The Federal Employees Health Benefits program covers 8 million federal employees, retirees, and their families. With 132 plan options and premiums rising 12.3% in 2026, choosing and using the right plan matters more than ever.
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Plans and enrollment · Plan types
Plan types explained
FEHB offers 132 plan options in 2026 across several plan structures. The plan type determines how you access care, whether you need referrals, and how flexible your provider access is.
Fee-for-Service (FFS)
Traditional indemnity-style plans. Use any provider nationwide, no referrals required. Government pays its share; you pay your cost-share. Blue Cross Blue Shield FEP is the largest FFS plan. Higher premium, maximum flexibility.
Health Maintenance Organization (HMO)
Area-specific. Must use the HMO's network. Often lower out-of-pocket costs but limited to the plan's geographic area. Good for employees who stay in one metro area. Kaiser and local HMOs are examples.
Consumer-Driven Health Plan (CDHP)
Paired with a Health Savings Account (HSA). Higher deductible, lower premium. You pay the full cost until the deductible is met; then cost-sharing kicks in. Strong choice if you are healthy and want to build HSA savings.
High Deductible Health Plan (HDHP)
Similar to CDHP but may be paired with an HRA (Health Reimbursement Arrangement) instead of an HSA. Higher deductible, lower premium.
Standard vs High option
Most plans offer multiple tiers. Standard is lower premium with lower benefits. High option is higher premium with lower out-of-pocket costs when you use care. The right choice depends on your expected utilization.
How to find the right plan type
Low healthcare users: CDHP or HMO Standard. Moderate users: FFS Standard or HMO High. High users or complex chronic conditions: FFS High or a plan with strong specialty coverage. Always check your specific medications against the formulary.
Premium is the most visible difference between plans but not the most important. Two plans with the same premium can cost you very different amounts depending on how you actually use healthcare.
1
List your medications and expected care
Before comparing plans, write down every medication you take, plus any anticipated procedures, specialist visits, or ongoing care needs. This is your comparison baseline.
2
Check each plan's formulary for your medications
Every plan has a formulary (covered drug list). Log into the plan's portal or use OPM's comparison tool to check your specific drugs. Tier placement determines what you pay. A plan with a lower premium but your key drug on Tier 3 may cost more overall.
3
Calculate total annual cost, not just premium
Add your total annual premium (your share) + estimated out-of-pocket (based on last year's claims if you have them). The cheapest-premium plan is often not the cheapest overall plan.
4
Check if your doctors are in-network
HMO plans restrict you to their network. Verify your current providers are included before switching. FFS plans allow any provider but network care is cheaper.
5
Use the government contribution to your advantage
The government pays the lesser of 72% of the weighted average premium OR 75% of the total premium for your plan. For lower-cost plans, you get the full 75% government contribution, making them even cheaper.
OPM publishes the government's weighted average premium each year
Any plan premium below that amount will get the maximum 75% government contribution. This is a powerful way to keep your share low while still getting solid coverage.
Plans and enrollment · Your card
Your FEHB card
Your FEHB ID card is your credential at every medical appointment, pharmacy, and urgent care visit. It identifies you to providers and contains the information needed to bill your plan.
What it shows
Your name, member ID, group number, and your health plan's name and contact information. Some cards also show your prescription drug group number if it differs.
Receiving your card
You receive your FEHB card directly from your health plan after enrollment or plan change. Allow 10-14 days from enrollment date. Cards arrive at your address on file with the plan.
Lost or damaged card
Call the member services number on the back of your card (if you have it) or the customer service number listed in your plan brochure. Most plans can ship a replacement in 5-10 business days and provide a temporary card or ID number by phone immediately.
Dependent cards
Eligible dependents on your plan receive their own card. Verify that all dependents have current cards, especially for adult children on the plan.
Before your card arrives
Call your plan's member services with your name and Social Security Number. They can verify your enrollment and provide the member ID verbally so providers can look you up.
Plans and enrollment · Postal workers
Postal Service Health Benefits (PSHB)
The Postal Service Health Benefits (PSHB) program launched January 1, 2025. If you are a USPS employee, retiree, or eligible family member, you are now in PSHB rather than FEHB. PSHB is similar but has a critical Medicare difference.
Who is in PSHB
USPS employees, USPS annuitants (retirees), and their eligible family members. About 2 million people transitioned from FEHB to PSHB in January 2025.
What changed vs FEHB
PSHB is administered by OPM like FEHB. Benefits align with FEHB. The key difference: Medicare-eligible PSHB annuitants and their family members must enroll in Medicare Part B to maintain PSHB benefits. This was not required under FEHB.
Medicare Part B requirement for PSHB retirees
If you are a USPS annuitant who becomes Medicare-eligible (age 65 or qualifying disability), you must enroll in Medicare Part B. Failing to do so means losing PSHB coverage. This differs from FEHB retirees who can decline Part B.
2026 PSHB premium increase
Average enrollee share increase: 11.3% in 2026 (slightly lower than FEHB's 12.3%). 75 plan options across 17 carriers in 2026.
PSHB prescription drug coverage
PSHB prescription drug benefits align with FEHB except for Medicare Part D integration. PSHB plans coordinate with Medicare Part D for Medicare-eligible members differently than FEHB plans.
How to manage your PSHB enrollment
Through PostalEASE (liteblue.usps.gov) for active employees, or through OPM's retirement services for annuitants. Same Open Season rules apply (November 10 to December 8 annually).
USPS retirees: Medicare Part B is required for PSHB
Unlike FEHB retirees who can opt out of Medicare Part B, PSHB retirees must have Part B to keep PSHB. If you are approaching 65, plan accordingly.
