees Health Benefits Program (FEHBP)(FEHB) Program, and they could choose to participate in other
health 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 certaindesignated congressional staff (with respect to their service as
Members or
staff) are either created under the ACA or offered through an exchange established
under the ACA. A final rule issued by the
Office of Personnel Management (OPM) amends FEHBP FEHB
eligibility regulations to comply with
Section 1312(d)(3)(D) of the ACA. Under the final rule,
beginning January 1, 2014, Members and
designated congressional staff are no longer able to
purchase FEHBPFEHB plans as active employees;
however, if they enroll in a health plan offered
through a small business health options program
(SHOP) exchange, they remain eligible for an
employer contribution toward coverage.
Additionally, the final rule allows Members and
designated congressional staff who are eligible
for retirement to enroll in a FEHBPFEHB 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 are 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 RS21974R43922, Federal Employees
Health Benefits Program (FEHBP): Available Health Insurance Options, by Annie L. Mach and
Ada S. Cornell.(FEHB) Program: An Overview.
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Contents
Introduction...................................................................................................................................... 14
Health Insurance Coverage .............................................................................................................. 25
Coverage for Annuitants (Retirees) Members and Staff............................................................................................... 5
Coverage for Retirees ...................................................................................................... 3.......... 6
Election of Coverage and Plan Choices .................................................................................... 47
Employer Contributions ............................................................................................................ 58
Cost of Coverage ....................................................................................................................... 58
Other Health Benefits Related to Federal Employment .................................................................. 69
Federal Flexible Spending Account Program ............................................................................ 69
Federal Employees Dental and Vision Insurance Program ....................................................... 79
Federal Long Term Care Insurance Program............................................................................. 7 10
Office of the Attending Physician ............................................................................................. 7 10
Military Treatment Facilities ..................................................................................................... 8 10
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
Contacts
Author Contact Information................................................ 11
Appendixes
Appendix. Selected Premiums in the D.C. SHOP Exchange ........................................................... 10
Contacts
Author Contact Information12
Acknowledgments ......................................................................................................................... 12
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Introduction
Many private- and public-sector firms offer employer-subsidizedsponsored health benefitsinsurance to their
employees and contribute toward the cost of that insurance as part of an employee’s
compensation package. Among large employers in the United
States (those with 200 or more
employees), 9998% offered health insurance coverage to their
employees in 20132014.1 On average,
large employers subsidizedcontributed 81% of the cost of self-only
coverage and 7473% of the cost of family
coverage.2 Twenty-eightthree percent of large employers that
offer health benefits to their employees
offer retiree coverage. Among firms with 5,000 or more
workers, 4849% offer retiree coverage.3
The federal government, as an employer, also offers health benefits to its employees and
annuitants (retirees). retirees.4
The federal government offers employer-subsidizedsponsored health insurance
through the Federal Employees Health Benefits Program (FEHBP and contributes toward the
cost of that coverage through the Federal Employees Health Benefits (FEHB) Program,
administered by the Office of Personnel Management (OPM). Prior to 2014, Members of
Congress and congressional staff were eligible to participate in FEHBPFEHB in the same way that most
other federal employees and annuitantsretirees are eligible to participate.45 That is, Members and staff
could could
purchase a health plan offered under FEHBPFEHB, receive an employer contribution toward the
coverage, and carry the coverage into retirement (provided they were 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.
1
Kaiser Family Foundation and the Health Research & Educational Trust, Employer Health Benefits, 20132014 Annual
Survey, Menlo Park, CA, August 2013September 10, 2014, http://kff.org/private-insurancehealth-costs/report/20132014-employer-health-benefits-survey/.
2
Ibid.
3
Ibid.
4
In the statute, retirees are referred to as annuitants. In this report, the term retirees will be used.
5
/.
2
Ibid.
3
Ibid.
4
For more information about how FEHBPFEHB works for most federal employees, see CRS Report RS21974R43922, Federal
Employees Health Benefits Program (FEHBP): Available Health Insurance Options, by Annie L. Mach and Ada S.
Cornell.(FEHB) Program: An Overview.
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The Office of Personnel Management (OPM).
