Taxes

Chapter 2
Insurance

Section 1
Federal Employees Health Benefits Program

The Federal Employees Health Benefits (FEHB) program is open to almost all federal and postal employees on a voluntary basis. By enrolling in an FEHB plan, employees have an opportunity to acquire protection against the cost of health care service for themselves and certain family members.

Key features of FEHB are:

• Within 60 days from the date you are hired (or become eligible, if previously ineligible), you may enroll in a health benefits plan with group-rated premiums and benefits.

• Coverage is provided without a medical examination or restrictions because of age, current health, or pre-existing conditions.

• There are no waiting periods for benefits to kick in after the effective date of enrollment.

• There is catastrophic protection against unusually large medical bills.

• You have an annual opportunity, during open seasons, to enroll in a health benefits plan if you are not already enrolled or, if you are enrolled, to change to another plan or option.

You can remain in the program after retirement if you meet certain requirements (see Coverage After Retirement, below).

The cost of FEHB premiums is shared by the enrollees and the government, with active employees paying their share through payroll deductions, typically on a pretax basis, and retirees through annuity deductions on a post-tax basis.

Open seasons are held from the Monday of the second full workweek in November through the Monday of the second full workweek in December. Outside an open season, employees also can enroll or make other changes due to certain life events; retirees also may make certain changes due to those events although typically cannot newly enroll. See Changes Outside of Open Season, below.

Note: An existing enrollment is renewed automatically in the open season each year. While the plans that are available and their coverage areas are largely stable, plans sometimes reduce coverage areas or drop out of the program. Typically this is announced in the open season and is effective as of the start of a plan (calendar) year. Affected enrollees who do not elect new coverage are automatically re-enrolled in another plan; see Benefits Administration Letter 16-202 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

There are about 265 health plan offerings in the program, a large majority of them health maintenance organizations (HMOs). There are several variations in plan design. Some plans are sponsored by employee organizations, and generally, to enroll in them you must be a member of the organization. Some organization plans are open to all FEHB-eligible people as adjunct members; others are restricted to specific agencies or occupations. HMOs are open to those within the geographic area serviced by that plan. Consult the plan brochure for eligibility information. (Note: Some plans offer “telehealth” visits—by mobile application, online video or phone—to providers who may be outside a geographic coverage area, for certain services such as behavioral health, in-home monitoring of chronic illnesses and dermatology.)

Federal and postal workers also are covered by Medicare hospital insurance (Part A) for which they pay 1.45 percent of salary each biweekly period. Medicare eligibility typically begins at age 65. See FEHB and Medicare, below.

FEHB Eligibility and Enrollment Rules

Generally, federal and postal employees are eligible to voluntarily participate in the FEHB program unless their position is specifically excluded by law or regulation. Eligible persons also include presidential appointees, employees of the Judicial Branch and most employees of the Legislative Branch. See below for certain exceptions and limitations; also see 5 CFR 890 and www.opm.gov/healthcare-insurance/healthcare/reference-materials/reference/eligibility-for-health-benefits.

Individual agencies determine eligibility. If your agency denies you coverage and offers you no supporting documentation, look up the rule in the sources listed above, or contact your agency’s headquarters insurance officer.

Neither employees nor their eligible family members are required to pass a physical examination to enroll. Similarly, neither employees nor those family members can be excluded from joining an FEHB plan because of a pre-existing medical condition or other reasons outside the eligibility criteria.

See FEHB Coverage After Retirement, below in this section, for policies regarding coverage after retirement. See FECA Compensation Payments in Chapter 5, Section 5 for policies regarding coverage for those on workers’ compensation.

These types of enrollment are available:

Self-Only—A self-only enrollment provides benefits only for you as the enrollee. While you may elect self-only coverage even if you have family members who otherwise would be eligible, they will not be eligible for FEHB coverage upon your death or disability.

Self Plus One—A self plus one enrollment provides benefits for you and one eligible family member (of your choosing, if you have more than one). You may change your covered family member during the annual open season, upon a change in family status, upon a change in coverage, or upon a change in eligibility, so long as the change is consistent with the event. See Changes Outside of Open Season, below.

Self and Family—A self and family enrollment provides benefits for you and all your eligible family members. All of your eligible family members are automatically covered, even if you didn’t list them on your Employee Health Benefits Registration Form (SF 2809) or an electronic equivalent. You cannot exclude any eligible family member and you cannot provide coverage for anyone who is not an eligible family member.

An “eligible family member” means an enrollee’s spouse, including a spouse in a common law marriage recognized in the state of residence. It does not include domestic partnerships, civil unions or other arrangements not formally recognized as a marriage. Also eligible are former spouses under certain conditions (see Chapter 7, Section 3) and children under age 26 (or any age if they are incapable of self-support because of a mental or physical disability that began before age 26), including legally adopted children, recognized children born out of wedlock, stepchildren and, in certain circumstances, foster children.

For a foster child to be eligible as a family member on your enrollment: the child must live with you; the parent-child relationship must be with you, not solely the child’s biological parent; you must be the primary source of financial support for the child; you must expect to raise the child to adulthood; and you must sign a certification stating that your foster child meets those requirements.

Note: Children of a same-sex domestic partner were eligible for coverage under certain conditions during 2014-2015; that coverage generally ended effective in 2016 due to a 2015 U.S. Supreme Court ruling requiring all states to conduct and recognize same-sex marriages. A temporary extension of eligibility for children of a same-sex domestic partnership when the enrollee was stationed overseas expired September 30, 2018. Children enrolled under that exception at the time of its expiration became eligible for temporary continuation of coverage as described below; see Benefits Administration Letter 18-203 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Proof of family member eligibility may be required, and must be provided upon request, to the carrier, the employing office or OPM as pertinent. Rules at 5 CFR 890.308 describe requirements for such requests, documentation that establishes eligibility, procedures to remove someone found ineligible, effective dates and reconsideration rights. Those removed may be eligible for a 31-day temporary extension of coverage, conversion to a nongroup contract and/or temporary continuation of coverage.

A federal employee under age 26 is automatically covered under a parent’s self and family enrollment. Adult children in that situation cannot have their own FEHB enrollment unless they have their own eligible family member or members (spouse and/or child/children) whom they choose to cover under their own enrollment, or the parent is enrolled in an HMO plan and the adult child lives outside its coverage area. An adult child may be voluntarily removed from a parent’s FEHB coverage as described below. Turning age 26, or acquiring an eligible family member or members, is a qualifying life event that allows an adult child to personally enroll in the FEHB for self plus one or self and family coverage, as appropriate.

Eligible children may be covered under an FEHB policy even if they also are eligible for employer-sponsored health insurance other than FEHB. If they have such coverage, that policy generally becomes the primary payer. If the primary insurer does not fully cover the illness or injury, the FEHB plan may act as a secondary payer, depending on its benefits structure. The enrollee must inform both plans that the child has other insurance coverage.

Guidance is in Benefits Administration Letters 10-201 and 11-202 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Children who lose FEHB coverage due to reaching age 26 become eligible for 36 months of additional coverage at their own expense; see Temporary Continuation of Coverage below in this chapter.

FEHB-eligible persons subject to court or administrative orders requiring them to provide health benefits for a child/children must enroll for self plus one or for self and family, as pertinent, in a health plan that provides full benefits in the area where the child/children live or provide documentation to their agency that they have obtained other health benefits for the child/children. See Chapter 7, Section 3.

See below for policies for removing an adult child from coverage in certain circumstances,

An enrollee’s parents or other relatives cannot be covered under a family policy.

Detailed family eligibility rules are at www.opm.gov/healthcare-insurance/healthcare/reference-materials/reference/family-members/#geneligcov. (Note: A small number of FEHB plans offer “affinity products” that allow people associated with enrollees, such as dependents beyond age 26 and unmarried domestic partners, to purchase health insurance coverage. Such insurance is separate from the FEHB, operates on its own terms, and has no government contribution. Any such products are described in a plan brochure’s “Non-FEHB” section.)

When both spouses are eligible to enroll personally and there are no eligible children, each may enroll individually or one may enroll for self plus one (or self and family, although in most plans there would be a cost disadvantage). Eligible children of a couple in which both spouses are eligible to enroll personally would be covered only if one spouse enrolls under the self plus one or self and family option; enrolling individually does not cover children.

If you are a new employee, you may enroll in any available plan, option, and type of enrollment within 60 days after your date of appointment, unless your position is excluded from coverage. If you were employed in a position that was excluded from coverage and then appointed to a position that conveys coverage, you may enroll within 60 days after the change. If you are a non-appropriated fund (NAF) employee who moves to appropriated fund employment, you are eligible for coverage just as any other new employee, even if you have continued coverage under the NAF retirement system.

At the time an employee becomes eligible to enroll, the employing office usually provides a Standard Form 2809, Employee Health Benefits Registration Form, also available at www.opm.gov/forms (some agencies have electronic equivalents). Eligible employees may enroll during the annual open season or at other specified times (see the Table of Permissible Changes in Enrollment in this section). For information on specific plans see www.opm.gov/healthcare-insurance/healthcare.

Agencies must provide employees entering leave without pay status (including due to a furlough; see Furloughs in Chapter 9, Section 1), or whose pay is insufficient to cover their premium payments, written notice of their opportunity to continue their FEHB coverage. Employees in an authorized leave without pay or other type of non-pay status generally can continue health insurance coverage for up to one year of the non-pay period. The 365 days of non-pay status may be continuous or may be interrupted by periods in a pay status that last less than four consecutive months. Agencies must give employees the opportunity either to directly pay their share of the premiums for these periods or to incur a debt to the agency to be withheld from future salary.

Removal of Eligible Family Members—Rules at 5 CFR 890.308 allow removal of a family member from a self and family or a self plus one enrollment at any time in certain circumstances, most commonly for a covered spouse or adult child to enroll in health insurance sponsored by their own employer. Note: Generally, removal is not required just because the family member has other coverage—the family member can maintain both and the two would be coordinated.

A spouse may be removed if both the enrollee and the spouse provide a notarized request. Children who have reached the age of majority in their state of residence may be removed by the enrollee by providing proof that the child is no longer a dependent; such children also may personally request removal by submitting a notarized request.