Plans and enrollment · Dental and vision
FEDVIP dental and vision
The Federal Employees Dental and Vision Insurance Program (FEDVIP) provides separate dental and vision coverage. It is entirely optional and separate from your FEHB health plan. Enrollees pay the full premium with no government contribution.
FEDVIP is separate from FEHB
Your FEHB plan may include some dental and vision coverage, but FEDVIP provides dedicated, more comprehensive dental and vision insurance. You can have both.
Who is eligible
Federal employees, retirees, and their eligible family members. Uniformed services members (but not TRICARE beneficiaries for dental since TDP is separate). Some contractor employees at agencies with a special eligibility arrangement.
Dental options (2026)
11 dental carriers with multiple plan options. 2026 average premium increase: 3.3%. Covers preventive, basic, and major dental including crowns and root canals. Orthodontia coverage varies by plan.
Vision options (2026)
Several vision carriers. 2026 average premium increase: 0.47%. Covers annual exams, eyeglasses or contact lenses with a frame/lens allowance, LASIK discounts at some plans.
No government contribution
Unlike FEHB, the government pays nothing toward FEDVIP premiums. You pay the full premium, pre-tax through payroll deduction.
Enrollment
Enroll at benefeds.com during Open Season (November 10 to December 8). Coverage starts January 1. You can also enroll within 60 days of becoming eligible (new employee, new retiree).
Whether you need to stay in-network depends on your plan type. HMO plans require network providers. FFS plans allow any provider but reward in-network use with lower cost-sharing.
1
Know whether your plan has a network restriction
HMO: must use network providers (except emergencies). FFS (like BCBS): any provider but in-network is cheaper. CDHP/HDHP: varies by plan, check your brochure.
2
Use your plan's provider directory
Log into your plan's member portal or call member services. Search by specialty, location, and accepting new patients. Directories are updated more frequently than printed materials.
3
Call the provider to confirm before scheduling
Provider directories can be 30-90 days behind. Always call and ask: "Do you accept [plan name] and are you currently in-network for my plan?" Specify your exact plan, not just "federal insurance."
4
Confirm for each family member
A provider may be in-network for your plan type but not for all enrollment options within your plan. Verify separately for dependents.
Your plan type fundamentally changes how you access care. Understanding your plan's rules prevents unexpected out-of-network bills and ensures you use your benefits correctly.
HMO care rules
You must use providers within the HMO's defined service area and network. A primary care physician (PCP) coordinates your care. Specialist visits typically require a referral. Going outside the network (except emergencies) means you pay the full cost.
FFS care rules
Any licensed provider in the country. No referrals required. In-network providers bill FEHB directly and charge you only your cost-share. Out-of-network: you may need to file your own claim, and the plan pays at the lower non-network rate.
CDHP/HDHP care rules
Varies by plan. Most CDHP/HDHP plans function like FFS with a network preference. The HSA pairing means you pay full cost until the deductible is met, after which normal cost-sharing applies.
Emergency care: all plan types cover it
All FEHB plans must cover emergency care regardless of network status. You can go to any ER. You may still owe your plan's emergency copay.
Switching plan types during the year
Generally not allowed outside of Open Season or a QLE. If you enroll in an HMO and move outside the service area mid-year, you qualify for a QLE to switch.
Providers and care · Referrals
Referrals and specialist visits
Whether you need a referral depends entirely on your FEHB plan type. FFS plans never require referrals. HMO plans typically require them for all specialists.
FFS plans: no referrals
Blue Cross Blue Shield FEP and other FFS plans have no referral requirement. See any specialist directly.
HMO plans: referral required
For most specialist visits on an HMO, your PCP must issue a referral. Self-referring to a specialist on an HMO means the visit is not covered (or covered at the more expensive out-of-network rate).
Mental health: usually self-refer
Most FEHB plans allow direct access to in-network mental health providers without a referral, even on HMO plans. Federal mental health parity laws strongly encourage this.
Emergency referrals: not needed
Emergency care never requires prior authorization or a referral. Stabilization is covered regardless of whether your PCP is involved.
Specialist to specialist
If your specialist wants to refer you to another specialist, the referral usually comes from that specialist. Your PCP does not need to be re-involved on FFS plans. On HMO, each specialist requires a new referral chain.
Out-of-network specialist on HMO
Generally not covered unless the HMO cannot provide the specialty care in their network. In that case, they must provide you with a referral to an out-of-network specialist and cover it at network rates.
Providers and care · Mental health
Mental health coverage
Federal mental health parity law (MHPAEA) requires FEHB plans to cover mental health and substance use disorder benefits at the same level as medical and surgical benefits. In practice, this means broad coverage.
Self-referral to mental health providers
FEHB plans generally allow direct access to in-network licensed mental health providers without a PCP referral. Even on HMO plans, mental health access is typically direct.
What is covered
Individual and group therapy, psychiatry, medication management, inpatient psychiatric hospitalization, intensive outpatient programs (IOP), partial hospitalization programs, substance use disorder treatment.
Telehealth mental health
All FEHB plans cover telehealth, and telehealth mental health is widely available. Video therapy is often cheaper and more accessible than in-person. Verify your plan's telehealth cost-sharing.
Prior authorization for higher levels of care
Inpatient psychiatric stays and intensive outpatient programs typically require prior authorization. Your provider or the facility will usually initiate this. Ask them to confirm authorization before admission.
Employee Assistance Program (EAP)
Most federal agencies offer a separate EAP with free short-term counseling (typically 4-8 sessions). EAP does not use FEHB benefits. Use it first for short-term needs; it preserves your FEHB benefits for longer-term care.
Parity complaints
If your plan denies mental health care that would be covered for a comparable medical condition, you can file a parity complaint with OPM or your state insurance regulator.
