Chelsey Tucker graduated with a Bachelor of History degree from Metropolitan State University in 2019. She now writes about insurance with her specialty being life insurance and has been quoted on Help Smart Phone and MEL Magazine.

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Dan Walker graduated with a BS in Administrative Management in 2005 and has been working in his family’s insurance agency, FCI Agency, for 15 years. He is licensed as an agent to write property and casualty insurance, including home, auto, umbrella, and dwelling fire insurance. He’s also been featured on sites like Reviews.com.

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Reviewed by Daniel Walker
Licensed Auto Insurance Agent

UPDATED: Mar 19, 2020

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The lowdown...

  • The Affordable Care Act provides for participation by Members of Congress and their staffs
  • Members of Congress can buy health insurance on the Obamacare business exchange
  • Members of Congress and staff participate as a small health insurance group
  • The Members and Congressional employees purchase health coverage among options designated by the Office of Personnel Management
  • Some Members and staff get coverage through outside companies such as a spouse’s employer

Members of Congress elected after 1984 and their staffs contributed to Social Security. They had participation options in the same benefits programs available to federal workers including employer-paid health insurance. The Affordable Care Act brought the individual mandate and a particular set of requirements for Members of Congress and their staffs.

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Impact of the Individual Mandate

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The Affordable Care and Patient Protection Act of 2010 requires that every eligible person gets and keep qualified health insurance coverage. Nearly every person must comply with the mandate. Some may be exempt because they do not meet the federal tax filing threshold, do not have taxable income, or are not lawfully present in the United States.

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Summary of Congress and its Health Care

Before the ACA, Congress and staff got health coverage like other Federal employees in the Federal Employee Health Benefits program.

The employer contributed an agreed sum, and the employee paid the balance for high-quality healthcare for individuals or families. The terms of the law applied to federal employees, Members of Congress, and their staffs.

The Affordable Care Act Noted the Congress

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The Affordable Care Act provided that Congress must get its health coverage from a plan created under the ACA or offered through a Marketplace exchange. These provisions meant that Members and staff could no longer simply opt into the federal system for other employees.

The law authorized the Director of the Office of Personnel Management to select the appropriate vehicle for Congressional health insurance coverage.

Open Enrollment for Congress

The open enrollment period for the Congressional health group coincides with the open season for FEHB.

For the calendar year 2017, the Congressional member and staff coverage open season is November 14, 2016, through December 12, 2016. New hires will get offers within 60 days of hire.

Those with qualifying life events can get a new 60-day period for sign up. Open enrollment for Congress members and staff permits an opportunity to upgrade or change plans within limits set by OPM for the employer contribution.

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Employer Contribution and Costs

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The employer contributes an average of 72 percent of the costs of premiums for Members and Congressional Staff. The ACA permits price discrimination based on tobacco usage, age, and location. DC constitutes a single zone location, and the District decided not to allow pricing based on tobacco usage.

The sole price variance factor is age. Employer-sponsored insurance in the private sector averages about 80 percent of the costs of the health plan.

Eligible Persons for Congressional Coverage

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The Congressional personnel offices determine whether an employee can get health insurance contributions. They list the official and non-official staff. Benefits can go as directed to official staff whether full-time or part-time employees. The SHOP program plans can cover the employee and family.

The family includes the spouse, and children whether natural foster care or adopted. SHOP plans renew automatically when available in the following calendar year and open season. In many cases, one must act to change it and do nothing to continue a current plan. All Obamacare plans are qualified health coverage.

Employers and SHOP

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The Small Business Health Options Program is an exchange designed for employers that provide insurance for their employees. The program provides a direct and simple way to offer health coverage to employees. The original design focused on employers with less than 50 employees.

The SHOP program offered tax incentives to small business owners that provided funds to pay employee health insurance. These employers could get tax credits that would protect profits in profit-making years. In 2016, the Shop program opened to small businesses with more than 100 employees.