Removal of a family member is not considered a qualifying life event in itself and therefore does not allow the enrollee to decrease plan coverage (for example from self and family to self plus one) unless the enrollee has a separate qualifying life event. Removal from an enrollment of a federal employee who is the adult child or spouse of another federal employee similarly is not a qualifying life event that would allow the adult child or spouse to enroll in his or her own FEHB enrollment, unless the adult child has a spouse and/or child(ren) to cover.

Children who are minors under the laws of their state of residence may be removed from an enrollment only by a court order.

Once removed under these procedures, an eligible family member may regain coverage under the applicable self plus one or self and family enrollment only if requested by the enrollee during an open season, or within 60 days of the removed family member losing other health insurance coverage. In the latter case the enrollee must provide written consent to reinstatement of coverage from the family member, proof of eligibility of the spouse or child as a family member such as a marriage license or birth certificate, and proof of the loss of other health insurance coverage.

Also see Benefits Administration Letter 18-201 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

If the enrollee is enrolled in premium conversion, IRS rules prohibit the decrease in or cancellation of the enrollment outside of an open season in the absence of a qualifying life event. Those removed from coverage are not eligible for a 31-day temporary extension of coverage, conversion to a nongroup contract or temporary continuation of coverage. Reinstatement is allowed only during an open season or if the individual loses other coverage.

Part-Time EmployeesPart-time employees are eligible for coverage under the same terms as full-time employees, except that the government share of the total premium is prorated according to the number of hours the employee works. The employee must pay the difference. (Note: Employees working part-time as phased retirees receive the full government share; see Phased Retirement in Chapter 3, Section 1).

Temporary, Seasonal and Intermittent EmployeesEmployees on temporary appointments or on seasonal or intermittent schedules are eligible to enroll in FEHB if they are expected to work at 130 hours per month for at least 90 days (total, not annually). Note: These policies do not apply to the U.S. Postal Service because it has a separate health program for its non-career employees; see Chapter 12, Section 4.

If your employing office expects you to meet the standards, you are eligible to enroll upon notification by that office. Hours of employment for this purpose consist of regularly scheduled work and overtime plus Family and Emergency Medical Leave Act leave, injury compensation leave, leave to perform active military duty and leave for medical treatment for disabilities incurred in military duty. If the expectation of your hours changes from less than 130 hours per calendar month to 130 or more, you become eligible to enroll upon notification by your employing office, so long as you meet the 90-day standard. The determination is prospective only; agencies do not have to count the actual number of hours worked per month.

If you are expected to meet the 130 hour a month standard but to work fewer than 90 days, you are considered to be in a waiting period. If the expectation changes to at least 90 days of employment, you will be eligible to enroll upon notification by your employing office, but no later than the 91st day of employment.

If you enroll under these provisions, you receive the full government contribution to premiums. Standard rules about breaks in service, continuity of coverage and non-pay status generally apply.

Employing offices must promptly determine eligibility of new employees and of current employees who become newly eligible, and must promptly offer eligible employees an opportunity to enroll. Under limited circumstances, eligibility can be waived due to an agency’s mission needs.

Note: Those eligible under these policies but who are not enrolled may enroll if their employment status changes from temporary, seasonal or intermittent to full-time, since that change is considered a qualifying life event. Similarly, an enrolled employee may decrease or increase enrollment type, change from one plan or option to another, or make any combination due to such a change in employment status.

Once you are enrolled under these policies, eligibility and the government contribution to premiums will not be revoked, regardless of your actual work schedule, your employer’s expectations of your subsequent work schedule, or entry into non-pay status unless you: separate from federal service; receive a new appointment (in which case eligibility will be determined by the rules applicable to the new appointment); or exceed 365 days in non-pay status (subject to extension, if applicable, for time off work on the types of leave described above).

If you separate from service with eligibility for an annuity under a federal employee retirement program, the coverage counts toward the five-year requirement as described in FEHB Coverage After Retirement, below in this section, and the standard government contribution continues during your retirement. If you separate without retirement eligibility, you are eligible for continued coverage as described in Temporary Continuation of Coverage, below in this section. Also see Benefits Administration Letters 14-210 and 17-203 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Note: Prior to changes to 5 CFR 890 effective November 17, 2014, most temporary employees were eligible for FEHB only after a year of current continuous employment, and if eligible they had to pay the entire cost of the premium; seasonal employees were eligible only if they worked at least six months a year, and if eligible they typically received a prorated government share of premiums depending on the hours they worked; and seasonal employees working six months or fewer a year and all intermittent employees were prohibited regardless of their working schedules. There were exceptions that made eligible certain temporary employees engaged in wildland firefighting or fire protection or in certain emergency response work, regardless of their work schedules; they received the government contribution toward coverage when employed and could continue coverage when not employed at their own expense. Temporary employees who had completed one year of continuous employment and were eligible for coverage without a government contribution under the prior policy may enroll with a full government contribution if they meet the 90 day and 130 hour per month standards. Employees falling under the exceptions for firefighting, fire protection or emergency response who do not meet those standards remain covered by those prior policies.

Affordable Care ActThose who are eligible for FEHB but choose not to take it (or who are ineligible for FEHB) are eligible to enroll in insurance excchange plans under the Patient Protection and Affordable Care Act, Public Law 111-148. However, there is no government contribution to the premiums for those plans and premiums must be paid on an after-tax basis. In addition, if an employee is enrolled in an exchange plan rather than FEHB and the employee dies, coverage under FEHB for survivors would not be available even if they are eligible for a survivor annuity. The same is true if the employee retires: FEHB coverage would not be available since an employee must be enrolled in an FEHB plan on the date of retirement to continue coverage in retirement (see FEHB Coverage After Retirement, below).

Under the Act, members of the House and Senate and their personal staffs were excluded from FEHB eligibility (they may get coverage through another source such as employer-sponsored health insurance of a spouse including, if pertinent, a spouse’s FEHB coverage). Each member’s office is responsible for deciding which positions are affected by this policy by each October for the following year, and the designation cannot be changed during a plan year. While members of Congress and affected staff may enroll in any plan for which they are eligible, the employer contribution continues only if they choose the D.C. Health Link Small Business Market plan. The employer contribution for that plan is paid under the same formula applying under FEHB. At retirement they are eligible to return to the FEHB so long as they meet the rules for carrying FEHB into retirement (see FEHB Coverage After Retirement, below); for them, enrollment in the ACA plan counts toward meeting the five-year coverage requirement.

See Benefits Administration Letter 13-207 at www.opm.gov/retirement-services/
publications-forms/benefits-administration-letter
.

Note: P.L. 115-97 of 2017 repealed, effective with tax year 2019, a tax penalty the ACA imposed on those failing to maintain coverage meeting certain standards, with certain exceptions. All FEHB plans had qualified as providing such coverage for those personally enrolled or covered under another person’s enrollment, spouse equity or temporary continuation of coverage.

USPS Health Benefits PlanA related but separate program, the USPS Health Benefits Plan, is available to certain non-career employees of the U.S. Postal Service. See Chapter 12, Section 4.

Pathways ProgramParticipants in the career developmental Pathways Program (see Special Hiring, Recruitment and Placement Programs in Chapter 8, Section 1) are eligible to enroll and cover family members who meet FEHB eligibility standards if the Pathways appointment is scheduled to last at least 12 months and they are scheduled to be in pay status at least one-third of that time. Coverage continues while in non-pay status as long as the individual is in the Pathways Program. See 5 CFR 890.303.

FEHB Plan Options

The FEHB program allows federal employees and annuitants to choose among fee-for-service plans, which work on a reimbursement model, health maintenance organization (HMO) plans, which provide care on a prepaid basis through contracts with physicians and hospitals in a particular geographic area, options that offer features of both, and plans with variant funding arrangements.

Fee-for-Service PlansThe government-wide “service health benefit plan” is a fee-for-service plan provided through Blue Cross and Blue Shield organizations open to all who are eligible for FEHB. It is called a service benefit plan because it works on the principle of paying benefits either to the enrolled participant or directly to the doctor or hospital that provides the treatment or service. Blue Cross and Blue Shield also offers a network-only option.

Another type of FEHB fee-for-service plan is the employee organization plan. Some of these plans are exclusive to certain groups of employees, while others allow any FEHB-eligible person to join the plan as an adjunct member of the organization.

A preferred provider organization option in a fee-for-service plan gives enrollees the choice of using doctors and other providers within the plan’s network (the PPO benefit) at a lower cost, or using ones outside the plan’s network.

A fee-for-service plan may also make available a point of service option through a network of providers. There is an incentive for enrollees to use these providers because doing so usually results in a waiver of deductibles and a smaller co-payment.

HMOs—Types of HMO options in the FEHB include (note: these plans are open only to enrollees who live in a defined geographic area):

• Group Practice Prepayment Plans—These plans have their own medical center or centers and their own doctors who practice as a group.

• Individual Practice Prepayment Plans—In these plans, doctors agree to accept payments from the plan instead of requiring the patients to pay their usual charge.

• Mixed Model Prepayment Plans—These are a combination of group practice and individual practice plans,

Some HMOs offer a point of service option in which enrollees may use providers who are not part of the HMO network. However, there is a greater cost associated with choosing non-network providers. Enrollees usually pay deductibles and coinsurances that are substantially higher than when they use a plan provider. They also need to file a claim for reimbursement.

‘Consumer-Driven’ Options—Such plans feature a pool of money available to be spent up-front, then a deductible, and then standard coverageeither HMO-based or fee-for-service. The catastrophic limit usually is higher than what is common in other plans. The plans are designed to encourage enrollees to be selective in their use of health care. Unused portions of the allowance can be rolled over to future years, subject to certain limits.

High-Deductible Health Plans—These are plans that feature a high deductible and a tax-favored accounteither a health savings account or health reimbursement arrangementwhose money can be used to pay the deductible and certain other medical costs.

A health savings account is available to anyone who is not eligible for Medicare benefits (generally, meaning not 65 or older) and who does not have another potential source of paying the deductible, such as a spouse’s separate health insurance plan or a flexible spending account (thus, with the exception noted below, enrollees in HSA plans may not have health care FSAs, although they remain eligible for dependent care FSAs). Plans with a health savings account option must offer a health reimbursement arrangement, which is available for those who do not qualify for an HSA. Those with HRAs are not limited in their FSA options.

In HSA/HRA plans, the minimum deductible is set according to the tax code; plans may set higher deductibles, up to certain limits. The account is funded by a portion of the premiums. HSA account holders (but not HRA account holders) may invest additional funds with the combined total of automatic and voluntary contributions limited to annual maximum amounts established by the IRS. These investments are made by sending money directly to the plan, not by payroll deduction; investors then take a deduction from their taxes for that year. The tax code also sets limits on contributions and out-of-pocket expenses, both of which are inflation-indexed each year.