Providers and care · Urgent and emergency
Urgent and emergency care
Emergency care is covered by all FEHB plans at any facility in the country. Urgent care coverage varies by plan but is generally well-covered at network urgent care centers.
Emergency care: covered anywhere
True emergencies (chest pain, stroke, severe injury, difficulty breathing) are covered at any emergency room in the U.S. regardless of network status. You owe your plan's emergency copay. For HMO plans, follow up with your PCP after stabilization.
Urgent care centers: network matters
For non-emergency urgent needs (minor injuries, ear infections, flu), urgent care centers are much cheaper than ERs. Most plans cover in-network urgent care at a lower copay than an ER visit. Verify network status using your plan's directory before arriving.
What you typically pay at an ER (varies by plan)
A typical FFS FEHB plan charges $150-$250 ER copay or a percentage of the bill after the deductible. HMO plans often have a flat copay of $100-$200. Check your plan brochure.
What you typically pay at urgent care (varies by plan)
Usually $30-$75 copay at a network urgent care center. Significantly cheaper than an ER for non-emergency care.
Nationwide coverage for active employees who travel
FFS plans cover you nationwide. HMO plans typically cover emergency care nationwide but routine/urgent care only in their service area. If you travel frequently, FFS may be a better fit.
Coverage and benefits · Core benefits
What FEHB covers
All FEHB plans must cover a core set of benefits required by OPM. Plan brochures detail the specifics. Here are the benefits that apply across all plans.
Preventive care
ACA-required preventive services are covered at no cost-share in all FEHB plans. Annual wellness visits, cancer screenings, vaccines, blood pressure checks, and more.
Primary care
Office visits for routine and sick care. Covered under all plans, though cost-sharing varies.
Specialist care
Cardiology, oncology, orthopedics, and all other specialties. Network and referral requirements vary by plan type.
Mental and behavioral health
Covered at parity with medical benefits under federal law. Therapy, psychiatry, inpatient, substance use.
Hospital care
Inpatient medical and surgical care, intensive care, maternity. Cost-sharing varies significantly; check your plan.
Maternity care
Full prenatal, delivery, and postpartum care covered under all plans. Newborns are automatically covered from birth for 31 days.
Prescription drugs
All plans cover prescriptions through a formulary. Tier structure determines cost. Mail order for maintenance medications is widely available and usually cheaper.
Laboratory and imaging
Blood work, X-rays, CT, MRI, and other diagnostic tests covered. Prior authorization may apply for high-cost imaging.
Coverage and benefits · Dental and vision
Dental and vision
Most FEHB health plans include limited dental and vision benefits as part of the basic plan. For comprehensive dental and vision, FEDVIP provides dedicated coverage at no government contribution.
Dental in FEHB health plans (basic)
Most FEHB plans include some dental coverage: typically emergency dental care, extractions, and some preventive care. Comprehensive dental (cleanings twice yearly, fillings, crowns, dentures) is usually not included or is very limited.
Vision in FEHB health plans (basic)
Many plans include one routine eye exam per year and limited eyewear benefits (a set dollar allowance for frames or contacts). The allowance is often $150-$200, well below the cost of quality eyewear.
FEDVIP for comprehensive coverage
If you want cleanings, fillings, crowns, orthodontia, or comprehensive eyewear coverage, FEDVIP is the right solution. Enroll during Open Season at benefeds.com. You pay the full premium; no government contribution.
FEHB plan dental/vision varies widely
Some FEHB plans (especially HMOs and BCBS High) include more dental and vision than others. Review your specific plan brochure before assuming coverage is minimal or assuming FEDVIP is always necessary.
HSA-eligible CDHP plans and FEDVIP
If you have an HSA through a CDHP plan, you can use your HSA funds to pay for FEDVIP premiums, dental work, and vision expenses not covered by insurance.
Coverage and benefits · Pharmacy
Pharmacy benefits
Every FEHB plan covers prescription drugs, but formularies, tiers, and costs vary significantly between plans. Verifying your medications before choosing a plan is one of the most important enrollment steps.
Formulary tiers
Plans group drugs into tiers based on cost: typically Tier 1 (preferred generics, lowest cost), Tier 2 (non-preferred generics and preferred brands), Tier 3 (non-preferred brands), and specialty tiers. Your cost depends on which tier your drug falls on.
Mail order pharmacy
Most plans offer mail order for 90-day supplies of maintenance medications at a lower per-unit cost than retail. Typically two to three times cheaper for long-term medications. Set up through your plan's pharmacy benefit manager.
Specialty drugs
High-cost specialty drugs (biologics, chemotherapy, MS medications) are on their own tier with significant cost-sharing. Check whether a plan has a specialty drug cap or out-of-pocket maximum that limits your exposure.
Generic substitution
Pharmacies will generally substitute a generic when available and the prescriber has not written "dispense as written" (DAW). Generics are significantly cheaper and bioequivalent. Allow substitution unless your doctor has a specific medical reason against it.
Prior authorization for some drugs
Some plans require PA for non-preferred brands, specialty drugs, or drugs above a quantity limit. Your prescriber submits the PA; if denied, an exception process is available.
Step therapy
Some plans require trying a lower-cost drug first before approving a higher-cost one. Your prescriber can request a step therapy exception for medical necessity.
Coverage and benefits · Medicare coordination
FEHB with Medicare
Federal retirees face one of the most complex benefit coordination decisions in healthcare: whether to enroll in Medicare Part B while keeping FEHB. The answer depends on your health needs, your specific plan, and whether you are USPS/PSHB.
Medicare Part A: almost always enroll
Part A (hospital) has no premium for most federal retirees (you paid into it during federal service). Enroll at 65 regardless of FEHB. Part A and FEHB coordinate, often eliminating hospital cost-sharing.
