USPS Form 24 – Fill Out and Use This PDF

Appendix D

How to Use POSTALEASE to Manage Your FEHB Enrollment

NOW YOU ARE READY TO ENROLL

•If you have access to the PostalEASE Employee Web on the Internet (https://liteblue.usps.gov), at an Employee Self- Service Kiosk (available in some facilities), or on the Postal Service Intranet (from the Blue page), using these may be simpler than using the telephone. Just follow the instructions.

•Otherwise, call the Employee Service Line to reach PostalEASE toll-free at 1-877-4PS-EASE (1-877-477-3273, option 1) or 1-866-260-7507 for TTY.

•When prompted, select Federal Employees Health Benefits.

•Follow the script and prompts to enter your Employee ID, your USPS PIN, and information from your completed PostalEASE FEHB Worksheet.

AFTER COMPLETING YOUR ENTRIES YOU SHOULD NOTE THE FOLLOWING INFORMATION

•Record the confirmation number you receive from PostalEASE:

•Your enrollment will be processed on this date:

•Your enrollment will be reflected in your paycheck that is dated:

It is recommended that you keep this information and your PostalEASE FEHB Worksheet.

You may contact the Human Resources Shared Service Center (HRSSC) for assistance if:

•you are deaf or hard of hearing, or

•you cannot use the telephone, Internet, Employee Self Service kiosk or Intranet for a medical reason, or

•you receive a message in PostalEASE directing you to contact the HRSSC when attempting to make a change.

Just call the Employee Service Line at 1-877-477-3273. When prompted, select 5 for the HRSSC. Then select Benefits to speak with a representative who will assist you.

To reach the HRSSC using TTY, call 1-866-260-7507. Leave your name and email address or phone number where you can be reached along with a message indicating your call is regarding a PostalEASE related issue.

If you currently have an FEHB enrollment and you do not want to make any changes . . . do nothing.

Dual฀enrollment is when you or an eligible family member under your Self and Family enrollment are covered under more than one FEHB enrollment. No enrollee or family member may receive benefits under more than one FEHB enrollment.

If you or a family member receives benefits under more than one plan, it is considered fraud and your are subject to disciplinary action.

WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)

POSTALEASE FEHB Worksheet

Changes due to a qualifying life event (QLE) cannot be made via PostalEASE

This worksheet will help you prepare to call PostalEASE, or use PostalEASE on the Internet (https://liteblue.usps.gov), on an Employee Self-Service Kiosk (now available in some facilities) or on the Postal Service Intranet (from the Blue page). You may contact the Human Resources Shared Service Center (HRSSC) by calling 1-877-477-3273, Option 5 or TTY, 1-866-260-7507 for assistance if:

•you are deaf or hard of hearing or

•you cannot use the telephone, Internet, Employee Self Service kiosk or Intranet for a medical reason or

•you receive a message in PostalEASE directing you to contact the HRSSC when attempting to make a change.

Please Note:

•If you wish to make any change that is not listed under “Type of Action You Are Requesting” below, you must submit your paperwork to the

HRSSC. You will need to provide documentation showing that your election is due to a QLE and that you are contacting the HRSSC within the required time frame.

For more information on QLEs, please refer to the appropriate Guide to Benefits mailed to you for FEHB Open Season:

•RI 70-2 for Postal Police and Non-Bargaining Management career USPS employees • RI 70-2A for APWU, NALC, NPMHU and NRLCA career employees

•RI 70-2IN for career U.S. Postal Inspectors, Office of the Inspector General, and PCES employees • RI 70-2IT for IT/ASC career employees,

•RI 70-2NU for career USPS Nurse employees • RI 70-8PS for certain temporary (noncareer) USPS employees.

Except for open season and the adding of new family members, most enrollments and changes of enrollment are effective on the first day of the pay period after receipt of this form at the HRSSC. The HRSSC can give you the specific date on which your enrollment or enrollment change will take effect.

PART 1 – EMPLOYEE INFORMATION

1)฀฀New฀Plan฀Name:฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀2)฀฀New฀Enrollment฀Code:

3)฀฀Old฀Plan฀Enrollment฀Code฀(if you are changing plans or canceling your current plan)

PART 5 – YOUR OTHER GROUP INSURANCE (Not used for waiving enrollment as a new employee).

PART 6 – PERSONAL INFORMATION

POSTALEASE FEHB Worksheet

Employee฀Name: ________________________________________________________ EIN:__________________________________

PART 7 – DEPENDENT INFORMATION (for Self and Family coverage only)

A complete mailing address (if different from the USPS employee’s) and other insurance information, if any, must be provided for each covered dependent. If you are adding or updating information for a dependent who does not reside with you, you will need to use the PostalEASE Employee Web on the Internet (https://liteblue.usps.gov), an Employee Self-Service Kiosk (available in some facilities) or on the Postal Service Intranet (Blue page) or contact the HRSSC to process your FEHB enrollment or change.

POSTALEASE FEHB Worksheet

PART 8

Employee฀Signature _____________________________________________________ Date ____________________________________

Email฀Address_________________________________________________________฀฀฀฀Preferred฀telephone฀number__________________

FOR HRSSC USE ONLY

REMARKS: Specific information on type of qualifying life event, reason for correction, type of certification, supporting documentation, reason for verification, etc., should be provided here.

Processing฀NOTES:

Privacy฀Act฀Statement: Your information will be used to process your enrollment in the Federal Employees Health Benefits

system and to manage your claim under that plan. Collection is authorized by 39 U.S.C. 401, 409, 410, 1001, 1003, 1004,1005, and 1206 and 1206; and 29 U.S, 2601 et seq.

Providing the information is voluntary, but if not provided, we may not process your request. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the U.S. Postal Service (USPS) or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits: to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel; the Selective Service System, records pertaining to supervisors and postmasters may be disclosed to supervisory and other managerial organizations recognized by USPS; and to financial entities regarding financial transaction issues.

OPM฀Privacy฀Act฀and฀Paperwork฀Reduction฀Act฀Notice: The information you provide on this form is needed to document

your enrollment in the Federal Employees Health Benefits Program (FEHB) under Chapter 89, title 5, U.S. Code. This information will be shared with the health insurance carrier you select so that it may (1) identify your enrollment in the plan, (2) verify your and/or your family's eligibility for payment of a claim for health benefits services or supplies, and (3) coordinate payment of claims with other carriers with whom you might also make a claim for payment of benefits. This information may be disclosed to other Federal agencies or Congressional offices which may have a need to know it in connection with your application for a job, license, grant, or other benefit. May also be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or social security administrative agencies to determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition, to the extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local law enforcement agency. While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your enrollment. We request that you provide your Social Security Number so that it may be used as your individual identifier in the FEHB Program. Executive Order 9397 (November 22, 1943) allows Federal agencies to use the Social Security Number as an individual identifier to distinguish between people with the same or similar names. Failure to furnish the requested information may result in the U.S. Office of Personnel Management's (OPM) inability to ensure the prompt payment of your and/or your family's claims for health benefits services or supplies. Agencies other than the OPM may have further routine uses for disclosure of information from the records system in which they file copies of this form. If this is the case, they should provide you with any such uses which are applicable at the time they ask you to complete this form.

Public฀Burden฀Statement: We think this form takes an average of 30 minutes to complete, including the time for reviewing

instructions, getting the needed data, and reviewing the completed form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management, OPM Forms Officer, (3206-0160), Washington, D.C. 20415-7900. The OMS number 3206-0160 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.