Money in the account is available to be withdrawn tax-free to pay the deductible plus certain other qualified medical expenses that do not count toward the deductible. HRA account holders must pay eligible expenses out of the account; an HSA account holder has the option of drawing down the account or paying the cost out of pocket. Money not spent in any one year can be rolled over for use in future years. HSA accounts earn interest tax-free; HRA accounts do not earn interest. There is no limit on how high the accounts can build. Money drawn out for expenses other than the allowable medical costs is taxable, plus a penalty may apply.

An HSA enrollee can keep the account even if retiring or leaving the government. Funds in an HRA are forfeited if the account holder leaves federal employment—if still employed—or switches health insurance plans.

After the deductible is paid, such plans feature coverage more or less comparable to that of the carrier’s plans that do not feature such accounts. Certain types of preventive care do not count against the deductible.

Participation in HSA/HRA plans does not affect the “premium conversion” arrangement through which active employees may pay FEHB premiums with pretax dollars (see Pretax Payment of FEHB Insurance Premiums, below).

Although the IRS generally doesn’t permit individuals to hold both an HSA and a health care flexible spending account, an exception applies for FSAs that cover only certain expenses. See the information about “limited” health care FSAs under Health Care Accounts in Chapter 1, Section 9.

Unlike flexible spending account allotments, employees who elect HSA allotments may modify their allotments at any time so long as the change is prospective and in accordance with the payroll provider’s procedures. The HSA allotment election will continue until the employee modifies or revokes that allotment election.

HSA enrollees may make pretax allotments to those accounts through payroll withholding using the same method that they would use to establish other allotments from pay. Employees are responsible for ensuring their enrollment and contributions are in accordance with IRS rules. Neither payroll providers nor self-service system providers verify employee eligibility or check to ensure employee contributions are within annual limits. There is a 20 percent penalty for medical expenses paid from an HSA that are later found to be non-eligible. (Note: Over-the-counter drugs or medicines are eligible for reimbursement only if prescribed by a doctor, with the exception of insulin, for which no prescription is needed.)

Detailed Plan Information—Plan brochures and a comparison tool are at www.opm.gov/healthcare-insurance/healthcare/plan-information.

FEHB Premium Rates

The premium rates for FEHB plans typically change each year, following the annual contract negotiations between OPM and each insurance carrier. Any new plan rates resulting from these negotiations begin on the first day of the first pay period in January of the following year for active employees, and January 1 for retirees.

FEHB premium costs are shared by the government and the participating employee or annuitant. The maximum government contribution is set at 72 percent of the weighted average cost of all plans, not to exceed 75 percent of the cost of any specific plan. The enrollee pays the balance, which averages about 30 percent of the total premium.

The government contribution is the same for most federal employees, with the following exceptions:

• For part-time employees, the government contribution is prorated according to the percentage of full-time work regularly performed. (Note: Employees working part-time as phased retirees receive the full government share; see Phased Retirement in Chapter 3, Section 1).

• Temporary, seasonal or intermittent employees, if eligible, receive the full government share but exceptions apply; See FEHB Eligibility and Enrollment Rules, above.

• The U.S. Postal Service contributes an additional amount toward the cost of premiums for its employees but not its retirees.

Premium Assistance—Public Law 111-03, the Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009, allows states to subsidize health insurance premium payments for certain children in low-income households who have access to qualified employer-sponsored health insurance coverage. Most FEHB plans, excluding high-deductible health plans, meet the act’s definition. FEHB-eligible enrollees who meet the criteria for child health assistance in their state are eligible to receive state premium subsidy assistance payments to help them pay FEHB premiums. In addition, premium assistance may be available through Medicaid or other state-run programs.

Benefits Administration Letter 09-203 (at www.opm.gov/retirement-services/

publications-forms/benefits-administration-letters) directed that FEHB enrollees eligible for such assistance are to receive it directly—state policies may allow for subsidies to be paid to the employer instead—and the employing agency is to continue to withhold the full employee share of the premium. See the table of permissible changes in FEHB enrollment in this section for allowable changes if you or an eligible family member gain or lose such assistance.

A separate form of premium assistance is available in certain circumstances as described in Temporary Continuation of Coverage, below.

Direct Payment of Premiums—Employees, retirees and injury compensationers who have insufficient salaries/annuities/compensation benefits on an ongoing basis to cover their health insurance premiums may pay those premiums directly. Most commonly, this arises when employees go on non-pay status such as extended leave without pay. Employing offices are required to give written notice to employees as soon as possible after the office becomes aware that they are in non-pay status or their pay is insufficient to cover premiums. The notice offers employees the choice of terminating the enrollment or continuing the enrollment and agreeing to pay the premiums directly or incur a debt to the agency. If the written notice is not acted on and returned within 31 days (45 days for employees residing overseas), the employing office will terminate the enrollment. Employees whose FEHB enrollment is terminated may re-enroll in any FEHB plan upon returning to pay and duty status without having to wait for an open season or qualifying life event.

Pretax Payment of FEHB Insurance Premiums

All employees in the Executive Branch who are participating in the FEHB and whose pay is issued by an Executive Branch agency are eligible to have their premiums paid with pretax dollars. This includes deductions for retroactive coverage, payback of premiums from a prior period of leave without pay and other adjustments.

This premium conversion arrangement results in reductions in federal income, Social Security and Medicare taxes. In many jurisdictions, state and local taxes will also be reduced. On the other hand, federal retirement, Thrift Savings Plan and life insurance benefits are not affected by participation in premium conversion. For example, it does not affect base salary for the purpose of determining “high 3” salary years for retirement benefits calculation.

Participation in premium conversion is automatic unless you waive it using the FEHB Premium Conversion Election/Waiver form, available from agency personnel offices and at www.opm.gov/retirement-services/publications-forms/benefits-administration-
letters/2000/00-215_attach3.pdf.

You may change participation status in premium conversion during the annual FEHB open season, or during the calendar year upon a qualifying life event (see Changes Outside of Open Season, below).

Participation continues uninterrupted year to year unless you opt out. Enrollment or participation in premium conversion ends if you leave federal government employment. If you are eligible and elect to participate in Temporary Continuation of Coverage, you pay those premiums directly and are not eligible for premium conversion.

While annuitants generally are not eligible for premium conversion (see the exception below), re-employed annuitants employed in positions that convey FEHB eligibility may participate in premium conversion. For them to do so, their FEHB enrollment must be transferred from their retirement system to the employing agency. For considerations relating to re-employed annuitants, see Chapter 4, Section 4. (Note: Those in “phased” retirement status remain eligible for premium conversion because they do not separate from service; see Phased Retirement in Chapter 3, Section 1.)

Premium conversion may result in somewhat lower Social Security benefits for federal employees who pay Social Security taxes on their salaries, primarily those under the Federal Employees Retirement System. Therefore, in rare situations mainly involving lower-paid employees, it may be advantageous to pay full Social Security taxes rather than the lower ones resulting from premium conversion. Note: These cases do not involve employees covered by CSRS or CSRS Offset.

An employee participating in premium conversion generally has the same flexibility as a person who chooses not to participate. Because of the tax laws, there are two exceptions that might play into a decision to take or waive premium conversion. Those who waive premium conversion can at any time drop health insurance or change to self-only. However, those participating in premium conversion may do so only during an open season or at the time of a “qualifying life event” (see Changes Outside of Open Season, below). See www.opm.gov/healthcare-insurance/healthcare under Reference Materials.

Premium Conversion for Some Retirees—Section 845 of the Pension Protection Act of 2006 allows limited pretax payment of FEHB premiums (among certain other forms of insurance) for retired “public safety officers.” OPM in Benefits Administration Letter 07-201 (at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters) determined that the Civil Service Retirement System and the Federal Employees Retirement System are eligible retirement plans under the act and that retired public safety officers are deemed to have made an FEHB premium conversion election for this purpose. To qualify, the distribution must be paid directly from the retirement system to the insurance provider.

As a result, retired public safety officers whose CSRS or FERS annuity payments include a direct premium payment to an FEHB carrier may self-identify eligibility for, and self-report, a tax exclusion to the Internal Revenue Service. Premiums of up to $3,000 for coverage of the enrollee, spouse or dependents can be excluded, but only for amounts that otherwise would be included in taxable income, and the amount excluded cannot be used to claim a medical expense deduction.

IRS Publication 721, Tax Guide to U.S. Civil Service Retirement Benefits, defines public safety officers as including law enforcement officers, including those of the Capitol Police and Supreme Court Police, firefighters, Customs and Border Protection officers, air traffic controllers, nuclear materials couriers, and diplomatic special security agents of the State Department. That publication, at www.irs.gov/pub/irs-pdf/p721.pdf, also contains additional information on this tax advantage. Consult a tax adviser for guidance.

Changes Outside of Open Season

Outside of open season, you can enroll in the FEHB program, change your level of enrollment or cancel coverage only in connection with certain events called qualifying life events (QLEs). In some cases, a change in premium conversion (see above) also is allowed. Detailed policies and instructions are on Standard Form 2809 at www.opm.gov/forms. Also see the table of permissible changes in FEHB enrollment in this section.

The major QLEs that permit enrollment or change in enrollment are:

• A change in family status: marriage; birth or adoption of a child; acquisition of a foster child; legal separation or divorce; and death of a spouse or dependent.

• A change in employment status: you are re-employed after a break in service of more than three days; you return to pay status after your coverage terminated during leave without pay status or because you were in leave without pay status for more than 365 days; your pay increases enough for premiums to be withheld; you are restored to a civilian position after serving in the uniformed services; you change from a temporary appointment to an appointment that entitles you to a government contribution; or you change to or from part-time career employment.

• You or a family member lose FEHB or other coverage: under another FEHB enrollment because the covering enrollment was terminated, canceled, or changed to self-only; under another federally sponsored health benefits program; under Medicaid or similar state-sponsored program for the needy; because your membership terminates in the employee organization sponsoring the FEHB plan; or under a nonfederal health plan.

• For employees not participating in premium conversion, a determination that an FEHB-eligible employee or a family member who is eligible for FEHB family coverage is eligible for premium assistance under a Medicaid or State Children's Health Insurance Program.