Medicare Part B: the big decision
Part B (medical) has a monthly premium ($202.90/month in 2026 plus potential IRMAA). For FEHB retirees, Part B is optional. The trade-off: lower out-of-pocket costs vs. the Part B premium cost.
When Part B is usually worth it
High healthcare utilization, expensive medications, or anticipated major care. FEHB + Part B often results in near-$0 out-of-pocket for most services. The Part B premium pays for itself if your FEHB cost-sharing exceeds ~$2,400/year.
When Part B may not be worth it
Healthy retirees with low healthcare use on a high-deductible FEHB plan. If you rarely meet your FEHB deductible, the Part B premium may exceed your benefit.
PSHB retirees: Part B required
Unlike FEHB retirees, USPS/PSHB retirees and their family members must enroll in Medicare Part B at age 65 to maintain PSHB benefits. This is mandatory, not optional.
Coordination of benefits
With FEHB + Medicare Part B, Medicare pays first for Medicare-covered services. FEHB pays most or all of the remainder. Some FEHB plans waive all cost-sharing when Part B is primary.
Late enrollment penalty
If you delay enrolling in Part B past your initial enrollment window, you pay a 10% premium penalty for each year of delay, permanently. Your FEHB coverage does NOT exempt you from this penalty.
A SHIP counselor can model your specific Part B decision
State Health Insurance Assistance Program counselors are free and trained on FEHB-Medicare coordination. Find yours at shiphelp.org.
Coverage and benefits · Gaps
Common coverage gaps
FEHB is comprehensive, but some services are commonly excluded or limited. Knowing the gaps before you need care prevents surprises.
Comprehensive dental and vision
Most FEHB plans have limited dental and vision. Comprehensive coverage requires FEDVIP enrollment at additional cost.
Long-term custodial care
FEHB does not cover nursing home or assisted living care for activities of daily living. Federal Long Term Care Insurance Program (FLTCIP) is separate. Check enrollment windows if interested.
Cosmetic procedures
Not covered unless medically necessary (reconstructive after illness/injury). Bariatric surgery coverage varies significantly by plan.
Experimental treatments
Clinical trial participation and investigational treatments are generally excluded. Some plans cover routine care costs associated with clinical trials.
Acupuncture and alternative medicine
Limited coverage. Some plans cover limited acupuncture or chiropractic. Most alternative medicine is excluded or has very limited benefits.
Care outside the U.S.
HMO plans typically cover emergency care overseas only. FFS plans generally provide some overseas coverage but reimbursement is more complex. Frequent international travelers may benefit from a travel health supplement.
Fertility treatments
Coverage varies significantly. Some plans cover IVF and fertility treatments; others do not. Check the brochure if this matters to you.
Costs and premiums · 2026 overview
2026 premium overview
FEHB premiums increased an average of 12.3% in 2026, the second consecutive year of double-digit increases. This follows 13.5% in 2025. The increase is driven by an aging workforce, rising prescription drug costs (especially GLP-1 medications), and increased behavioral health utilization.
Average enrollee share increase
12.3% in 2026. This is the average. Some plans saw decreases; others saw increases well above average. Always check your specific plan.
Government contribution
The government pays the lesser of 72% of the weighted average premium for all plans OR 75% of your specific plan's premium. For lower-cost plans, this typically means the government pays 75%.
Enrollee share range
Varies enormously. A lower-cost plan like GEHA Standard or BCBS FEP Blue Focus might cost an employee $80-$120/month in self-only premiums. Higher-option FFS plans might be $200-$350+/month.
Pre-tax premiums
FEHB premiums for active employees are deducted pre-tax under the Federal Flexible Benefits Plan. This reduces your taxable income. Retirees pay post-tax.
PSHB premiums
USPS employees and retirees saw an average 11.3% enrollee share increase in 2026, slightly lower than FEHB.
How to find your exact 2026 premium
Use OPM's plan comparison tool at opm.gov/healthcare-insurance/healthcare/plan-information/compare-plans. Select your enrollment type (Self Only, Self Plus One, Self and Family) and your agency location.
The federal government pays a significant portion of your FEHB premium. Understanding how the contribution is calculated helps you choose plans where the government pays the maximum share.
The formula
Government pays the lesser of: (A) 72% of the weighted average enrollee premium for all plans in the same enrollment type, or (B) 75% of the total premium for your specific plan.
What this means in practice
For lower-cost plans below the weighted average, the government typically pays 75% of the total premium. For higher-cost plans above the average, the government share falls well below 75%.
2026 example
If the government's weighted average monthly contribution for Self Only is around $340 (72% of weighted average), and your plan's total premium is $400/month, the government pays $300 (75% of $400). You pay $100/month.
Active vs retired
The government pays the same contribution percentage whether you are an active employee or a retiree. Retiree coverage is not cheaper or more expensive in terms of the government's share.
Self Plus One vs Self and Family
In some plans, the enrollee share for Self Plus One is higher than for Self and Family. If you are covering one family member, always compare both enrollment types. You can enroll either one.
PSHB government contribution
OPM calculates separate weighted averages for PSHB. The same 72%/75% formula applies.
Costs and premiums · Deductibles
Deductibles and cost-sharing
FEHB plan deductibles and cost-sharing structures vary enormously. Some plans (like traditional HMOs) have no deductible. Others (especially CDHPs and HDHPs) have high deductibles before any coverage kicks in.
HMO and traditional FFS
Many traditional plans have no or very low deductibles ($100-$300). You pay copays from the first visit. Predictable and easy to budget.
CDHP and HDHP
High deductibles ($1,500-$3,000 for Self Only in many plans) before cost-sharing begins. Paired with an HSA, the deductible is funded partly through pre-tax contributions. Best for healthy enrollees who rarely use care.