On October 2, 2013, OPM issued a final rule that amends FEHBPFEHB eligibility to
comply with
Section 1312(d)(3)(D) of ACA on October 2, 2013.5the ACA.6 Under the rule, Members and
certain designated congressional staff
were no longer able to purchase a health plan offered under FEHBP
FEHB beginning January 1, 2014;
however, if they enroll in a health plan offered through an appropriate
small business health
options program (SHOP) exchange,67 they remain eligible for an employer
contribution toward
coverage. Additionally, Members and staff who obtain coverage through a
SHOP exchange under
this arrangement may purchase a FEHBPFEHB plan upon retirement from the
federal government,
provided they otherwise meet the criteria to do so.7 This report summarizes
the provisions of the
final rule and discusses how they affect current and retired Members and designated
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
FEHB.8 The final rule and the ACA do
not require 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. 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.
WhileAlthough 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 RS21974R43922, Federal Employees Health Benefits Program
(FEHBP): Available Health Insurance Options, by Annie L. Mach and Ada S. Cornell.
Health Insurance Coverage
Beginning(FEHB)
Program: An Overview.
Health Insurance Coverage
Coverage for Members and Staff
As of January 1, 2014, Members of Congress and certaindesignated 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 the ACA defines the terms “Members of
of Congress” and “congressional staff” as follows:
The term “Member of Congress” means any member of the House of Representatives or the
Senate.
5
Office of Personnel Management6
OPM, “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
67
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 ManagementR43771, Small Business Health Options Program
(SHOP) Exchange, by Annie L. Mach.
8
OPM, “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/FR2013FR-2013-10-02/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) was required to designate its staff prior to
November 2013 for the plan year effective January 1, 2014; for subsequent plansplan years, the
designations must be made prior to Octoberduring the month of September of the preceding year (or at the time of
hiring for
individuals whose employment begins during the year).10 The designation will beis made
annually,
and individuals will maintain their designations for the entire FEHBPFEHB plan year, so long as they
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 FEHBPFEHB.
Coverage for Annuitants (Retirees)Retirees
OPM indicates that Members and congressional staff designated as working for an official office
of a Member (hereinafter “staff” or “designated staff”) who purchase coverage through an
exchange will have the ability to enroll in plans offered through FEHBP when they become
annuitantsFEHB in retirement, provided
they meet the eligibility criteria to do so under 5 U.S.C. Section 8905.12 The
eligibility criteria are
generally the same criteria that all other federal employees must meet to
continue FEHBPFEHB coverage
in retirement. The criteria are (1) eligibility for retirement from the
federal government,13 and (2)
continuous enrollment in a health plan offered under FEHBPFEHB (or in
the case of Members and staff,
offered through ana SHOP exchange) for the five years of service
immediately prior to retirement.
To be clear, OPM has indicated that Members’ and staff’s SHOP
exchange coverage counts toward the five-year requirement.
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
toward the five-year requirement. The final rule does not apply to Members or staff who retired
before December 31, 2013. If these retirees were enrolled in a plan under FEHB, nothing would
prohibit them from continuing their coverage under a FEHB plan.
9
Ibid.
5 CFR §890.102(c)(9)(ii).
11
Ibid.
12
The final rule allows Members and staff to transfer to coverage offered under FEHBPFEHB on becoming annuitants
(retirees), but , but
the proposed rule did not. Under the proposed rule, Members and staff were unable to return to FEHBP FEHB
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.
10
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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 planDesignated Congressional Staff
.
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, known as DC Health Link (hereinafter the “DC SHOP”).15
The open enrollment period for Members and designated staff coincides with the FEHB open
enrollment period, running mid-November to mid-December each year.16 For the 2015 plan year,
the open enrollment period was November 10, 2014 through December 10, 2014, with 68 plan
staff was November 11, 2013 through December 9,
2013.16 Members and staff were able to select a plan from 112 options offered in the gold tier on
the DC SHOP exchange.17 Coverage began on January 1, 2014, for.17 For those Members and staff who
selected a
plan during the initial open enrollment period. (For Members and staff previously covered by
a plan offered under FEHBP, their coverage under that plan terminated December 31, 2013.) (November 11, 2013, through December 9, 2013),
coverage began on January 1, 2014.18
Members and staff can 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 LinkSHOP webpage when enrolling, these are the only dependents you may
enroll.”1819 OPM indicates that enrollment in a SHOP plan will lastlasts for one year, unless an
employment 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 coverageCoverage through the DC SHOP terminates once Members and staff separate from federal
service, but Members
and staff, staff and eligible family members may have the option to enroll in a FEHBP FEHB
plan under Temporary Continuation of
Coverage (TCC) in such situations.19 TCC is also available to FEHBP enrollees and is similar to
Coverage (TCC), under the same rules for other federal
employees.20 TCC is similar 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., and
is also available to FEHB enrollees.21 TCC enrollees may initially enroll in any FEHBPFEHB plan and
14
5 CFR §890.102(c).
In addressing the question as to whether individualindividuals who reside outside the D.C.DC region will be able to obtain a health
plan through the D.C.DC SHOP exchange that provides in-network coverage outside the D.C.DC region, OPM notes that the
DC 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/.