When one of these events occurs, you may: enroll; change your enrollment between self-only, self plus one and self and family consistent with the event; change your enrollment to another FEHB plan or option; or cancel your enrollment. A change to self-only may be made only if the QLE causes you to be the last eligible family member under the FEHB enrollment. A cancellation may be made only if you can show that as a result of the QLE, you and all eligible family members now have other health insurance coverage. Note: If you have family coverage and a life event (such as a child aging out of eligibility) occurs so that you have only one eligible family member remaining, a change to self plus one is not automatic; you must elect it.

Note: If you are subject to a court or administrative order requiring you to provide coverage for a child or children, you may not decrease your enrollment type in a way that eliminates coverage of a child identified in the order as long as the order is in effect and you have at least one child identified in the order who is still eligible under the FEHB, unless you provide documentation (to your agency if employed or to OPM if retired) that you have other coverage for the child(ren). See Chapter 7, Section 3, and 5 CFR 890.

Changing Family Member Covered by Self Plus OneIf you have a self plus one enrollment, you may change your covered family member outside an open season upon a change in family status, upon a change in coverage or upon a change in eligibility, so long as the change is consistent with the event. For example, if you have a self plus one enrollment that covers your spouse and then have a child, you could not switch from covering your spouse to covering your child as the second person (although you could increase to self and family to cover both). However, if you have self plus one coverage on a child but not on your spouse and the child loses eligibility by turning age 26, you could change the designation of the second person to your spouse (you also could switch to self-only); the carrier may request documentation to prove the eligibility of the newly designated family member. If you do not change the second person from 31 days before to 60 days after the event, you will have to wait until the next open season or the next qualifying life event. Retroactive switching of a covered family member is not allowed. See Benefits Administration Letters 15-205 and -208 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Leave Without Pay—In certain circumstances, entering or returning from a period of leave without pay may constitute a qualifying life event. If you enter a period of LWOP of more than 31 days, you have the option to terminate or continue FEHB coverage. If you elect to continue FEHB coverage, you must choose one of the options to pay your share of the premium. These options are pay-as-you-go (paying your share of the FEHB premium directly to your agency while on LWOP), and catch-up (where the agency remits your share of the FEHB premium to OPM during the period of LWOP and you repay it on return to pay status). In addition, under IRS rules an agency may, but is not required to, offer a prepay option.

Preadmission Certification Procedures

Under the FEHB, plans have cost containment measures in place. All plans require preadmission certification of all non-emergency hospital admissions. If you are enrolled in a managed fee-for-service plan, the preadmission certification provision makes you responsible for ensuring that the requirement is met. You or your doctor must check with your FEHB plan before you are admitted to the hospital. If that doesn’t happen, your benefits for the admission will be reduced. Check your plan’s brochure for terms.

Patients’ Rights

The FEHB program complies with a Patients’ Bill of Rights. Under its provisions, consumers have the right to:

• receive accurate, easily understood information to help them make informed decisions about their health plans, professionals and facilities, including: accreditation status; compliance with state or federal licensing, certification, or fiscal solvency requirements; disenrollment rates; years in existence; corporate form; and compliance with standards (state, federal, and private accreditation) that assure confidentiality of medical records and orderly transfer to caregivers.

• information about networks and providers, including: board certification status and geographic location of all contracting primary and specialty care providers; whether they are accepting new patients; language(s) spoken and availability of interpreters; and whether their facilities are accessible to the disabled.

• a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care. This includes: direct access to women’s health care providers for routine and preventative health care services; direct access to a qualified specialist within the network of providers for complex or serious medical conditions that need frequent specialty care; and transitional care for those with chronic or disabling conditions or who are pregnant where the provider either drops out of the program or is terminated under the carrier’s contract.

• access to emergency health care services when and where the need arises. Health plans use a “prudent layperson” standard in determining eligibility for coverage of emergency services without prior authorization.

• full participation in all decisions related to their health care. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators.

• considerate, respectful care from all members of the health care system at all times and under all circumstances. Consumers who are eligible for coverage under the terms and conditions of a health plan or program or as required by law must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

• confidential communication with health care providers and assurances of confidentiality for their personal health care information. Consumers also have the right to review and copy their own medical records and request amendments to their records.

Coordination of Benefits

FEHB carriers must follow standard coordination of benefit rules established by the National Association of Insurance Commissioners (NAIC) in order to make sure that payments to providers and enrollees do not duplicate payments of other health benefits coverages the enrollee may have.

The most common instances where OPM coordinates with other programs are:

• Tricare and CHAMPVA. FEHB carriers coordinate Tricare/CHAMPVA benefits according to their statutes. Tricare covers certain dependents of military persons and retirees of the military. CHAMPVA provides health coverage to disabled veterans and their eligible dependents. When Tricare or CHAMPVA and FEHB cover the enrollee, FEHB pays first. See FEHB, CHAMPVA and Tricare, below.

• FEDVIP. Some FEHB plans provide some dental and/or vision benefits. For enrollees of plans offering those benefits who also are enrolled in the Federal Employees Dental and Vision Insurance Program (see Section 4 of this chapter), the FEHB carrier pays first and the FEDVIP carrier pays part or all of the rest, depending on the plan’s terms.

• Medicaid. When the enrollee has Medicaid and FEHB, FEHB pays first.

• Medicare. Most retirees are eligible for Medicare at age 65. FEHB carriers coordinate with Medicare and Medicare makes the final determination regarding who is primary. The most common situation is when you or your spouse are age 65 or over and have Medicare. Generally, in that case, if you are an active federal employee, FEHB pays first and if you are retired, Medicare pays first. Medicare’s rules for coordinating benefits are described in FEHB plan brochures. To facilitate benefits coordination with Medicare, OPM and carriers work with Medicare, including through an OPM-Medicare data matching agreement. Also see FEHB and Medicare, below.

• Spouse coverage. Benefits of enrollees (whether active employees or retirees) with coverage both through FEHB and through a spouse’s private sector employer are coordinated according to the NAIC guidelines. Generally, an enrollee’s own coverage is primary to coverage through a spouse.

• Other group coverage. Benefits of enrollees who have other insurance of their own, such as coverage as a retiree from private employment, are coordinated according to the NAIC guidelines. Generally, the plan that covers a person as a current employee pays before the plan that covers the person as a retiree.

• No-fault coverage. FEHB carriers coordinate the payment of medical and hospital costs under no-fault or other automobile insurance that pays benefits without regard to fault according to the NAIC guidelines.

• Children’s coverage. Where a child covered under an FEHB policy has employer-sponsored health insurance of his or her own, that policy is the primary payer and FEHB is the secondary payer.

Temporary Continuation of Coverage

Temporary Continuation of Coverage (TCC) allows limited extensions of FEHB coverage for federal employees who separate from employment without entitlement to continue it as a retiree (see FEHB Coverage After Retirement, below), and for covered family members who lose eligibility under certain circumstances. An enrollee who loses FEHB coverage other than by voluntary cancellation (or involuntary separation due to misconduct) has a 31-day temporary extension of coverage, at no cost, in the same enrollment category held at separation. If elected, TCC takes effect on the day that period ends and lasts up to 18 months after the date of separation.

Note: During the 31-day extension, you alternatively may convert your enrollment to a nongroup contract, without providing evidence of good health, from the carrier of the plan you are enrolled in when you separate. Contact the carrier directly for information. A nongroup contract may offer fewer benefits, have a higher cost or both, and you will have to pay the entire cost directly to the plan. A nongroup contract also is effective on the day after the extension ends.

TCC enrollees must pay both the employee and government shares of the premium plus a 2 percent administrative charge. However, under 5 U.S.C. 8905a(d)(4), Defense Department employees who are involuntarily separated by a reduction in force or who volunteer to be separated from a “surplus position” pay only the employee contribution if they elect TCC. See Defense Department RIF and Placement Benefits in Chapter 9, Section 2.

Eligibility for “premium conversion”—payment of premiums with pretax dollars—ends when you separate.

For a former employee, a TCC enrollment covers the same family member(s) as covered under the regular enrollment. Family members must continue to meet the same eligibility requirements as under a regular enrollment. A new family member, such as a new spouse or a newborn child, can be added to a TCC enrollment.

It is the responsibility of the worker’s employing office to provide notice to the employee (within 61 days after regular FEHB enrollment terminates) of the right to enroll under TCC. Generally, separating employees must submit their TCC election notice to their employing agency within 60 days after the date of separation or within 65 days after the date of notice from the employing agency, whichever is later.

Employees should ask their agency to provide them with TCC information before or on the day they separate. TCC enrollments—and premiums—begin on the day after the 31-day extension of coverage ends. Coverage is retroactive to that date if the enrollment processing is completed later; in such cases, the costs for that period are billed retroactively. If the enrollee does not pay the bill for the retroactive coverage, the TCC enrollment is canceled retroactively to the beginning date and the person is not eligible to re-enroll.

To apply for TCC, separating employees (or their child or former spouse, as applicable) must complete Standard Form 2809, Employee Health Benefits Registration Form, available from personnel offices or at www.opm.gov/forms (or its electronic equivalent) and submit it to their employing office within the time limit noted above. Employing offices can accept late enrollments in very limited circumstances.

Eligible individuals may enroll in any plan for which otherwise qualified (some plans require that enrollees live or work in a certain geographic area or belong to a sponsoring employee organization) and any level of enrollment.

Your current spouse is not eligible for TCC in his or her own right, even if you are separated from the government and you decide not to elect TCC or you die. However, the end of a marriage by divorce or annulment is a qualifying event allowing enrollment, and your now-former spouse would become eligible for TCC. See Chapter 7, Section 3 for policies on continued FEHB enrollment for former spouses through a court order. Family members eligible to be covered under a former spouse’s own TCC are limited to children of both the federal employee and the former spouse.

For children, the qualifying events for TCC in their own right are:

• losing eligibility as a family member of a current FEHB enrollee, most commonly on reaching age 26 (see FEHB Eligibility and Enrollment Rules, above);

• in the case of children whose coverage has continued beyond age 26 because of their inability to support themselves due to a disability occurring before they reached age 26, recovering from the disability or becoming self-supporting; and

• in the case of death of the sponsoring employee or annuitant, ineligibility for a survivor annuity or the end of a survivor annuity (see Survivor Benefits for Children in Chapter 3, Section 4 regarding death of an annuitant; see Benefits Upon Death in Service in Chapter 8, Section 4 regarding death of an active employee).