Out-of-pocket maximum
All FEHB plans have an annual out-of-pocket maximum. Once reached, FEHB pays 100% of covered in-network care for the rest of the year. Maximums vary from about $2,000 to $7,000 depending on plan and enrollment type.
Coinsurance vs copay
Copay: a fixed dollar amount per visit ($30 primary care, $50 specialist). Coinsurance: a percentage of the allowed charge (20% after the deductible). FFS plans often use coinsurance; HMOs typically use copays.
FEHB and Medicare coordination
When you have Medicare Part B as primary, Medicare pays first. FEHB pays secondary. Many FEHB plans waive all deductibles and cost-sharing when Medicare has paid its share, resulting in $0 out-of-pocket.
Costs and premiums · FSA
FSAFEDS flexible spending accounts
FSAFEDS allows active federal employees to set aside pre-tax dollars for eligible healthcare and dependent care expenses. Contributions reduce your taxable income. Three account types are available.
Health Care FSA (HCFSA)
For any eligible medical, dental, and vision expenses not covered by your FEHB plan. 2026 maximum contribution: $3,400 (up from $3,300 in 2025). Use it or lose it at year-end (with a grace period to March 31 of the following year).
Limited Expense Health Care FSA (LEX HCFSA)
For dental and vision expenses only. Compatible with HSA-eligible CDHP plans. Allows you to have both an HSA (for medical) and a dental/vision FSA simultaneously.
Dependent Care FSA (DCFSA)
For eligible dependent care expenses: childcare, after-school programs, elder care when dependent care is needed so you can work. 2026 maximum: $7,500 (significantly increased from $5,000 in 2025).
How to enroll
Enroll each year during Open Season at fsafeds.com. Coverage does NOT automatically renew. You must re-enroll each year to participate.
Who is eligible
Active federal employees. Retirees are NOT eligible for FSAFEDS. If you have an HSA through a CDHP plan, you cannot have a full HCFSA (but you can have a LEX HCFSA).
Claims deadline
All FSAFEDS claims for 2026 expenses must be filed by April 30, 2027.
FSAFEDS does not automatically renew
Unlike your FEHB plan, your FSA enrollment expires every December 31. Re-enroll at fsafeds.com each Open Season or you will have no FSA in the new year.
Costs and premiums · EOB
Reading your EOB
Your Explanation of Benefits (EOB) arrives after every medical visit or prescription fill. It is not a bill. It shows what your plan paid, what you may owe the provider, and what counts toward your deductible.
What an EOB shows
Date of service, provider, service description, amount billed by provider, amount allowed by your plan (the negotiated rate), what your plan paid, and what you owe.
EOB is not a bill
Wait for the provider's actual bill before paying anything. The EOB tells you what to expect; the provider's invoice is what you pay. The amounts should match.
Amount billed vs amount allowed
"Amount billed" is what the provider charged. "Amount allowed" is what your plan agreed to pay as the maximum. In-network providers accept the allowed amount; the difference is written off. Out-of-network providers can bill you the difference.
Tracking your deductible and out-of-pocket
Your EOB usually shows a running total of what you have applied toward your annual deductible and your out-of-pocket maximum. Use this to track where you stand.
Errors on EOBs
Common: duplicate claims, wrong procedure code, incorrect member information. If an EOB shows a service you did not receive, call your plan immediately. It may indicate billing fraud.
Accessing EOBs
Log into your plan's member portal. Most plans allow you to view, print, or download EOBs electronically. Set up email notification when new EOBs arrive.
Claims and disputes · How claims work
How claims work
Most claims are invisible to you. In-network providers submit claims directly to your FEHB plan and accept payment. You pay your cost-share at the time of service or receive a bill afterward.
1
In-network visit: provider handles it
You present your FEHB ID card. The provider submits the claim electronically to your plan. The plan processes it and pays the provider directly. You owe your cost-share (copay, coinsurance, or deductible).
2
You receive an EOB
Your plan sends an Explanation of Benefits showing the claim details. Review it for accuracy. Compare against the provider's bill when it arrives.
3
Out-of-network or self-pay: you may need to file
If an out-of-network provider does not file on your behalf, you submit a claim form to your plan with the itemized bill and payment receipt.
4
Claim filing deadline
FEHB plans have claim filing deadlines (typically 1-2 years from date of service). Filing late means the claim may be denied. Check your plan brochure for the specific deadline.
Claims and disputes · Denied
A claim was denied
FEHB claim denials happen for several correctable reasons. Most are resolved with a single call to your plan's member services.
1
Read the denial notice
Your EOB or denial letter must state the reason. Common reasons: prior authorization not obtained, service not covered, provider not in-network, benefit limit reached, information missing from claim.
2
Call your plan's member services
Explain the situation. Many denials are administrative. The representative can tell you whether the claim can be resubmitted with corrections or whether you need to file an appeal.
3
Ask your provider to resubmit if needed
Wrong billing codes, missing diagnosis codes, and missing authorization numbers are all provider-side errors. Ask your provider to correct and resubmit.
4
File a reconsideration or appeal if the denial was substantive
For clinical denials (service not medically necessary), submit a written appeal with your doctor's letter of medical necessity and supporting clinical documentation. Deadlines apply.
FEHB appeals move from your plan to OPM to federal court. Most disputes resolve at the plan level. Acting within deadlines is essential.
Step 1: Reconsideration by your plan
File a written request for reconsideration with your plan within the timeframe specified in the denial notice (typically 60-90 days). Include a physician letter of medical necessity and supporting documentation. The plan must respond within 30 days.
Step 2: OPM review
If your plan upholds the denial, you can request OPM review within 90 days. OPM reviews the plan's decision independently. This is the second administrative level.
