FEHB (federal employees + retirees)
The Federal Employees Health Benefits Program covers ~8 million federal employees, retirees, and dependents. Plans are private carrier contracts administered by OPM, with appeal rights under 5 CFR Part 890 layered over standard ERISA/ACA-like internal review.
What this plan type is
FEHB is the largest employer-sponsored health plan group in the US. The Office of Personnel Management (OPM) contracts with private carriers (Blue Cross Blue Shield Federal Employee Program, GEHA, NALC, etc.) to offer health coverage to federal employees, retirees with 5+ years of service, and their dependents. Plans are subject to a unique FEHB Act framework with OPM as the regulator rather than HHS or DOL.
Your appeal rights
5 CFR §890.105 governs FEHB disputed claims. Process: (1) reconsideration by the carrier, (2) review by OPM after carrier denial. OPM's decision is final administratively; judicial review under the Administrative Procedure Act may be available in some circumstances. Standard internal carrier appeal is 60 days to file, plan has 30 days to decide.
Common denial patterns
- Not covered under the FEHB plan brochure
- Out-of-network reduction
- Prior auth absent
- Medical necessity per UM
What's unique about this plan type
- OPM review at second level — federal employee adjudication
- Annual Open Season in November/December — beneficiaries can switch plans
- All plans must follow the FEHB plan brochure (FEHB-1) — the binding document
- FEHB Act preemption similar to ERISA preemption — state law generally does not apply
Frequently asked questions
What is a FEHB (federal employees + retirees)?
FEHB is the largest employer-sponsored health plan group in the US. The Office of Personnel Management (OPM) contracts with private carriers (Blue Cross Blue Shield Federal Employee Program, GEHA, NALC, etc.) to offer health coverage to federal employees, retirees with 5+ years of service, and their dependents. Plans are subject to a unique FEHB Act framework with OPM as the regulator rather than HHS or DOL.
What appeal rights does a FEHB (federal employees + retirees) member have?
5 CFR §890.105 governs FEHB disputed claims. Process: (1) reconsideration by the carrier, (2) review by OPM after carrier denial. OPM's decision is final administratively; judicial review under the Administrative Procedure Act may be available in some circumstances. Standard internal carrier appeal is 60 days to file, plan has 30 days to decide.
What's unique about a FEHB (federal employees + retirees)?
OPM review at second level — federal employee adjudication Annual Open Season in November/December — beneficiaries can switch plans All plans must follow the FEHB plan brochure (FEHB-1) — the binding document FEHB Act preemption similar to ERISA preemption — state law generally does not apply
Other plan types
- NSAApplies to FEHB plans
- MHPAEAParity applies to FEHB
- ACA Marketplace (individual / family) planIndividual and family plans purchased through Healthcare.gov or a state-based exchange. Appeal right
- Employer-sponsored fully-insured planAbout 35% of employer-covered Americans are on fully-insured employer plans — the employer pays prem
- ERISA self-funded employer planAbout 65% of employer-covered Americans are on a self-funded ERISA plan. The employer (or a TPA) bea
- Medicaid managed care (MCO)Medicaid managed care plans cover ~80 million Americans. Appeals follow 42 CFR Part 438 Subpart F an
Sources
Appeal a FEHB (federal employees + retirees) denial
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