Since the enrollment will be in the child’s name, the child must complete the election form and the child will be billed for the coverage. A child’s spouse and children are eligible for coverage.

An employee’s children and former spouse can continue TCC for up to 36 months after the date of the event if it occurs while the child or former spouse is covered as a family member of an employee or annuitant under a regular FEHB enrollment, or the date of the employee’s separation if the qualifying event occurs while the child or former spouse is covered under the TCC enrollment of a former employee.

Also see Standard Form 2810, Notice of Change in Health Benefits Enrollment at www.opm.gov/forms and the FEHB Handbook at www.opm.gov/healthcare-insurance/healthcare/reference-materials.

FEHB and Medicare

Upon reaching age 65, most federal employees and retirees become eligible for Medicare. Generally, plans under the FEHB program help pay for the same kind of expenses as Medicare. FEHB plans also provide coverage for prescription drugs, routine physicals, emergency care outside of the United States and some preventive services that Medicare doesn’t cover. Some FEHB plans also provide coverage for dental and vision care.

However, Medicare covers some orthopedic and prosthetic devices, durable medical equipment, home health care, limited chiropractic services, and medical supplies, which some FEHB plans may cover only partially or not at all. For a fuller description of Medicare, see Chapter 5, Section 8.

FEHB carriers coordinate with Medicare and Medicare makes the final determination regarding who is primary. The most common situation is when you or your spouse are age 65 or over and have Medicare. Generally, in that case, if you are an active federal employee, FEHB pays first and if you are retired, Medicare pays first, as described below.

FEHB plans are limited to paying the Medicare fee schedule amount for physician services provided to retired FEHB enrollees age 65 and over who are not enrolled in Medicare Part B. Medicare participating providers can collect no more than the Medicare fee schedule amount from these enrollees. Medicare non-participating providers can collect no more than the limiting charge amount, which is 115 percent of the fee schedule amount. This reduces both what the plan and the enrollee can be charged by doctors.

Medicare Enrollment Issues—Most Medicare-eligible persons on reaching age 65 are eligible for Part A (hospital insurance) benefits premium-free. Part A will help cover some of the costs that an FEHB plan may not cover, such as deductibles, coinsurance, and charges that exceed the plan’s allowable charges. There are other advantages to enrolling in Part A, such as being eligible to enroll in a Medicare managed care plan.

Enrollees don’t have to take Part B (primarily physicians’ services) coverage if they don’t want it, and an FEHB plan can’t require them to take it. However, there are some advantages to enrolling in Part B:

• An enrollee must be enrolled in both Parts A and B to join a Medicare Advantage plan.

• An enrollee has the advantage of coordination of benefits between Medicare and the FEHB plan, reducing out-of-pocket costs.

• An FEHB plan may waive its co-payments, coinsurance, and deductibles for Part B services.

• Some services covered under Part B might not be covered or only be partially covered by an FEHB plan.

Anyone enrolled in an FEHB HMO may go outside of the plan’s network for Part B services and receive reimbursement by Medicare when Medicare is the primary payer.

Those who don’t enroll in Medicare as soon as they are eligible must wait for the general enrollment period (January 1-March 31 of each year) to enroll, and Part B coverage will begin the following July 1. Their Part B premiums will go up 10 percent for each 12 months that they could have had Part B but didn’t take it. However, this penalty generally does not apply to those who didn’t take Part B at age 65 because they were covered under health insurance such as FEHB as an active employee or were covered under a working spouse’s group health insurance plan. They may sign up for Part B without penalty within eight months from the time the enrollee or spouse stops working or is no longer covered. An enrollee also can sign up at any time when covered by the group plan.

Medigap Enrollment Issues—FEHB is not one of the standardized Medicare supplemental insurance policies known as Medigap (or Medicare SELECT) policies. However, many FEHB plans and options will supplement Medicare by paying for costs not covered by Medicare, such as the required deductibles and coinsurance, and by providing additional benefits not provided under Medicare.

An FEHB enrollee generally doesn’t need to purchase a Medigap policy since FEHB and Medicare will coordinate benefits to provide comprehensive coverage for a wide range of medical expenses.

Part D Enrollment Issues—Persons eligible for both FEHB and Medicare may enroll in both FEHB and the Medicare Part D prescription drug program. However, both OPM and the Centers for Medicare and Medicaid Services provide information to potential enrollees stating that FEHB prescription drug coverage is generally better than that of plans available under Medicare Part D and that duplicative coverage is unnecessary. Nevertheless, some FEHB enrollees elect to purchase Part D. In some cases, they are eligible for Medicare’s subsidies for low-income individuals that reduce or eliminate premiums, deductibles and cost-sharing under Part D. Individuals eligible for this subsidy and wishing to take it may need to maintain their FEHB coverage because prescription drug benefits are integrated into FEHB plans; beneficiaries may not terminate FEHB drug benefits without losing their medical benefits as well. Benefits for those enrolled in both are coordinated.

Which Pays First—Medicare law and regulations determine whether Medicare or FEHB is primary (pays benefits first). Medicare automatically transfers claims information to the FEHB plan once a claim is processed, so the enrollee generally doesn’t need to file with both.

An FEHB plan must pay benefits first when the enrollee is an active federal employee or re-employed annuitant (even if age 65 or older) and either the enrollee or covered spouse has Medicare, unless the re-employment position is excluded from FEHB coverage or the enrollee is enrolled in Medicare Part B only. An FEHB plan must also pay benefits first for the enrollee or a covered family member during the first 30 months of eligibility or entitlement to Part A benefits because of End Stage Renal Disease, regardless of employment status.

Medicare must pay benefits first when the enrollee is an annuitant, and either the enrollee or covered spouse has Medicare. Medicare also must pay benefits first when the enrollee is receiving workers’ compensation and the Office of Workers’ Compensation Programs has determined that the enrollee is unable to return to duty.

FEHB Enrollment Issues—As an enrollee, you may change FEHB enrollment to any available plan or option at any time beginning on the 30th day before becoming eligible for Medicare. You may use this enrollment change opportunity only once. You may also change enrollment during the annual open season, or because of another event that permits enrollment changes (such as a change in family status).

Once Medicare becomes the primary payer, you may find that a lower-cost FEHB plan is adequate. Also, some plans waive deductibles, coinsurance, and co-payments when Medicare is primary. (Note: Several FEHB plans are conducting pilot programs in which those enrolled in both FEHB and Medicare may voluntarily participate. The FEHB plan pays part or all of the cost of the enrollee’s Medicare Part B premium and in return, the enrollee must pay the same cost sharing as enrollees in the plan who are not enrolled in Medicare.)

An FEHB fee-for-service plan won’t necessarily cover all out-of-pocket costs not covered by Medicare. A managed fee-for-service plan’s payment is typically based on reasonable and customary charges, not on billed charges. In some cases, Medicare’s payment and the plan’s payment combined will not cover the full cost.

Out-of-pocket costs for Part B services will depend on whether the doctor accepts Medicare “assignment.” When a doctor accepts assignment, you can be billed only for the difference between the Medicare-approved amount and the combined payments made by Medicare and your FEHB plan. When a doctor doesn’t accept assignment, you can be billed up to 115 percent of the Medicare-approved amount (the “limiting charge”) when the FEHB plan’s payment and Medicare’s payment don’t cover the full cost.

Although you will usually have to pay the FEHB HMO’s required co-pays and deductibles, some HMOs waive such payments when Medicare is primary. However, you must still use the HMO’s participating provider network to receive services and get required referrals for specialty care.

Medicare Managed Care Plan IssuesIf you enroll in a Medicare managed care plan, you may not need FEHB coverage because the Medicare managed care plan pays many of the same benefits. Review their benefits carefully before making a decision.

If you provide documentation to your retirement system that you are suspending FEHB coverage to enroll in a Medicare managed care plan, you may re-enroll in FEHB if you later lose or cancel the Medicare managed care plan coverage. If you voluntarily cancel Medicare managed care plan coverage, you must wait until the next open season to re-enroll in FEHB. If you involuntarily lose coverage under the Medicare managed care plan, you may re-enroll in FEHB from 31 days before to 60 days after losing the Medicare managed care plan coverage, and your re-enrollment in FEHB will be made effective the day after the Medicare managed care plan coverage ends. An involuntary loss of coverage includes when the Medicare managed care plan is discontinued or when you move outside its service area.

Each FEHB plan brochure provides information on how that plan’s benefits are coordinated with Medicare. Some HMOs participating in FEHB will coordinate to the enrollee’s greater advantage for those who enroll in the company’s FEHB HMO and its Medicare managed care plan.

Further information on FEHB and Medicare is at www.opm.gov/healthcare-insurance/healthcare/medicare.

FEHB, Tricare, and CHAMPVA

“Tricare for Life” coverage for Medicare-eligible uniformed services retirees, their survivors and eligible dependents is advantageous for cost reasons for many Medicare-eligible military health care beneficiaries who also are eligible under the FEHB. Further, the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides beneficiaries of the Department of Veterans Affairs who are over age 65 with coverage secondary to Medicare similar to benefits provided to uniformed services beneficiaries under the Tricare or Tricare for Life programs.

Annuitants and Former Spouses—Current FEHB annuitants and former spouses who are eligible for these programs may suspend (rather than cancel) their FEHB coverage and premium payments. Regulations at 5 CFR 890 allow these individuals to re-enroll in the FEHB during an open season, or immediately if they are involuntarily disenrolled from the non-FEHB coverage. The intent is to allow eligible beneficiaries to avoid the expense of continuing to pay FEHB premiums while they are using other coverage, without endangering their ability to return to the FEHB in the future. The policy also applies to those eligible to enroll in Tricare’s Uniformed Services Family Health Plan.

Annuitants or former spouses can suspend FEHB coverage to use Tricare or CHAMPVA at any time. Annuitants can call OPM’s Retirement Information Office at (888) 767-6738 to obtain a suspension form. Former spouses can get the form from the employing office or retirement system maintaining their enrollment. Eligible individuals must submit a completed suspension form and provide all necessary documentation to show eligibility for Tricare or CHAMPVA during the period beginning 31 days before and ending 31 days after the date they designate as using Tricare or CHAMPVA instead of FEHB coverage. If the documentation showing your eligibility for Tricare is received within that period, the suspension becomes effective at the end of the day before the day you designated. Otherwise, the suspension becomes effective at the end of the month in which OPM receives your documentation.

