Health Benefits for Members of Congress
Ada S. Cornell
Information Research Specialist
February 12, 2013
Congressional Research Service
7-5700
www.crs.gov
RS21982
CRS Report for Congress
Pr
epared for Members and Committees of Congress
Health Benefits for Members of Congress
Summary
Members of Congress and retired Members are eligible for private insurance coverage under the
same system as other federal employees, the Federal Employees Health Benefits Program
(FEHBP). FEHBP is the largest employer-sponsored health plan in the United States, covering
more than 8 million federal employees, retirees, and their families.
Retired federal employees, including retired Members, who meet the minimum enrollment period
requirements and who are eligible for an immediate annuity may continue to participate in
FEHBP in retirement. Current federal employees, including Members of Congress, may also
participate in the Federal Flexible Spending Account Program (FSAFEDS) to set up tax-exempt
flexible spending accounts for reimbursement of health care, child care, and elder care expenses
not otherwise reimbursed or covered by insurance. Current and retired federal employees,
including Members of Congress, may enroll in the Federal Employees Dental and Vision
Insurance Program (FEDVIP) for supplemental dental and vision insurance coverage. They may
also apply for long-term care coverage under the Federal Long Term Care Insurance Program
(FLTCIP).
All federal employees, including Members of Congress, pay the same payroll taxes as other
workers for Medicare Part A coverage, and they are eligible to enroll in Medicare Part B, Part C,
and Part D. Current Members, unlike other federal employees, are also eligible to receive health
care services from the Office of the Attending Physician in the U.S. Capitol and at military
hospitals.
The Patient Protection and Affordable Care Act (ACA; P.L. 111-148) requires health insurance
exchanges to be established in every state by January 1, 2014. The ACA requires that the only
health plans the federal government may make available to Members of Congress and certain
congressional staff as a benefit of their federal employment are health plans created under the
ACA or offered through health insurance exchanges established under the ACA. The Director of
OPM has resolved a lack of clarity in the law as to the effective date of this provision by
concluding that this provision will not be effective until the health insurance exchanges become
operational. Therefore, this provision does not currently affect Members of Congress or their
staffs’ participation in FEHBP. Regulations providing interpretive guidance have not yet been
promulgated as of the date of this report.
This report covers health benefits made available to Members of Congress through federal
government employment, including FEHBP, dental and vision insurance, flexible spending
accounts, long-term care insurance, services at the Office of the Attending Physician and military
hospitals, and Medicare. It also offers a comparison of FEHBP to health benefits offered by the
private sector and state and local governments and a discussion of the effect of the ACA on
Members’ health benefits.
This report will be updated as warranted.
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Health Benefits for Members of Congress
Contents
Introduction ...................................................................................................................................... 1
Federal Employees Health Benefits Program .................................................................................. 1
Eligibility and Participation ....................................................................................................... 1
Continuation of Health Benefits for Retirees ............................................................................ 2
Plans and Options ...................................................................................................................... 2
Premiums ................................................................................................................................... 3
Comparability of FEHBP to Health Benefits Offered by Private and State and Local
Government Employers .......................................................................................................... 3
Other Health Benefits ...................................................................................................................... 4
Federal Flexible Spending Account Program ............................................................................ 4
Federal Employees Dental and Vision Insurance Program ....................................................... 5
Federal Long Term Care Insurance Program ............................................................................. 5
Medicare Eligibility for Current and Former Members of Congress ........................................ 6
Office of the Attending Physician ............................................................................................. 6
Military Treatment Facilities ..................................................................................................... 6
Effect of the ACA on Health Benefits for Members of Congress .................................................... 7
Tables
Table 1. Average Biweekly 2013 FEHBP Premiums for Annuitants and Non-Postal
Employees: Government Contribution and Enrollee Contribution .............................................. 3
Contacts
Author Contact Information............................................................................................................. 7
Acknowledgments ........................................................................................................................... 7
Congressional Research Service
Health Benefits for Members of Congress
Introduction
Current and retired Members of Congress are eligible to participate in the Federal Employees
Health Benefits Program (FEHBP) under the same rules as other federal employees. The federal
government is the largest employer in the United States, and FEHBP is the largest employer-
sponsored health insurance program. FEHBP was authorized under the Federal Employees Health
Benefits Act of 1959 (P.L. 86-382), and it is administered by the Office of Personnel Management
(OPM).
This report provides a brief description of FEHBP eligibility, participation, health benefit plan
options, and premiums. It compares FEHBP to private-sector and state and local government
health benefit programs in the United States.1 It also covers other health benefits made available
to Members of Congress through federal government employment, but does not examine other
private benefits or veterans benefits that some Members may use. Lastly, this report discusses the
effect of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) on Members’ health
benefits.