16
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-d3b9-4fc7-9416431e535f933a9416-431e535f933a.
17
The D.C.DC 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
For Members and staff previously covered by a plan offered under FEHB, their coverage under that plan terminated
December 31, 2013.
19
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a.
1920
Ibid.
15
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plan and 21
COBRA generally applies to group health plans maintained by private-sector employers, or by state or local
governments, and requires most group health plans to provide a temporary continuation of group health coverage that
otherwise might be terminated. For more information, see Department of Labor, FAQs about COBRA Continuation
Health Coverage, http://www.dol.gov/ebsa/faqs/faq-consumer-cobra.html.
15
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.
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 are able to receive an employer contribution toward coverage purchased
through the D.C. SHOP exchangeDC SHOP. The employer contribution is calculated using the statutory
formula for
health plans offered under FEHBP.20FEHB.22 The percentage of premiums paid by the federal
government 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
average of all FEHBP
FEHB 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 selfonly coverage and $948.18 per month for self and family coverage.23 The employer
contribution to
a plan for a part-time worker is generally prorated, following FEHB program
guidelines..22 OPM indicates that Members’Member and staff’s
contributions to premiums are collected by
payroll deduction and the contributions are tax
preferred, as they are for FEHBPFEHB enrollees.2324 OPM
has a “Premium Contribution Calculator” to help Members and staffs estimate their share of the
premium, available at http://www.opm.gov/healthcare-insurance/changes-in-health-coverage/
eligibility-enrollment/#url=Members-of-CongressStaff.
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 FEHBPFEHB—the premium for any particular plan
for for
self or family coverage is the same for any individual who enrolls in the plan, regardless of
the the
individual’s characteristics (e.g., age) or health status. In contrast, plans offered in the small
group group
market, such as those that will be available through the SHOP exchanges, are including the DC SHOP, 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.ee.g., 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 FEHB
where they would be
charged the same premium.
Plans offered through D.C.’s SHOP exchange the DC SHOP 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.
24
Under ACA, state may also allow insurers to vary premiums by geographic rating area and whether or not an
(continued...)
21
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Other Health Benefits Related to Federal
Employment
Section 1312(d)(3)(D) of
premiums based on an enrollee’s age.25 Detailed information on the plans and premiums available
through the DC SHOP is at http://www.dchealthlink.com.26
22
5 CFR §890.501(h).
5 U.S.C. §8906.
24
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a.
25
Under ACA, state may also allow insurers to vary premiums by geographic rating area and whether an enrollee uses
tobacco products; however, DC only has one geographic rating area and has decided not to allow insurers to vary
premiums based on tobacco use.
26
Sample premiums for 2015 SHOP plans are available at “January 2015 Rates for Health Insurance Products to be
Sold in DC Health Link ‐ SHOP,” at http://disb.dc.gov/sites/default/files/dc/sites/disb/publication/attachments/9-15-14Small-Business-SHOP-Approved-Rates-for-Health-Insurance-Products-Sold-on-DC-Health-Link-for-2015.pdf.
23
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.
Other Health Benefits Related to Federal
Employment
Section 1312(d)(3)(D) of the ACA and the final rule only affect the health insurance coverage the
federal government may make available to Members and certaindesignated 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.2527 Some of
these health benefits are available to all federal employees and annuitantsretirees, while others are only
available to active employees or Members, Members, and staff.
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
Active federal
employees eligible for FEHB (including current Members and staff eligible for SHOP coverage)
are also eligible to participate in FSAFEDS, whether enrolled in FEHBPFEHB or not. There are three options
within FSAFEDS
types of FSAs:
•
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,
hearing aids, and infertility treatments. Employees can choose to deposit between $250 and
$2,500
$100 and $2,550 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
(...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.