An annuitant, survivor, or former spouse may not suspend his or her own FEHB coverage while allowing family members to continue coverage under the FEHB. The coverage of all family members is suspended as well. Nor can an annuitant, survivor, or former spouse suspend his or her family members’ FEHB coverage while remaining covered under the FEHB. An annuitant, survivor, or former spouse can change to self-only coverage, but this cancels all family members’ coverage and takes away their future enrollment eligibility.

If you suspend FEHB coverage to use Tricare or CHAMPVA instead, you can re-enroll in the FEHB for any reason during a future open season. If you are involuntarily disenrolled from Tricare or CHAMPVA, you are eligible to immediately re-enroll in the FEHB. Your request to re-enroll must be received within the period beginning 31 days before and ending 60 days after your Tricare or CHAMPVA coverage ends. Otherwise, you must wait until an open season.

If an annuitant dies during his or her suspended FEHB enrollment, his or her survivor will be eligible to re-enroll in the FEHB as long as the annuitant was enrolled in self and family coverage when he/she suspended FEHB coverage and made arrangements to leave a survivor annuity.

Active Employees—Actively working civil service employees may not suspend their FEHB coverage to use CHAMPVA, Tricare or Tricare for Life. However, they can cancel their coverage for that purpose. Employees who do not participate in premium conversion may cancel their enrollment at any time. For employees who participate in premium conversion, eligibility for CHAMPVA or Tricare is not a qualifying life event that would allow them to cancel their FEHB enrollment. These employees may cancel only during an annual FEHB open season.

If an employee who canceled FEHB coverage to use CHAMPVA, Tricare or Tricare for Life decides to return to FEHB coverage, the employee can do so during a future open season. If the employee loses CHAMPVA, Tricare or Tricare for Life coverage involuntarily, the employee can immediately re-enroll in the FEHB.

Before you cancel FEHB coverage as an active employee to use Tricare or Tricare for Life, consider the following:

• To be eligible to continue FEHB coverage after retirement, a retiring employee must be enrolled under the FEHB program (or covered as a family member) for the five years of service immediately before retirement, or, if less than five years, for all service since the first opportunity to enroll (waivers are allowed in certain situations; see FEHB Coverage After Retirement, below). Employees can count their coverage under Tricare toward meeting this requirement. However, the employee must be enrolled in an FEHB health plan on the date of retirement to continue coverage.

• If the employee dies when the cancellation is in effect, any surviving spouse will not be eligible to continue FEHB health benefits coverage.

Further information about Tricare is at https://tricare.mil and information about CHAMPVA is at www.va.gov/COMMUNITYCARE/programs/dependents/champva/index.asp.

FEHB Coverage After Retirement

Eligibility—Federal employees are allowed to continue their health benefits coverage after they retire if they meet certain conditions. Generally, you must retire on an immediate annuity; and you must have been continuously enrolled under the FEHB program (or covered as a family member) for the five years of service immediately preceding your retirement or, if less than five years, for all service since your first opportunity to enroll (see 5 U.S.C. 8905(a)). While you can count coverage under Tricare toward meeting this requirement, to continue coverage in retirement, you must be enrolled in an FEHB health plan on the date you retire.

Note: The term continuous enrollment includes separate periods of federal employment interrupted by a break in service, as long as FEHB coverage was in effect at the time of the break and has been continuous since the break, and the combination totals five years or, if less than five years, for all service since your first opportunity to enroll (see 5 U.S.C. 8905(a)).

Employees who separate and are eligible for a deferred annuity cannot begin health insurance coverage when their deferred annuity begins. Employees must retire on an immediate annuity to be eligible to continue their health insurance coverage. (For employees retiring under FERS, an immediate annuity includes one based on the MRA+10 provision (minimum retirement age and ten years of service) even though the employee may postpone receipt of that annuity to a later date.)

Under 5 CFR 630.212, employees who are retiring because of a downsizing have the right to use their accrued annual leave to qualify for continuing their health insurance into retirement under certain circumstances. The Office of Personnel Management will grant pre-approved waivers of the five-year requirement to employees who:

have been covered under the FEHB program continuously since the beginning date of the agency’s latest statutory buyout authority, or OPM-approved buyout or early retirement authority;

• retire during the statutory buyout or OPM-approved buyout/early retirement period; and

• receive a buyout, take early optional retirement, or take discontinued service retirement based on an involuntary separation due to reduction in force, directed reassignment, reclassification to a lower grade, or abolishment of position.

Employees who meet these requirements do not need to write a letter requesting a waiver. Instead, agencies must attach a memorandum to the employee’s retirement application stating that the employee meets the requirements for a pre-approved waiver by OPM. That certification must include the number of the public law granting the agency’s buyout authority and the beginning and ending dates of the agency’s buyout period. OPM also may waive the eligibility requirements when it determines that an individual’s failure to satisfy the requirements was due to exceptional circumstances and that it would be against “equity and good conscience” not to allow the individual to be enrolled in FEHB as an annuitant (see 5 U.S.C. 8905(b) and 5 CFR 890.108). Individuals seeking waivers must provide OPM with evidence that they intended to have FEHB coverage as an annuitant, that the circumstances that prevented them from meeting the eligibility requirements were beyond their control, and that they acted reasonably to protect their right to continue coverage into retirement. They must include: all health benefit enrollment forms (SF 2809’s and SF 2810’s) or electronic enrollment verification; service history SF 2801-1 for CSRS or SF 3107-1 for FERS; proof of coverage under Tricare if applicable; a copy of the agency buyout or early retirement authority letter from OPM, if applicable; the exact date the employee plans to retire; and any medical documentation the employee wants OPM to consider if an employee or a family member has a medical condition that is a factor in the decision to retire. Waiver requests should be sent to: OPM, Retirement Benefits Branch, 1900 E St. N.W., Washington, DC 20415-3532.

Special Eligibility Rules for Defense Department Employees—5 U.S.C. 9902(i) authorizes a permanent buyout and early retirement program within DoD; the periods are renewed each fiscal year starting October 1. OPM will grant pre-approved waivers to DoD employees who:

• have been covered under the FEHB program continuously since the start of the current fiscal year;

• retire during the DoD buyout/early retirement period; and

• receive a buyout, take early optional retirement, or take discontinued service retirement based on an involuntary separation due to RIF, directed reassignment, reclassification to a lower grade, or abolishment of position.

DoD employees who meet the above requirement do not need to write a letter requesting a waiver. Instead, human resources offices must attach a memorandum that provides a statement that the employee meets the requirements for a pre-approved waiver by OPM, the beginning and ending date of the buyout/early retirement period during which the employee retired, and a statement that the employee was enrolled in the FEHB on the beginning date of the period during which he or she retired and that he or she was enrolled continuously to the date of retirement. Employees who do not qualify for a pre-approved waiver may request a waiver on a case-by-case basis as explained above.

Premiums—After retirement, the government continues to pay the same contribution that is paid for active employees. The applicable rate of the retiree’s share of the premium will be deducted from the monthly retirement annuity check. If the annuity is not enough to cover the health insurance premiums, the premiums can be paid directly to OPM, as explained in Direct Payment of Premiums, below.

Federal employees and retirees (excluding Postal Service employees) pay the same amount for their premiums. When postal employees retire, they no longer receive an additional amount toward their cost of health insurance, which requires them, as retirees, to pay the same as all other federal workers and retirees.

Retirees generally are ineligible to pay premiums with pretax money, as explained in Pretax Payment of FEHB Insurance Premiums, above.

Family Coverage—Retirees who are enrolled for self plus one or self and family can have family members continue coverage unless they become ineligible—for example, when a covered child reaches age 26. However, the widow(er) of a federal retiree who did not elect a survivor benefit cannot continue FEHB insurance after the retiree’s death (unless otherwise eligible, such as by being a federal employee himself or herself). A deceased employee must have been enrolled for self plus one or self and family at the time of death for survivors to remain eligible. All survivors who meet the definition of “family member” continue their health benefits coverage under the enrollment as long as any one of them is entitled to a survivor annuity.

Suspending Coverage—Medicare-eligible federal retirees and former spouses can suspend their FEHB enrollment and enroll in a Medicare-sponsored prepaid health plan. If that plan stops participating for any reason, they can re-enroll in FEHB without a break in coverage. However, if they voluntarily disenroll from the Medicare plan, they may not reinstate their FEHB coverage until the annual open season. Medicare-eligible retirees interested in making this choice should contact their retirement system. Former spouses who are Medicare-eligible should contact the agency that maintains their enrollment. See FEHB and Medicare, above.

Also, annuitants, survivors, and former spouses who are enrolled under the spouse equity provisions of FEHB may suspend their FEHB coverage to use the Peace Corps insurance program under 5 CFR 890. These individuals may re-enroll in the FEHB program immediately if they involuntarily lose their Peace Corps coverage, or during the annual FEHB open season.

Re-employed Annuitants—For special considerations for re-employed annuitants, see Chapter 4, Section 4.

Questions, Complaints, and Appeals

Questions about your health insurance policy should be addressed to your local personnel office. If that office needs further assistance, it should contact the designated agency insurance benefits officer at agency headquarters. The Office of Personnel Management posts general information on the FEHB program as well as certain information on individual plans and links to sites of the plans at www.opm.gov/healthcare-insurance/healthcare. In addition, insurance carriers maintain toll-free numbers where you can get answers to questions about coverage, plan brochures and other information.

If you don’t agree with your health plan’s decision regarding a claim, review and follow the directions in the disputed claims section of the brochure. This section will tell you how to ask the plan to reconsider your claim. You must explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered.

If the plan again denies the claim, the disputed claims section of the brochure will tell you how to ask OPM to review the claim. You may check on the status of your claim review by calling the OPM contracts division at the number provided on the acknowledgment OPM will send you. However, OPM cannot give you a decision over the phone until it has completed the review and issued a written final decision.

Decisions by the contracts division are the final level of OPM review. If you are dissatisfied with the decision, you may file a complaint in the appropriate federal district court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies.

For More Information

More detailed information about the federal government’s health insurance program and policies are in FEHB law (5 U.S.C. 89), regulations (5 CFR 890) and the FEHB Handbook at www.opm.gov/healthcare-insurance/healthcare under Reference Materials. General information and plan contacts are at www.opm.gov/healthcare-insurance/
healthcare/plan-information/plans.