In this report, the terms current federal employees or active federal employees mean all current
federal employees, including current Members of Congress. The terms annuitants or retirees
mean all retired federal employees, including retired Members of Congress.
Federal Employees Health Benefits Program
Eligibility and Participation
FEHBP covers over 8 million individuals, including current federal employees, retired federal
employees, and eligible dependents. Participation in FEHBP is voluntary, and approximately 90%
of federal employees are enrolled in FEHBP through individual or family plans.2 Participation
rates among current and retired Members of Congress are not publicly available.
New federal employees have 60 days to enroll in FEHBP, and they can enroll or change from one
plan to another during designated “open season” periods each year. Employees and annuitants
with special situations, such as a change in family status, can also enroll in a plan or change plans
outside of open season.3 Enrollees are not subject to medical examinations, waiting periods, or
preexisting condition exclusions prior to receiving coverage.
1 For more detailed information about FEHBP and OPM’s role in administering it, please refer to CRS Report
RS21974, Federal Employees Health Benefits Program (FEHBP): Available Health Insurance Options, by Annie L.
Mach.
2 Office of Personnel Management, “OPM Announces 2013 Federal Employees Health Benefits Program Premium
Rates,” press release, September 20, 2012, http://www.opm.gov/news/opm-announces-2013-federal-employees-health-
benefits-program-premium-rates,1758.aspx
3 Office of Personnel Management, Federal Employees Health Benefits Program Handbook, http://www.opm.gov/
insure/health/reference/handbook/fehb00.asp.
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Health Benefits for Members of Congress
Continuation of Health Benefits for Retirees
Upon retirement, federal employees have the opportunity to continue FEHBP coverage if certain
requirements are met:
• the employee must be entitled to retire on an immediate annuity; and
• the employee must have been continuously enrolled in FEHBP for five years
before the annuity starts, or the full period of service since the first opportunity to
enroll in FEHBP (if less than five years).4
The eligible retiree may enroll in individual coverage or family coverage, which covers a spouse,
dependent children up to the age of 26, and dependents who are incapable of self-support because
of a mental or physical disability that existed before the age of 26.5 For Medicare eligibility, see
section below titled “Medicare Eligibility for Current and Former Members of Congress.”
Plans and Options
There are 230 different health plans available in FEHBP for the 2013 plan year. This number
includes both nationally and regionally available plans. There are three categories of participating
plans:6
• The government-wide service benefit plan is the fee-for-service benefit plan
that pays providers directly for services (this slot has always been filled by Blue
Cross and Blue Shield).
• Employee organization plans are fee-for-service plans. All individuals eligible
to enroll in FEHBP may choose any employee organization plan, subject to small
annual membership dues.
• Comprehensive medical plans are the local Health Maintenance Organizations
(HMOs). Availability of these plans varies, depending on where the individual
resides.
Many FEHBP plans offer various levels of coverage, with different premiums and cost-sharing
structures for each option. For example, in 2013, Blue Cross and Blue Shield offers a “standard”
option with more extensive coverage and a higher premium than the “basic” option. The
employee organization and comprehensive plans offer consumer-driven health plans (CDHPs)
and high-deductible health plans (HDHPs).7
4 OPM has the authority to waive the five-year requirement when it determines that it would be against equity and good
conscience to not allow an annuitant to be enrolled in FEHBP (P.L. 99-251). For more information, see
http://www.opm.gov/insure/health/reference/handbook/FEHB22.asp.
5 Dependents are allowed to remain in FEHBP until the age of 26 because of a provision in ACA, which became
effective in 2011. Certain former spouses may also qualify to enroll in FEHBP. For more information, see the section
“Eligibility” in CRS Report RS21974, Federal Employees Health Benefits Program (FEHBP): Available Health
Insurance Options, by Annie L. Mach
6 Office of Personnel Management, “OPM Announces 2013 Federal Employees Health Benefits Program Premium
Rates,” press release, September 20, 2012, http://www.opm.gov/news/opm-announces-2013-federal-employees-health-
benefits-program-premium-rates,1758.aspx
7 For more information about HDHPs, see CRS Report R41426, High-Deductible Health Plans and Health Savings
(continued...)
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All FEHBP plans cover a range of benefits, including hospital, surgical, physician, mental health,
prescription drug, catastrophic, and emergency care. There are variations in the amount the plans
pay for each benefit, the coverage of specific services, and the extent to which they protect
enrollees from the risk of catastrophic medical bills.
Premiums
The federal government and enrollees share the cost of the premiums for FEHBP plans. The
government’s contribution to premiums is set at 72% of the weighted average premium of all
plans in the program, not to exceed 75% of any given plan’s premium.8 The percentage of
premiums paid by the government is calculated separately for individual and family coverage, but
each uses the same formula. Annuitants and active employees pay the same premium amounts,
although active employees have the option of paying premiums on a pre-tax basis. Refer to Table
1 below for the average FEHBP premium for annuitants and active employees (non-postal
service)9 in 2013.
