Congress Members and Staff Eligible Only for SHOP Exchange Health Insurance

Beginning January 1, 2014, members of Congress and congressional staff will no longer be eligible to receive employer coverage through the Federal Employees Health Benefits Program (FEHBP). Under the Patient Protection and Affordable Care Act (PPACA) (P.L.111-148), the only health plans to be made available by the federal government to Congress members and staff will be those created under PPACA or offered through the District of Columbia small business health options program (SHOP) exchange.

According to a report issued by the Congressional Research Service, FEHBP eligibility requirements were amended to comply with PPACA by a final rule of the Office of Personnel Management on October 2, 2013. Under the final rule, members of Congress (members of the House of Representatives or the Senate) and congressional staff (full- and part-time employees of an official office of a member of Congress) will no longer be able to purchase a FEHBP health plan. However, by purchasing an individual or family health plan from the gold tier of the District of Columbia SHOP exchange, members and employees will remain eligible for an employer contribution toward their insurance coverage. The cost of plans through the SHOP exchange will vary only by the age of the enrollee.

The final rule only affects health insurance offered by the federal government to Congress members and staff. It does not affect eligibility to participate in the Federal Flexible Spending Account Program, the Federal Employees Dental and Vision Insurance Program, the Federal Long Term Care Insurance Program, and limited services from the Office of the Attending Physician and military treatment facilities. Additionally, Medicare eligibility of Congress members and staff is not affected by the final rule, nor does Medicare eligibility affect the ability to obtain coverage through the SHOP exchange.

Under the final rule, FEHBP coverage remains available to Congress members and staff under Temporary Continuation of Coverage in the event of termination from federal service. It is also available to members and staff once they become retirees, as long as the individuals are eligible for retirement from the federal government and were enrolled continuously in a health plan offered by an exchange for the five years of service immediately prior to retirement.