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Congressional Health Plans and Managed Care

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The Director of the Office of Personnel Management directed selections for employer contribution from the DC SHOP. The gold tier plans could get employer contributions.

For calendar year 2017, the types of managed care included in the contribution-eligible plans include HSA, High Deductible plans, and the below-described types of care.

  • HMO is the health maintenance organization. This type of plan uses a primary care physician to decide the course of medical care. The primary care physician can make referrals to network specialists. The referrals get the agreed cost sharing from the insurance company.
  • PPO is the preferred provider organization. This form of care does not use a primary care doctor, and clients can select any network resource. When using outside resources, clients must pay more than network cost-sharing rates.
  • POS is a variation of the HMO in which the primary care physician can make referrals to outside specialists. The insurance covers these outside referrals at a lower rate of cost sharing than network resources.
  • EPO is the exclusive provider organization. This type of plan does not use resources outside of the plan’s network.

OPM-Directed Employer Contributions

Members of Congress and their staff are eligible for employer contributions towards their health care costs. The Director of the Office of Personnel Management selected a range of gold tier health insurance plans available on the DC Health Link, and the DC SHOP portal.

The Director of OPM ruled that the contributions could go to any eligible employee that chose a gold plan from the DC Health Link Exchange; it was renamed the DC SHOP. The ruling concluded that the Washington DC location was appropriate as was the DC state-run exchange.

Tiers of Health Insurance

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Obamacare offers four tiers of health plans. The tiers have metal names and create groups of policies for comparison. The common elements are the values of the plan. The groups have similar amounts of insurance coverage for benefits. The below-listed-items essentially describe the four tiers,

  • Platinum is the top tier of Obamacare health plans. They have high premiums, low deductibles, low costs sharing, and fewer copays than other tiers. Platinum covers ninety percent of essential benefits leaving 10 percent for the consumer.
  • Gold is the second tier, and it also has high premiums, low deductibles and a very favorable ratio of coverage to coinsurance. Gold plans cover about 80 percent of essential benefits leaving 20 percent for the consumer.
  • Silver pays 70 percent of covered benefits leaving thirty percent for the consumer. Silver has medium high premiums and deductibles. Some silver plans are High Deductible Health Plans (HDHP) designed to work with Health Savings Accounts.
  • Bronze plans have the lowest premiums and the highest deductible, rate of customer coinsurance, and much more copays than gold or platinum. Bronze plans divide costs with the consumer on a 60 to 40 percent split.

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Legal Status of Congressional Health Insurance

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The federal government like many large employers offers health insurance to its employees as part of their compensation. Before the Affordable Care Act, Members, and their staffs could sign up with federal employees and use the Federal Employee Health Benefits.

The employer contributed to the employee’s selected health plan. Section 1312(d)(3)(D) of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) provides that Congress shall have access to health insurance plans only “are either created under the ACA or offered through an exchange established under the ACA.”

DC SHOP for Congressional Health Plans

The Office of Personnel Management designated a range of gold plans the DC SHOP portal of the DC Health Link Exchange for employer contribution for Members of Congress and Congressional employees. OPM directed that congressional staff and Members must select from a state exchange, namely, the DC Health Link.

OPM directed that Members and their staffs must select health insurance coverage from the DC SHOP Portal’s gold tier as a condition to receiving the employer’s health care premium contribution.

Congress Gets Health Insurance from Obamacare

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Section 1312 sets the path clearly and the rules assigned the final mechanism to the Office of Personnel Management. Congressional Members and staff get their insurance from the Obamacare portal for small business in Washington, D.C. They can select among a large number of gold plans with national networks.

The employer pays an average of 72 percent of the premiums. Comparison shopping is a great way to find the best plan for an individual or family among gold plans offered through the DC SHOP portal.

Comparison shopping is an excellent tool whenever a consumer must review and select a private insurance plan on the Obamacare Marketplace or any state exchange.

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