Table 1. Average Biweekly 2013 FEHBP Premiums for Annuitants and Non-Postal
Employees: Government Contribution and Enrollee Contribution
Government
Enrollee
Contribution
Contribution
Total Premium
Self $184.06
$80.74
$264.80
Family $410.92
$178.24
$589.16
Source: 2013 FEHBP Average Premium Tables provided by the Office of Personnel Management.
Comparability of FEHBP to Health Benefits Offered by Private and
State and Local Government Employers
As FEHBP is the largest employer-sponsored health insurance program in the United States, it is
difficult to compare FEHBP to health benefits offered by other employers. Any comparison must
be limited to large employers in the private sector and state and local governments.
Out of the 230 plans available through FEHBP, an enrollee’s choice is typically limited to 10 to
15 different plans, depending on where the individual resides. In a survey of large firms with
more than 200 employees, 55% offered one plan, 37% offered two plans, and 8% offered three or
more plans. For firms with more than 5,000 employees, a subset of the aforementioned group of
large firms, 26% offered one plan, 49% offered two plans, and 25% offered three or more plans.10
(...continued)
Accounts: An Empirical Review, by Carol Rapaport.
8 The Balanced Budget Act of 1997 (BBA 97, P.L. 105-33) established the current formula for determining the
government’s contribution to premiums.
9 The U.S. Postal Service (USPS) is unique within the federal government in regard to contributing to health care
benefits for its employees. Historically, the USPS has paid a larger share of employees’ health insurance premiums
compared to other federal agencies.
10 The Kaiser Family Foundation and the Health Research & Educational Trust, Employer Health Benefits, 2012
Annual Survey, September 11, 2012, p. 61, at http://ehbs.kff.org/.
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As stated previously, the federal government pays 72% of the weighted average premium of all
plans in the program, not to exceed 75% of any given plan’s premium for federal employees and
annuitants. Although premiums are calculated separately for single and family coverage, the
formula is the same. In a survey of large firms, on average employers paid 82% of the premium
for single plans and 75% of the premium for family plans for current employees.11 In a survey of
state and local government employers of all sizes, on average employers paid 88% of the
premium for single coverage and 76% of the premium for family coverage for current
employees.12
Federal government retirees are eligible for FEHBP coverage with the same benefits and the same
cost as active employees.13 In a survey of large firms that offer health benefits to active
employees, only 25% offer health benefits to retirees. In a survey of large state and local
government employers with more than 200 employees, a subset of the aforementioned group of
large firms, 77% offer health benefits to retirees.14
Other Health Benefits
Beyond FEHBP, active federal employees are also eligible for the Federal Flexible Spending
Account Program (FSAFEDS). Both active and retired federal employees are eligible for the
Federal Dental and Vision Insurance Program (FEDVIP) and the Federal Long Term Care
Insurance Program (FLTCIP). Federal employees and retirees are eligible for the same Medicare
benefits as other workers. Current Members of Congress are eligible to receive health care
services at the Office of the Attending Physician in the U.S. Capitol and at military treatment
facilities.
Federal Flexible Spending Account Program
OPM also administers a Flexible Spending Account (FSA) program, FSAFEDS. Current federal
employees eligible for FEHBP are also eligible to participate in FSAFEDS, whether enrolled in
FEHBP or not.15 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.
11 Ibid., p. 93.
12 Ibid., p. 96.
13 However, unlike active federal employees, annuitants cannot pay premiums with pre-tax dollars.
14 Ibid., p. 172.
15 For more details on Flexible Spending Accounts, see CRS Report RL32656, Health Care Flexible Spending
Accounts, by Janemarie Mulvey.
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• The Limited Expense HCFSA (LEX HCFSA) is for those enrolled in a HDHP
with a Health Savings Account, and it reimburses only eligible dental and vision
expenses which 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. 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.16
Federal Employees Dental and Vision Insurance Program
Dental and vision benefits are available to active federal employees and annuitants through the
Federal Employees Dental and Vision Insurance Program administered by OPM.17 Employees
and annuitants are not required to enroll in FEHBP to enroll in FEDVIP. Enrollees are responsible
for 100% of the premiums. 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 19.18 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.19
Federal Long Term Care Insurance Program
Federal employees and annuitants 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.20
16 Office of Personnel Management, Flexible Spending Accounts (FSAFEDS) FastFacts, http://www.opm.gov/insure/
fastfacts/fsafeds.pdf.
17 For more details on FEDVIP, see CRS Report RS22535, Federal Employees Dental and Vision Insurance Program
(FEDVIP), by Hinda Chaikind.