Step 3: External review
For certain clinical denials involving medical necessity, you may request an external review by an independent review organization (IRO). This is separate from OPM review and specifically reviews clinical decisions.
Step 4: Federal court
If all administrative remedies fail, you may file a civil action in federal district court. Requires legal representation. This step is taken in unusual circumstances only.
Expedited review
For urgent care situations where waiting for standard review timelines would seriously jeopardize your health, request an expedited determination. Plans must decide within 72 hours.
Enrollee advocate
OPM's Office of Insurance Programs can provide guidance on the appeals process. Contact them at 1-888-767-6738.
Claims and disputes · Balance billing
Balance billing
Balance billing happens when an out-of-network provider charges you the difference between what they billed and what your plan allowed. Federal law provides some protections against surprise balance bills.
What balance billing is
An out-of-network provider bills $500. Your plan allows $300. The plan pays 80% of $300 = $240. You owe $60 as cost-share. The provider also bills you the $200 balance. That $200 balance bill is the issue.
In-network providers cannot balance bill
Network providers agree to accept the plan's allowed amount as payment in full. They can bill you your cost-share (copay, coinsurance, deductible), but not amounts above the allowed amount.
No Surprises Act protections (2022)
Federal law protects you from unexpected out-of-network balance bills for emergency care, non-emergency care at in-network facilities by out-of-network providers (anesthesia, radiology), and air ambulance services. These providers cannot balance bill you beyond in-network cost-sharing.
When balance billing is permitted
If you knowingly and voluntarily chose an out-of-network provider for non-emergency care at an out-of-network facility, and signed an advance consent form, balance billing may be permitted.
What to do if you get a balance bill
Do not pay immediately. Call your plan's member services. If the No Surprises Act applies, report it to CMS at 1-800-985-3059. If it does not apply, negotiate with the provider directly.
Claims and disputes · Billing errors
Billing errors
Billing errors in healthcare are extremely common. Medical Billing Advocates of America estimates that up to 80% of medical bills contain some error. Review every EOB and bill carefully.
Duplicate billing
Same service billed twice. Compare your EOBs over time. If you see the same service, date, and amount appear twice, it is a duplicate.
Upcoding
Provider billed for a more expensive service than was actually provided. Example: billing for a comprehensive exam when you had a limited exam. Difficult to detect without medical records.
Unbundling
Billing separately for services that should be billed as a package. Example: billing separately for services that are normally included in a surgery fee.
Wrong patient or wrong date
Your billing record mixed with another patient's, or a service date that does not match your records.
Services you did not receive
A claim for a service or procedure you have no memory of. This can indicate a billing error or fraud. Report it immediately to your plan.
How to report errors
Call your plan's member services with the specific EOB and claim number. For services you never received, also report to OPM and potentially the FBI Health Care Fraud Division.
Life changes · Open Season
Open Season
FEHB Open Season runs from November 10 to December 8 each year. It is your annual window to evaluate and change your health, dental, and vision coverage for the next year.
What you can change during Open Season
FEHB plan (switch to any available plan, any plan type). Enrollment type (Self Only, Self Plus One, Self and Family). FEDVIP dental and vision enrollment. FSAFEDS elections (HCFSA, LEX HCFSA, DCFSA).
What you cannot change during Open Season
Life insurance (FEGLI) has separate enrollment rules. Long-term care insurance (FLTCIP) has its own open seasons. FERS/CSRS retirement contribution levels are not part of Open Season.
When changes take effect
FEHB and FEDVIP changes take effect the first day of the first full pay period in January (typically January 11 in 2026 for biweekly employees). Not January 1.
If you do nothing
Your current plan automatically continues. If your plan is discontinued, OPM will notify you and you will be enrolled in the designated default plan (GEHA High Option for FEHB; BCBS FEP Blue Focus for PSHB) unless you choose otherwise.
How to make changes
Active employees: through your agency's HR portal (MyEPP, GRB Platform, or similar). Retirees: through OPM's Retirement Services Online or by phone at 1-888-767-6738.
Research resources
OPM plan comparison at opm.gov, Consumers' Checkbook FEHB Guide (often free through your agency), and your plan's 2026 brochure (required reading; it defines your exact benefits).
FSAFEDS does not carry over and does not auto-renew
If you want an FSA in 2026, re-enroll at fsafeds.com during Open Season. Your election from 2025 does not roll over.
Life changes · Qualifying events
Qualifying life events
Outside Open Season, you can make FEHB enrollment changes only if you experience a qualifying life event (QLE). You have 60 days from most QLEs to make changes.
Marriage or domestic partnership
Add spouse or partner. 60 days from the date of marriage or domestic partnership registration. Change from Self Only to Self Plus One or Self and Family.
Birth, adoption, or placement for adoption
Add child to coverage. 60 days from the event. Newborns are automatically covered for 31 days from birth; you must formally enroll them within 60 days to maintain coverage.
Divorce or end of domestic partnership
Remove former spouse or partner. Required within 60 days. Failure to remove an ineligible dependent is a federal benefits violation.
Dependent child losing eligibility
A dependent child aging off at 26 or losing student status. You must remove them and they may qualify for COBRA-like continuation coverage.
Spouse or partner gaining or losing other coverage
If your spouse gets employer coverage, you may drop them. If they lose it, you can add them back. 60-day window.
Change in employment status
Moving from part-time to full-time, from temporary to career, or changes that affect FEHB eligibility.
Relocation out of HMO service area
If you move outside your HMO's service area, you qualify for a QLE to switch to an FFS plan.
Life changes · Retirement
Retiring from federal service
Federal retirees who meet eligibility requirements can keep FEHB coverage into retirement. This is one of the most valuable federal retirement benefits. Understanding the rules prevents losing it.
