Health Insurance for Members of Congress: Costs and Enrollment

Health insurance for Members of Congress works through the same kind of marketplace the Affordable Care Act created for the public. Since 2014, lawmakers and their designated personal-office staff have been required to buy coverage through DC Health Link, the District of Columbia’s health insurance exchange, rather than the Federal Employees Health Benefits (FEHB) Program that covers most federal workers. The government still pays a large share of the premium; the plan itself is a private policy sold on the exchange.

Where Members Buy Their Coverage

Section 1312(d)(3)(D) of the ACA says the only health plans the federal government may make available to Members of Congress and their staff “with respect to their service” are plans created under the ACA or offered through an ACA exchange.¹ That closed the door on the OPM-contracted FEHB plans Members had used before.²

OPM designated the Small Business Health Options Program (SHOP) channel within DC Health Link as the exchange Members and staff use, and set the Gold metal level as the tier they choose from, on the reasoning that Gold coverage most closely resembled the FEHB plans they had left behind.³⁴

For the 2026 plan year, three carriers offer Gold plans through DC Health Link SHOP:⁵

CareFirst BlueCross BlueShield, with 19 plan options
Kaiser Permanente, with 15 plan options
UnitedHealthcare, with 23 plan options

That comes to 57 Gold-tier plans. They are standard qualified health plans from private insurers, not a special government product. A senator enrolled in a Kaiser Gold plan has the same network, copays, and deductible structure as a small-business employee in DC who picked the same plan.

What the Government Pays and What the Member Pays

The coverage runs through a marketplace, but the government still contributes toward the premium the way any large employer would. Under 5 U.S.C. § 8906, the government’s share equals 72 percent of the weighted average of all FEHB plan subscription charges, figured separately for each enrollment tier.⁶ OPM’s regulations apply that same formula to a Member or staffer enrolled through SHOP.⁷

For 2026, the maximum monthly government contribution is:⁸

$703.65 for self only
$1,540.87 for self plus one
$1,685.73 for self and family

The Member or staffer pays whatever is left after that contribution is applied to the premium of the Gold plan they pick. If the plan costs more than the government’s cap, the balance comes out of the paycheck. If it costs less, the contribution covers the plan’s premium share and nothing extra changes hands.

Which Staff Get Pulled Into the Marketplace

The ACA defines “congressional staff” as all full-time and part-time employees working for a Member’s official office, whether in Washington or in a district or state office.¹ Each Member designates before October which employees count as official-office staff for the following calendar year, and those employees must use DC Health Link SHOP to receive the government contribution. OPM’s final rule left final authority over each designation with the employing office, recognizing that many aides split their time between personal-office and committee or leadership work and that the split can shift during the year.⁹

Staff who work only for a committee or a leadership office are not swept in by the ACA rule. Those employees stay eligible for the traditional FEHB Program and pick from the plans available to federal workers across the government.⁹

Enrollment Windows

A newly elected Member or newly hired designated staffer has 30 days to enroll. The clock starts on the later of the hire date or the date the administrative office enters the person’s eligibility into DC Health Link, which usually happens within one to three days.¹⁰ Miss the window and the next chance is annual open enrollment.

Open enrollment for the DC marketplace runs from November 1 through mid-to-late December, with coverage effective January 1. For 2026 coverage, the period opened on November 1, 2025.¹¹ Outside those weeks, a plan change requires a Special Enrollment Period triggered by a qualifying life event such as marriage, the birth of a child, or gaining or losing other coverage. The event must be reported to DC Health Link within 30 days.¹²

Alternatives a Member Can Choose Instead

The ACA provision restricts what the federal government may offer as an employer. It does not override coverage a person independently qualifies for. A Member old enough for Medicare can enroll in it. A Member with military service may use TRICARE. Anyone can take coverage under a spouse’s employer plan.

The trade-off is the employer contribution. The government’s premium subsidy applies only to plans bought through DC Health Link SHOP. A Member who picks Medicare or a spouse’s plan gets no federal employer contribution toward that alternative. For someone weighing Medicare against a Gold marketplace plan that carries a $703-per-month subsidy for self-only coverage, the math is worth running carefully.

Dental and Vision Are Separate

The ACA’s exchange requirement covers major medical only. Members and staff remain eligible for the Federal Employees Dental and Vision Insurance Program (FEDVIP), which OPM administers on its own track. Enrollment in FEHB or a DC Health Link plan is not a prerequisite for FEDVIP, so a staffer who gets medical coverage through the marketplace can still sign up for federal dental and vision. FEDVIP eligibility also carries into retirement without requiring prior enrollment during active service.

What Happens After Leaving Congress

Retiring With an Immediate Annuity

When a Member retires, DC Health Link coverage ends at the close of the month they leave office. To move into an OPM-contracted FEHB plan as a retiree, a former Member must meet two conditions:¹³

Eligibility for an immediate federal pension
Continuous enrollment in FEHB, DC Health Link, TRICARE, or CHAMPVA for the five years immediately before retirement, or for all federal service if shorter than five years

Time in a DC Health Link plan counts toward that five-year rule, so the 2014 switch did not reset anyone’s clock. A Member who meets both tests picks from the full range of FEHB retiree plans and keeps the government contribution.

Leaving Before Retirement Eligibility

A Member who loses an election or resigns before qualifying for a federal pension faces a gap. DC Health Link coverage ends, and there is no path to carry FEHB into retirement. Federal employees in this position can use a temporary continuation of coverage authorized under Title 5, similar to COBRA: the qualifying events and 18-month duration track COBRA, but the former employee pays the full premium plus an administrative surcharge with no government contribution. Buying an individual plan on the open marketplace or joining a new employer’s plan are the other options.

1
U.S. Government Publishing Office. Public Law 111-148 – The Patient Protection and Affordable Care Act
2
U.S. Office of Personnel Management. As a Member of Congress or Designated Congressional Staff, Why Am I No Longer Able to Be Covered by an OPM-Contracted FEHB Plan?
3
Centers for Medicare & Medicaid Services. Members of Congress and Staff Accessing Coverage through Health Insurance Exchanges
4
U.S. Office of Personnel Management. From Which Metal Level on the DC SHOP Will Members of Congress and Designated Congressional Staff Choose Their Plans?
5
DC Health Link. 2026 Health and Dental Plans
6
Office of the Law Revision Counsel. 5 USC 8906 – Contributions
7
eCFR. 5 CFR Part 890 – Federal Employees Health Benefits Program
8
U.S. Office of Personnel Management. Premiums
9
Federal Register. Federal Employees Health Benefits Program: Members of Congress and Congressional Staff
10
U.S. Office of Personnel Management. Newly Elected Member of Congress or Newly Hired Designated Congressional Staff Enrollment Timeline
11
Centers for Medicare & Medicaid Services. Marketplace 2026 Open Enrollment Period Report: National Snapshot
12
DC Health Link. Employees – Reporting a Qualifying Life Event
13
U.S. Office of Personnel Management. Will Members of Congress and Designated Congressional Staff Be Eligible for a Plan Contracted by OPM in Retirement?