18 Office of Personnel Management, FastFacts for Dental Insurance, http://www.opm.gov/insure/fastfacts/dental.pdf.
19 Office of Personnel Management, FastFacts for Vision Insurance, http://www.opm.gov/insure/fastfacts/vision.pdf.
20 Office of Personnel Management, FastFacts for The Federal Long Term Care Insurance Program (FLTCIP),
http://www.opm.gov/insure/fastfacts/fltcip.pdf.
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Health Benefits for Members of Congress
Medicare Eligibility for Current and Former Members of Congress
In general, individuals aged 65 and older are eligible for Medicare.21 Workers, including all
federal employees and Members of Congress, must pay a tax on their wages for Medicare
Hospital Insurance (Medicare Part A).22 Workers and their employers each pay a tax of 1.45% of
earnings.23
Participation in Medicare Part B, Medicare Advantage, and Medicare Part D (coverage for
prescription drugs) is voluntary, and enrollees pay a monthly premium.24 Generally, individuals
who do not enroll in Part B or Part D during their initial eligibility period are subject to a penalty.
However, individuals covered by FEHBP either through their own or a spouse’s active
employment (not annuitant coverage), may wait until either they or their spouse retires to enroll
in Part B without incurring a penalty. If an individual maintains FEHBP coverage and at a later
date decides to enroll in Part D, there is no late enrollment penalty.
Office of the Attending Physician
Members of Congress are eligible to receive limited services from the Office of the Attending
Physician (OAP) in the U.S. Capitol for an annual fee, whether or not they are enrolled in
FEHBP. The annual fee for 2013 is $576.25 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.26
Military Treatment Facilities
Members of Congress 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.27 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 Members of Congress.
FEHBP insurance may cover these expenses after a deductible or copayment is met. Members
pay out of pocket for expenses not covered by FEHBP or other insurance. Former Members and
dependents are not eligible for care at military hospitals.28
21 For more detail on Medicare eligibility and benefits, see CRS Report R40425, Medicare Primer, coordinated by
Patricia A. Davis and Scott R. Talaga.
22 This tax was initially established under the Tax Equity and Fiscal Responsibility Act of 1982 (P.L. 97-248, effective
January 1, 1983).
23 For a full discussion of wage taxes, see CRS Report 94-28, Social Security and Medicare Taxes and Premiums: Fact
Sheet, by Dawn Nuschler.
24 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.
25 Committee on House Administration.
26 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.
27 The National Capital Region includes Washington, DC and nearby jurisdictions in Maryland and Virginia.
28 32 C.F.R. §728.77.
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Effect of the ACA on Health Benefits for Members
of Congress
The Patient Protection and Affordable Care Act (ACA; P.L. 111-148) requires health insurance
exchanges to be established in every state by January 1, 2014, either by the state itself or by the
Secretary of Health and Human Services. The exchanges will not be insurers, but will provide a
marketplace for eligible individuals and small businesses to purchase private health insurance
plans. For more information on the exchanges, see CRS Report R42663, Health Insurance
Exchanges Under the Patient Protection and Affordable Care Act (ACA), by Bernadette
Fernandez and Annie L. Mach.
The ACA requires that the only health plans the federal government may make available to
Members of Congress and certain congressional staff as a benefit of their federal employment are
health plans created under the ACA or offered through health insurance exchanges, as created by
the ACA.29 The Director of OPM has resolved a lack of clarity in the law as to the effective date
of this provision by concluding that this provision will not be effective until the health insurance
exchanges become operational.30 Therefore, this provision does not currently affect Members of
Congress or their staffs’ participation in FEHBP. Interpretive questions may be raised regarding
implementation of this provision. These may include definitional issues for the terms Member of
Congress and congressional staff; whether affected persons may access health plans offered
through health insurance exchanges while continuing to be enrolled in FEHBP; how the provision
might affect annuitants; and whether the employer (federal government) contribution to the
premium might apply to coverage purchased outside of FEHBP. Regulations providing
interpretive guidance have not yet been promulgated as of the date of this report.31
Author Contact Information
Ada S. Cornell
Information Research Specialist
acornell@crs.loc.gov, 7-3742
Acknowledgments
This report was originally written by Barbara English. All questions should be addressed to the current
author.
29 The Patient Protection and Affordable Care Act, P.L. 111-148, §1312(d)(3)(D).
30 Letter from John Berry, Director of OPM, to Nancy Pelosi, Speaker of the House of Representatives, April 16, 2010.
31 For more detail on this provision, see CRS Congressional Distribution (CD) memorandum “Analysis of §
1312(d)(3)(D) of P.L. 111-148, The Patient Protection and Affordable Care Act, and its Potential Impact on Members
of Congress and Congressional Staff,” by Jennifer A. Staman, Todd B. Tatelman and Ida Brudnick, April 2, 2010,
available upon request from the memorandum’s authors. This memo was written before the OPM director stated the
provision is not effective until the exchanges become operational.
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