Eligibility to keep FEHB in retirement
You must have been continuously enrolled in FEHB (or covered as a family member) for the 5 years immediately before retirement. Some exceptions exist for employees who could not enroll earlier.
What changes at retirement
You pay the same premiums (same plan, same government contribution), but premiums are now deducted from your retirement annuity rather than your paycheck. Pre-tax premium deduction ends; you pay with after-tax dollars.
Keeping the same plan
You can keep your current plan without interruption. No new enrollment needed unless you want to switch during the first Open Season after retirement.
Survivor annuitant coverage
If you elect a survivor annuity for your spouse, your surviving spouse can keep FEHB if you die first. This requires electing a survivor annuity at retirement.
The 5-year rule importance
If you did not maintain continuous FEHB enrollment for 5 years before retirement, you lose the ability to carry FEHB into retirement permanently. There is no waiver. This is a permanent loss.
Verify your 5-year enrollment record before retiring
Gaps in FEHB coverage can disqualify you from carrying it into retirement. Check your HR records well before your planned retirement date.
Life changes · Medicare
FEHB and Medicare together
How FEHB and Medicare work together is one of the most important and commonly misunderstood aspects of federal retirement benefits. The interaction creates potential for near-zero out-of-pocket costs.
Medicare Part A: almost always enroll
Most federal retirees paid into Medicare during their careers and qualify for free Part A (hospital). Enroll at 65. Part A and FEHB coordinate on hospital claims.
Medicare Part B: optional for most FEHB retirees
Part B (medical) has a premium ($202.90/month in 2026). For standard FEHB retirees, enrolling in Part B is optional but often financially beneficial. Medicare pays first; FEHB pays the remainder.
PSHB retirees: Part B required
USPS annuitants must have Part B to maintain PSHB coverage. No exception.
How FEHB + Medicare coordinates
Medicare pays its standard amount first. Your FEHB plan pays most or all of what remains. For many plans with Part B primary, you pay $0 for covered services.
When to enroll in Part B
Sign up at 65 during your Medicare Initial Enrollment Period (IEP). If you miss it, you can enroll during General Enrollment (January-March) with a permanent late penalty, or during a Special Enrollment Period if you had qualifying coverage.
IRMAA income-related Part B premium
If your income exceeds $109,000 (single) or $218,000 (joint) in 2026, you pay more than the standard Part B premium. This is IRMAA. Budget for it if your income is near those thresholds.
When a federal employee or retiree dies, coverage for surviving family members depends on whether a survivor annuity was elected and whether FEHB coverage was maintained.
Active employees who die
Survivors may be eligible for continued FEHB coverage through a survivor annuity or under the Spouse Equity provisions. Contact your HR immediately upon an employee's death.
Retirees with survivor annuity elected
If you elected a survivor annuity at retirement, your surviving spouse can continue FEHB coverage indefinitely as long as they do not remarry before age 55 and continue the annuity. Same plan, same government contribution.
Retirees without survivor annuity
If no survivor annuity was elected, the surviving spouse loses FEHB coverage at the retiree's death. FEHB cannot be continued without a survivor annuity.
Temporary continuation of coverage (TCC)
Dependents who lose FEHB coverage due to death or other reasons can elect TCC for up to 36 months. They pay the full premium (enrollee + government share) plus a 2% administrative fee.
Updating beneficiary designations
OPM maintains separate beneficiary designations for life insurance and retirement. Update these whenever your family situation changes. They do not automatically follow your will.
Importance of the survivor annuity election
Choosing a reduced annuity to maximize monthly income is a valid financial decision but permanently eliminates the surviving spouse's FEHB and annuity. Model both scenarios before deciding.
The survivor annuity election is irrevocable after a window following retirement
You can change this election only within a limited period after retirement. After that window, it cannot be changed regardless of circumstances.
Help · Talk to someone
There are real people who help, free
FEHB has 132 plan options. These resources help you navigate without guessing.
For enrollment, claims, and benefits questions
OPM Retirement and Benefits
For retirees: questions about FEHB in retirement, survivor annuity, plan changes.
State Health Insurance Assistance Program. Free, unbiased help with the FEHB-Medicare interaction. One of the most underused resources for federal retirees.
Cross-cutting questions that span more than one topic. Tap any to see the answer.
Start with four questions:
1. What medications do you take? Check each plan's formulary for your specific drugs. A plan with a lower premium but your key medication on Tier 3 often costs more overall.
2. Do your doctors need to be in-network? If you want to keep specific providers, verify they are in the network before switching. HMO plans require it; FFS plans reward it but do not require it.
3. What is your health utilization? Healthy with few visits: consider a CDHP or HMO Standard. Moderate to high utilization: FFS or HMO High option may be cheaper overall when you add up cost-sharing.
4. Will you travel or work remotely? HMO plans only cover you in their service area (except emergencies). FFS covers you nationwide.
Use the Consumers' Checkbook FEHB Guide (often free through your agency) to run a total cost comparison factoring in your actual health use.
This is the biggest financial decision for most federal retirees. The short answer: probably yes for most people, definitely yes for PSHB/postal retirees.
Why Part B is usually worth it: When Medicare Part B is your primary payer, your FEHB plan pays secondary and often picks up everything Medicare does not. For many plans, this results in $0 out-of-pocket for most services. If your annual FEHB cost-sharing exceeds the Part B premium ($202.90/month, or $2,435/year), Part B pays for itself.
Why some skip Part B: Healthy retirees who rarely use healthcare may not hit the crossover point where Part B saves money. A good HDHP paired with no Part B can work if you are healthy and have HSA savings built up.
PSHB/postal retirees: Part B is required. No choice.
Critical warning: The late enrollment penalty for Part B is 10% per year of delay, permanently. Your FEHB does not exempt you. If you delay and later decide to enroll, you pay that penalty forever.