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.
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change the amount to set Participants may carryover up to $500 of unspent funds into the following year
when re-enrolling in a HCFSA or LEX HCFSA. The DCFSA does not allow carryover, but there
is a grace period through March 15 of the following year to incur for expenses against the prior
year’s account. During the annual FEHB open season, employees may change the amount to set
aside in the upcoming year or may choose not to deposit money in their
FSA.2728
Federal Employees Dental and Vision Insurance Program
Dental and vision benefits are available to active federal employees and annuitantsretirees (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 Vision
27
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a.
28
OPM, Flexible Spending Accounts (FSAFEDS) FastFacts, http://www.opm.gov/insure/fastfacts/fsafeds.pdf.
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Health Benefits for Members of Congress and Designated Congressional Staff
.
Insurance Program administered by OPM. FEDVIP enrollees are not required to enroll in FEHB.
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 six nationwide and four regional dental plans
covering a variety of preventive and major services, as well as orthodontics for dependents under
the age of 19.2829 For vision coverage, enrollees can choose from threefour nationwide vision plans that
cover routine eye exams and glasses or contact lenses. Plans vary in the other types of vision
services services
they cover, such as discounts on Lasik surgery, low vision therapy, prosthetic eyes, and
other services.29.30
Federal Long Term Care Insurance Program
Federal employees and annuitantsretirees (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.3031
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. 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 consultations,
and certain diagnostic tests. The office does not provide vision or dental care, and prescriptions
can be written but not dispensed.32
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.33 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
29
OPM, FastFacts for Dental Insurance, http://www.opm.gov/insure/fastfacts/dental.pdf.
OPM, FastFacts for Vision Insurance, http://www.opm.gov/healthcare-insurance/fastfacts/vision.pdf
31
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.
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Health Benefits for Members of Congress and Certain Congressional Staff
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.32 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
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.
33
The National Capital Region includes Washington, DC and nearby jurisdictions in Maryland and Virginia.
30
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Health Benefits for Members of Congress and Designated Congressional Staff
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rates for both inpatient and outpatient care provided to current Members of Congress. Members
pay out of pocket for expenses not covered by insurance. Dependents and former Members are
not eligible for care at military treatment facilities. 3334
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.3435 Workers, including all federal employees, Members, and
congressional staff, must pay a tax on their wages for Medicare Part A.3536 Workers and their
employers each pay a tax of 1.45% of earnings.3637
Participation in Part B, Medicare Advantage, and Part D is voluntary, and each requires that
enrollees pay a monthly premium to participate. 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 do not appear to affect their eligibility for any Medicare programs. Additionally, OPM
indicates that eligibility for Medicare does not affect Members’ and staff’s ability to obtain
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.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.
34
38
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 would switch to a plan offered under FEHB, and their FEHB
coverage would interact with Medicare coverage in the ways outlined for the programs.39
34
32 C.F.R. §728.77.
For more detail on Medicare eligibility and benefits, see CRS Report R40425, Medicare Primer, coordinated by
Patricia A. Davis and Scott R. Talaga.
35.
36
This tax was established for federal employees under the Tax Equity and Fiscal Responsibility Act of 1982 (P.L. 97248, effective January 1, 1983).
3637
For a full discussion of wage taxes, see CRS Report 94-28, Social Security and Medicare Taxes and Premiums: Fact
Sheet, by Dawn Nuschler.
37
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/FAQS/topic/insure/index.aspx?cid=
(continued...)
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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.38
(...continued)
.
38
OPM, Insurance FAQs: Members of Congress & Staff, http://www.opm.gov/healthcare-insurance/insurance-faqs/?
cid=6bf9dd32-d3b9-4fc7-9416-431e535f933a/.
39.
38
For more information about how FEHBPFEHB interacts with Medicare, see CRS Report RS21974R43922, Federal Employees
Health Benefits Program (FEHBP): Available Health Insurance Options, by Annie L. Mach and Ada S. Cornell.(FEHB) Program: An Overview.
35
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Appendix. Selected Premiums in the D.C. 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 2014.39 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.
39
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%.
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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, 7-3742Designated Congressional Staff
.
Author Contact Information
Ada S. Cornell
Information Research Specialist
acornell@crs.loc.gov, 7-3742
Acknowledgments
Annie Mach was one of the original authors of this report.
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