The “Managing My Own Health” site at www.opm.gov/healthcare-insurance/special-initiatives/managing-my-own-health provides information that enrollees can use in planning for screenings and other health care, plus online health care record keeping.

Section 2
Federal Employees’ Group Life Insurance Program

Group life insurance coverage is available to most federal employees, including part-time employees, through the Federal Employees’ Group Life Insurance (FEGLI) program. FEGLI is administered by Metropolitan Life Insurance Company under a contract with the Office of Personnel Management.

Eligible employees are automatically covered for Basic insurance upon hiring unless they waive it in writing before the end of their first pay period. FEGLI Basic provides group term life insurance plus accidental death and dismemberment insurance that provides double indemnity protection. The U.S. Postal Service pays the entire cost of Basic for its employees; other agencies pay one-third of the cost, with the enrollee paying the rest.

In addition to the Basic coverage, there are optional coverages available to enrollees who wish to augment their own coverage or have coverage on their family members. Although the premiums for optional coverages are paid entirely by enrollees, they are provided at group rates. Newly hired employees have 60 days from their entry date to elect any optional life insurance. No proof of insurability is required for any optional insurance elected in that time. After the initial election period, coverage may be increased only under certain circumstances and proof of insurability may be required, as described in Adding Coverage, below. Any coverage not elected is considered waived/canceled. A benefits calculator is at www.opm.gov/retirement-services/calculators/fegli-calculator.

Active employees unsure of how much coverage they have should contact their personnel offices. They also may check their most recent Standard Form 50, Notification of Personnel Action, block 27. Retirees should call (888) 767-6738 or email retire@opm.gov.

In general, if you drop FEGLI coverage as a retiree, you cannot reinstate it (see Chapter 4, Section 4 for special rules that apply to rehired annuitants). If you drop FEGLI coverage while an employee, you may reinstate it, provided you are found to be medically insurable, if an open enrollment period is held, or if you experience a qualifying life event. See Adding Coverage, below.

Premium rates change occasionally due to claims patterns, most recently in January 2016 when Basic insurance rates for retirees electing the 50 percent reduction or the no reduction option increased (there was no change in Basic rates for active employees) and rates for both active employees and retirees in Options A, B and C changed, in many cases increasing at older ages while decreasing or holding steady at younger ages.

Basic Life Insurance

The Basic insurance amount equals an employee’s annual pay rounded to the next higher thousand plus $2,000; the applicable rate consists of pay treated as basic pay for purposes of retirement as described in High-3 Salary Base in Chapter 3, Section 4. If the combination of salary and premium pay reaches an applicable annual salary cap (see Chapter 1, Section 2), the amount is based on the actual earnings received by the employee. The determination is made on an annual basis, not by pay period. (Note: In situations of concurrent employment, the amount of Basic and Option B insurance is based on the combined salaries. If an employee accepts a temporary position while in non-pay status from a covered position, the amount is based on the higher of the salaries.)

The cost of the Basic insurance is shared by the employee and the government, except that the U.S. Postal Service pays the entire cost for its employees. The non-postal employee share is two-thirds of the cost and is withheld from salary at the rate of 15¢ biweekly or 32.5¢ monthly per $1,000 of Basic coverage.

The group policy provides two kinds of Basic insurance during employment: life insurance without a medical examination; and additional accidental death and dismemberment (AD&D) insurance. AD&D pays the full amount of Basic coverage for death or the loss of two or more bodily members (defined as a hand, a foot or the loss of sight in one eye) and half of the Basic coverage for the loss of one member. It is not payable under certain circumstances (see FEGLI Benefit Payments, below), does not include the extra benefit for those under age 45 as explained below, and is not available to retirees.


The amount of Basic life insurance available to each eligible employee under age 45 is increased at no additional cost to the employee. For employees age 35 or under, their Basic insurance coverage is multiplied by two. Beginning at age 36, the multiplication factor declines by 0.1 percentage points each year, until it reaches 1.0 (that is, no additional coverage) for employees age 45 and over.

If you meet the qualifications to continue FEGLI into retirement as described in Life Insurance in Retirement, below, the amount of your Basic insurance in retirement is your Basic insurance amount at the time you separated as an employee (note: there is no accidental death and dismemberment coverage in retirement). This amount continues until you reach age 65, after which it will reduce by an amount of your choice (if you retired before age 65; immediately if you retired at or after that age). See Retirees and Compensationers: Coverage and Premiums, below.

Option A—(Standard Optional Insurance)

Federal employees insured under Basic coverage have the option of purchasing an additional $10,000 of FEGLI life insurance. The employee pays the full cost of this “standard optional insurance” coverage. The premium depends on the employee’s age and is withheld from salary. For employees (but not retirees), selection of the Option A life insurance coverage also results in an equal amount of accidental death and dismemberment protection, as described above under Basic Life Insurance. Retirees who reach age 65 no longer have to pay premiums, but the $10,000 optional insurance starts to decline at this point at the rate of 2 percent for each full calendar month until it reaches $2,500.

Applicable rates are in the tables titled “Biweekly Premiums for Employees” and “Monthly Premiums for Annuitants.”

Option B—(Additional Optional Insurance)

Federal employees insured under Basic coverage may elect “additional optional insurance” in an amount equal to one, two, three, four, or five times their actual rate of annual basic pay, rounded to the next $1,000 (note: the applicable rate consists of pay treated as basic pay for purposes of retirement as described in High-3 Salary Base in Chapter 3, Section 4). The employee pays the full cost. The premium depends on the employee’s age and is withheld from salary. Accidental death and dismemberment coverage is not included in this coverage.

Retirees at age 65 no longer have to pay premiums for additional optional insurance, but the amount of their coverage starts to decrease at this point at the rate of 2 percent each month for 50 months, at which point coverage ceases. However, employees are given an opportunity at the time of retirement to elect to keep up to the full amount of the additional optional insurance in force and continue to pay premiums (note: retirees are given an opportunity to change this election before it takes effect, as described under Retirees and Compensationers: Coverage and Premiums, below). An election may be canceled at a later date. Applicable rates are in the tables titled “Biweekly Premiums for Employees” and “Monthly Premiums for Annuitants.”

Option C—(Family Optional Insurance)

Federal employees insured under Basic coverage may elect “family optional insurance” to cover eligible family members (the employee’s spouse and unmarried dependent children under age 22). Eligibility does not apply to domestic partnerships, civil unions or other arrangements not formally recognized as a marriage; eligibility for a common law spouse depends on the laws of the state of residence.

The coverage amount is equal to up to five multiples of $5,000 for a spouse and up to five multiples of $2,500 for each eligible child. The employee pays the full cost. The premium depends on the employee’s age and is withheld from salary. Accidental death and dismemberment coverage is not included in this coverage.

Retirees at age 65 no longer have to pay premiums for family optional insurance, but their coverage amount starts to decrease at this point at the rate of 2 percent each month for 50 months, at which point coverage ceases. However, employees are given an opportunity at the time of retirement to elect to keep up to the full amount of the family optional insurance in force and continue to pay premiums (note: retirees are given an opportunity to change this election shortly before it is to take effect, as described under Retirees and Compensationers: Coverage and Premiums, below). An election may be canceled at a later date.

Applicable rates are in the tables titled “Biweekly Premiums for Employees” and “Monthly Premiums for Annuitants.”

Adding Coverage

Active employees have three opportunities to add coverage: during an open season, after providing medical information proving insurability, or on experiencing a qualifying life event (see below for a limited exception). Retirees may not add to their coverage; see Life Insurance in Retirement, below. Those in phased retirement are treated as active employees; also see Phased Retirement in Chapter 3, Section 1.

Open Season—There is no set schedule for open seasons; they are rare and typically are linked to changes in the program’s provisions or premium rates.
The allowable elections are determined in each instance. The most recent was
in September 2016 when active employees could elect coverage or increase existing coverage. Changes elected at that time were effective as of the first pay period of October 2017. The open season did not count as a first opportunity to elect coverage for purposes of carrying new or increased coverage into retirement (see Life Insurance in Retirement, below). Therefore, the five-year enrollment requirement for that purpose applies, meaning that those who newly elected or increased coverage cannot carry it into retirement if they retire before October 2022 (however, the full amount could be converted to an individual policy, as described below).

The open season did not apply to retirees except those who were re-employed at the time and who could elect or increase FEGLI coverage through their employed status; the five-year requirement applied to them for keeping that coverage after their subsequent retirement, however. See Benefits Administration Letters 16-204 and -208 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Proof of Insurability—As long as at least one year has passed since the effective date of your last waiver of life insurance coverage, you may enroll in Basic, may further enroll in Option A and/or B, or increase existing coverage under Option B by providing satisfactory medical information at your own expense using the Request for Insurance (SF 2822), available only at www.opm.gov/forms. You and your agency must complete part of the form. Then you take the form to your physician or other medical professional. He or she will examine you, complete the rest of the form, and send the form to the Office of Federal Employees’ Group Life Insurance (OFEGLI). If OFEGLI approves your request, your elections will be effective immediately, so long as certain conditions are met, such as being in pay status. You cannot elect or increase Option C multiples by providing medical information.

Qualifying Life Event—Within 60 days of experiencing a qualifying life event, you may elect Basic insurance and any optional insurance, including up to the maximum number of multiples available under Option B and Option C. A qualifying life event means marriage, divorce, the death of your spouse, or the birth or adoption of a child. You must complete a Life Insurance Election Form (SF 2817), available at www.opm.gov/forms, and submit it to your human resources office.

Rules at 5 CFR 870 allow for making a qualifying life event election up to six months after the event if the employing agency determines that the employee was unable to make a timely election for reasons beyond his or her control.

Special Election Opportunity—Employees who are assigned in their civilian capacity in support of a contingency operation—as well as Defense Department employees designated as “emergency essential”—who had previously waived FEGLI Basic coverage may elect it within 60 days of the notification of that assignment or designation, under 5 U.S.C. 8714a(b) and 5 CFR 870.503. During that same period, such persons also may elect Option A or elect or increase Option B insurance up to the maximum; those choices do not apply to Option C coverage. No open season, qualifying life event or medical information is necessary. To make those changes, affected employees should file a new life insurance election in either paper or electronic form and mark “Election Due to NDAA” in the Remarks section. For policy provisions see Benefits Administration Letter 12-201 and for the designations of eligibility see BAL 16-201, both at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Policies for employees who enter active military duty are in Employment Rights of Those on Military Duty in Chapter 8, Section 8.