Consult a free SHIP counselor (shiphelp.org) to model your specific situation.
Self Plus One covers you and exactly one eligible family member. Self and Family covers you and any number of eligible family members.
The important nuance: in some FEHB plans, the enrollee share for Self Plus One is higher than for Self and Family. If you are covering exactly one family member, always compare both enrollment types. You can enroll as Self and Family even if you only cover one dependent, and it may be cheaper.
If you are a single federal employee with no dependents, Self Only is typically the right choice unless you anticipate adding dependents soon (newborn, marriage).
FSAFEDS is the federal flexible spending account program. It lets you set aside pre-tax salary dollars for health, dental/vision, and dependent care expenses.
Health Care FSA (HCFSA): Up to $3,400 in 2026. Use for any eligible medical, dental, and vision expense not covered by insurance. Reduces your taxable income by the contribution amount.
Dependent Care FSA (DCFSA): Up to $7,500 in 2026. Use for childcare, elder care, after-school programs that allow you to work. The 2026 limit is significantly higher than 2025's $5,000.
Should you use it? If you have predictable out-of-pocket health costs or dependent care costs, yes. The tax savings are real. The main risk is the use-it-or-lose-it rule: money not spent by year-end is forfeited.
One important warning: FSAFEDS does not auto-renew. Re-enroll each Open Season at fsafeds.com or you will have no FSA in the new year.
If you were continuously enrolled in FEHB for 5 years immediately before retirement, you can carry FEHB into retirement. This is one of the most valuable federal retirement benefits.
What changes: premiums come out of your annuity check instead of your paycheck, and they are no longer pre-tax. The plan and government contribution remain the same.
What stays the same: your plan, your network, your benefits, and the government's share of the premium.
The 5-year rule is strict. Any gap in continuous enrollment in the 5 years before retirement means you lose FEHB in retirement permanently. Verify your enrollment history with HR before planning your retirement date.
FEDVIP (Federal Employees Dental and Vision Insurance Program) provides dedicated dental and vision coverage that most FEHB health plans do not fully include.
Dental: Most FEHB plans cover emergency dental and limited preventive care. For routine cleanings, fillings, crowns, or orthodontia, FEDVIP provides comprehensive coverage. The government pays nothing toward FEDVIP dental; you pay the full premium pre-tax.
Vision: FEHB typically includes one eye exam and a modest frame allowance. FEDVIP vision provides more comprehensive eyewear benefits and LASIK discounts. Premiums are very low (historically under $10/month for some plans).
Do you need it? If you need regular dental work, yes. If you rarely go to the dentist and have good natural vision, the FEHB vision benefit plus FEDVIP vision is probably sufficient without adding dental.
Enroll at benefeds.com during Open Season.
The government pays the lesser of:
(A) 72% of the weighted average premium for all plans of the same enrollment type, OR
(B) 75% of the total premium for your specific plan.
For lower-cost plans (below the weighted average), the government pays 75% of your plan's premium. For higher-cost plans, the government pays less than 75% because formula (A) kicks in.
In practice: if you choose a plan where the government contribution equals 75% of the premium, you are getting maximum government support. Many plans in the GEHA, MHBP, and BCBS FEP Blue Focus tiers hit this threshold.
The government pays the same share whether you are an active employee or a retiree.
Yes, with a qualifying life event (QLE). You have 60 days from most QLEs to make changes.
Common QLEs that allow adding family members: marriage or domestic partnership, birth or adoption of a child, a dependent gaining or losing other coverage.
You cannot add a family member just because you want to, or because an enrollment is cheaper with them included. The event must qualify.
For newborns: the baby is automatically covered for 31 days from birth. You must formally enroll them within 60 days to maintain coverage. If you miss this window, you wait until the next Open Season and the baby has no coverage in between.
The No Surprises Act (effective January 2022) protects you from unexpected out-of-network bills in specific situations:
Emergency care: You cannot be balance-billed for emergency care at any facility, regardless of network status.
Non-emergency care at an in-network facility: If you go to an in-network hospital or surgery center, the act protects you from balance bills by out-of-network providers working there (anesthesiologists, radiologists, pathologists).
Air ambulance: Protected from balance billing for medically necessary air ambulance transport.
In all protected cases, you owe only your plan's in-network cost-sharing, nothing more. If you receive a balance bill for a protected situation, dispute it with your plan and report it to CMS at 1-800-985-3059.
The Postal Service Health Benefits (PSHB) program launched January 1, 2025. All USPS employees, retirees, and their eligible family members moved from FEHB to PSHB automatically.
Benefits are essentially the same as FEHB. The key differences:
Medicare Part B requirement: PSHB annuitants (retirees) who are Medicare-eligible must enroll in Medicare Part B to maintain PSHB coverage. This is mandatory; FEHB retirees can opt out of Part B.
Prescription drug benefits: PSHB plans coordinate with Medicare Part D differently for Medicare-eligible members.
Plan options: PSHB had 75 plan options across 17 carriers in 2026. Subset of FEHB options.
Enrollment is through PostalEASE for active employees, and OPM Retirement Services for annuitants. Open Season runs the same dates as FEHB.
Data sources & methodology
Federal FEHB data
Office of Personnel Management (OPM) · 5 U.S.C. Chapter 89 (Federal Employees Health Benefits) · OPM Federal Benefits Open Season 2026 official announcement · Postal Service Health Benefits program (PSHB) per 2022 Postal Service Reform Act.
2026 figures
OPM 2026 FEHB premium announcement (October 2025) · Average enrollee premium increase 12.3% per OPM official release · FSAFEDS contribution limits per IRS Revenue Procedure 2025 · FEDVIP premium changes per OPM Open Season materials.
