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02-301 - BAL 02-301

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Civil Service
Retirement
System
Federal Employees’
Group Life
Insurance Program
Federal Employees
Health Benefits
Program
Federal Employees
Retirement
System
Long Term
Care Insurance
Program
United States
Office of
Personnel Management
The Federal Government’s Human Resources Agency
Retirement and Insurance Service
Benefits Administration Letter
Number: 02-301 Date: January 4, 2002
SUBJECT: HB-PC - ANNUAL REPORTING REQUIREMENT
\
The Internal Revenue Code requires that administrators of cafeteria plans file an annual information return
on the Form 5500 – Annual Return/Report of Employee Benefit Plan – with an attached Schedule F –
Fringe Benefit Plan Annual Information Return. To fulfill our Form 5500 reporting responsibilities as the
administrator of Health Benefits Premium Conversion (HB-PC), we will need input from all agencies of
the Executive Branch of the Federal government that have participating employees.
Our Form 5500 submission to the IRS for tax year 2001 will be based on the information that Executive
Branch agencies provide to us on the attached Input for Form 5500. If an agency has adopted HB-PC for
the benefit of its employees, but is not part of the Executive Branch, it will not submit an Input for Form
5500 to OPM, but must file its own Form 5500 directly with the IRS.
As the tax year 2001 Form 5500 for HB-PC must be submitted to the IRS by July 31, 2002, we will need
Executive Branch agencies to complete the Input for Form 5500 and fax it back to us no later than June 1,
2002; our fax number is 202-606-7944. If an agency performs payroll cross-servicing functions, it must
include on its Input for Form 5500 information for its own agency as well as for all client Executive
Branch agencies. Likewise, if an agency’s payroll functions are cross-serviced, it will not submit an Input
for Form 5500 to OPM.
If you have any questions about the matters discussed in this letter, we would prefer that you email them to us
at finance@opm.gov
, so that we may retain a record of them. You may also call us on
(202) 606-0606.
Robert A. Yuran, Chief
Financial Policy Staff
Retirement and Insurance Service
Attachment
Health Benefits Premium Conversion (HB-PC)
INPUT FOR FORM 5500
for Executive Branch Agencies
For the plan year ending on December 31, 2001
***Fax completed form to (202) 606-7944 no later than June 1, 2002***
Agency: Payroll Office Number:
Note: if your payroll functions are cross-serviced, do not complete this report; it will be
completed for you by your cross-servicer.
***In completing this report, it is important that you follow the instructions on the reverse***
1. Number of employees
2. Number of employees eligible to participate in HB-PC
3. Number of employees who participated in HB-PC
4. Total FEHB withholdings and contributions for HB-PC participants $
5. If you cross-service the payroll functions of other Executive Branch agencies, attach a list
of those agencies as an addendum to this report.
Name of preparer: Telephone:
Title of preparer: E-mail:
Signature of preparer: Date signed:
INSTRUCTIONS FOR COMPLETING THE INPUT FOR FORM 5500
Line 1: Number of Employees
Enter the total number of employees you paid on the last pay day in calendar year (CY) 2001.
Include ALL employees -- full-time, part-time, intermittent, etc.
Line 2: Number of Employees Eligible to Participate in HB-PC
Enter the total number of employees enrolled in the FEHB Program on the last pay day in CY
2001. Include in this number those for whom FEHB deductions were made and those for whom
you made no FEHB deductions (e.g., those on LWOP).
Line 3: Number of Employees who Participated in HB-PC
Enter the sum of:
The number of HB-PC participants on the last pay day in CY 2001
Plus: the number of employees with pre-tax FEHB deductions, who subsequently waived
participation in HB-PC during CY 2001
Plus: the number of HB-PC participants who terminated or cancelled their FEHB
coverage during CY 2001.
Line 4: Total FEHB Withholdings and Contributions for HB-PC Participants
Enter the total amount of FEHB withholdings and contributions remitted to OPM for all HB-PC
participants during CY 2001.
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