Salary Changes

The amount of your Basic and Option B insurance may change if your salary rate changes; the applicable rate consists of pay treated as basic pay for purposes of retirement as described in High-3 Salary Base in Chapter 3, Section 4. If your salary rate increases or decreases sufficiently to bring you above the amount to which your salary has been rounded for coverage purposes, the new amount of insurance will be effective on the date the salary rate change occurs. For premium withholding purposes, a salary rate change is deemed to occur: on the stated effective date of the change or the date such change is approved, whichever is later; or on the effective date of the change when a retroactive adjustment is actually the correction of an error, unless otherwise stipulated in a law providing for the change.

Note: If you elect a living benefit (see below), salary changes will have no effect on the amount of Basic.

Filing a FEGLI Claim

To receive payment of the death benefits, a FEGLI participant’s beneficiary or other survivor must submit a claim on the form provided—FE-6 for the death of participants, FE-6 DEP for claims for Option C coverage on family members—and furnish written proof of the covered individual’s death and of the claimant’s right to payment.

For active employees, the individual’s employing office can supply a claim form upon request and will submit the notification to the Office of Federal Employees’ Group Life Insurance (OFEGLI). For retirees, contact the Office of Personnel Management, Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045, phone (888) 767-6738 or TDD (800) 878-5707, www.opm.gov/forms. To receive payment of dismemberment benefits under AD&D coverage, file form FE-7, available from the same sources. An accident that results in loss of life, limb, or eyesight must be reported within 20 days after the incident occurs. Proof of the loss resulting from the accident must be submitted on the form provided not later than 90 days after the date of the loss. However, if it is not possible to furnish notice or proof in the time specified, the requirements will be met if such notice or proof is furnished as soon as reasonably possible. The Office of Federal Employees’ Group Life Insurance has the right to have a physician examine individuals during the period that they are claiming benefits for loss of limb or eyesight, as well as the right to require an autopsy in the event of a claim for accidental death benefits (unless the autopsy is forbidden by law).

All claims are settled by the Office of Federal Employees’ Group Life Insurance, P.O. Box 6080, Scranton, PA 18505-6080, phone (800) 633-4542, fax (570) 558-8659. For overnight deliveries only, the address is OFEGLI, 10 Ed Preate Dr., Moosic, PA 18507.

FEGLI Beneficiaries: Order of Precedence

When you die, if you did not assign ownership and there is no valid court order on file, the Office of Federal Employees’ Group Life Insurance (OFEGLI) will pay benefits:

• first, to the beneficiary(ies) you designated;

• second, if there is no such beneficiary, to a surviving spouse, as described in Option C—(Family Optional Insurance), above; 


• third, if none of the above, to your child or children, with the share of any deceased child distributed among descendants of that child (a court will usually have to appoint a guardian to receive payment for a minor child);

• fourth, if none of the above, to your parents in equal shares or the entire amount to your surviving parent;

• fifth, if none of the above, to the executor or administrator of your estate; and

• sixth, if none of the above, to your other next of kin as determined under the laws of the state where you lived.

You do not need to name a beneficiary if you are satisfied to have the death benefits of your insurance paid in that order of precedence. If you wish to make a designation, complete a Designation of Beneficiary (SF 2823), available from your personnel office or at www.opm.gov/forms, and submit it to your human resources office. Witnesses to the designation may not be named as beneficiaries.

Note: If a court has issued a decree of divorce, annulment, or legal separation that calls for the benefits to be paid to someone else, OFEGLI will pay benefits in accordance with that court order. The court decree must be received in the employing agency before the insured’s death. In the case of retirees, the same document must be received by OPM. The law also allows a court to direct the insured individual to make an irrevocable assignment of coverage other than Option C to the person(s) named in the court order (see Assignment of Benefits, below). However, the court documents do not themselves serve as an official assignment; the insured must still complete an Assignment of Insurance Form. If you assigned ownership of your life insurance, OFEGLI will pay benefits: first, to the beneficiary(ies) designated by your assignee(s), if any; and second, if there is no such beneficiary, to your assignee(s).

A designation of beneficiary is automatically canceled 31 days after you cease to be insured. If your insurance is continued or reinstated when you retire or while you are receiving federal workers’ compensation benefits, your designation of beneficiary is placed on file in the OPM and remains in effect. To be valid, your designation of beneficiary must be received by the employing office before your death. If you name more than one beneficiary, be sure to specify the exact share you wish each person to receive. If designated beneficiaries die before you do, their rights and interests in your insurance benefits end automatically. If any person otherwise entitled to payment as explained above fails to make a benefits claim within one year after your death, or if payment to such a person within that period is prohibited by federal statute or regulation, payment may be made in the order of precedence shown above as if that person died before you did.

FEGLI Benefit Payments

FEGLI benefits generally are payable if death or accidental injury occurs while an employee or retiree is insured and proper notice and proof are presented (typically, in accordance with the claims filing procedures outlined above). The two general types of benefit payments made under FEGLI are:


Death Benefits—The amount of your life insurance is payable in the event of your death while insured, no matter how caused.

Payment Under the Accidental Death and Dismemberment Insurance—Benefits under this type of insurance are payable if, while insured, you receive bodily injuries solely through violent, external, and accidental means (other than due to the exceptions noted below) and if as a direct result of the bodily injuries, independently of all other causes, and within 90 days afterwards you lose your life, limb, or eyesight.

The full amount of your accidental death and dismemberment insurance (equal to your Basic insurance amount, plus Option A coverage if you have it) is payable in the case of loss of life under such circumstances. One-half the amount of such insurance is payable to you for the loss of one limb or sight of one eye, or the full amount for two or more such losses.

For all such losses resulting from any one accident, no more than the full amount of accidental death and dismemberment insurance is payable. If a loss of a hand or foot or the sight of one eye occurs in a different accident after a previous loss of such member, the benefit payable for the subsequent loss is one-half the amount of accidental death and dismemberment insurance. The payment of benefits for any loss will not affect the amount of benefits payable for losses resulting from any subsequent accident.

Payment Procedures—Beneficiaries receiving $5,000 or more may choose between receiving a single payment or having the insurance provider establish an account of the amount of the benefit. Beneficiaries with accounts may make withdrawals of $250 or more, up to the full amount in the account, at any time. The account pays interest but is operated by the insurance provider and is not federally insured. Beneficiaries receiving less than $5,000 receive a single payment for the entire amount.

Exceptions—Payment for accidental death or dismemberment will not be made if your death or loss is caused or contributed to by:

• physical or mental illness;

• the diagnosis or treatment of a physical or mental illness;

• ptomaine or bacterial infection, unless the loss is caused by an accidentally sustained external wound;

• a war (declared or undeclared), any act of war, or any aggression by armed forces, against the United States, in which nuclear weapons are being used;

• a war (declared or undeclared), any act of war, armed aggression, or insurrection, in which the employee is, at the time bodily injuries are sustained, in actual combat;

• suicide or attempted suicide;

• intentional infliction of self-injury;

• self-administration of illegal or illegally obtained drugs;


• driving a vehicle while intoxicated, as defined by the laws of the jurisdiction in which you were operating the vehicle.


Assignment of Benefits

Any FEGLI-covered employee, retiree, or compensationer may irrevocably assign his/her life insurance benefits to another person or persons, including an individual, a corporation or a trust. Assignment means that you transfer ownership and control of your Basic, Option A, or Option B insurance (if you have these coverages) to the assignee(s). Thereafter, life insurance premiums will continue to be withheld from your salary, annuity, or compensation payment. You will not be able to cancel your life insurance coverage or cancel the assignment. Such an assignment voids all prior beneficiary designations and prohibits you from making any future designations. The assignee becomes the beneficiary (unless the assignee designates someone else). Family optional insurance may not be assigned. Assignments are generally made to comply with a court order upon divorce, for inheritance tax purposes, to obtain cash before death from a viatical settlement firm (for terminally ill individuals), or to satisfy a debt. If you assign your life insurance, you may not elect living benefits (see below).

If you are an employee and would like to request an assignment, use form RI 76-10, Assignment, Federal Employees’ Group Life Insurance, available from the sources in Filing a FEGLI Claim, above (online, select Retirement and Insurance Forms).

Living Benefits

Any FEGLI-covered employee, retiree, or compensationer who has been diagnosed as terminally ill with a life expectancy of nine months or less may elect a living benefit. Living benefits are life insurance benefits paid to individuals while they are still living, rather than paid to a beneficiary or survivor upon the individual’s death.

Only Basic insurance is available for living benefits. Employees may elect either all of their Basic benefit or a partial benefit in multiples of $1,000. Retirees and compensationers may elect only a full living benefit. With a full benefit, withholding of premiums for Basic insurance ceases; with a partial benefit, they are recalculated. (Note: Living benefits also may be elected by someone with power of attorney on behalf of an employee, retiree or compensationer.)

Living benefits can be elected only once and an election cannot be retracted. If a full living benefit is elected, no Basic life insurance will remain. If a partial living benefit is taken (an option only available to employees), the amount of the remaining Basic insurance will be frozen. It will not change, even if there is a subsequent change in salary. However, you may assign any remaining insurance.

If you believe you qualify for and wish to elect a living benefit, use form FE-8, Claim for Living Benefits, available by calling OFEGLI at (800) 633-4542 (the form is not available through agencies or online). That office will send you the form and a calculation sheet, so you can determine the amount of Basic insurance available to you. This will take into account the age multiplication factor for employees under age 45 and the post-65 reduction for annuitants age 65 and over. The benefits received will be reduced by an amount representing interest lost to the life insurance fund because of the early payment of benefits.

If OFEGLI approves your request for a living benefit, you will receive a check, along with an explanation of benefits. You can change your mind about electing a living benefit up until you cash or deposit the check. If you decide not to go through with the living benefit, you should write “Void” on the check and return it to OFEGLI. If a living benefit payment is not cashed before your death, your representative must return the check to OFEGLI. Your beneficiaries may then file a claim for death benefits.

If OFEGLI does not approve your request for a living benefit, there are no appeal rights. However, you may furnish additional medical evidence to support your claim or may reapply if future circumstance warrant.

Discontinuing FEGLI Coverage

Unless you’ve assigned it to someone else, you may discontinue your Basic or Optional insurance coverage at any time by providing a written waiver of insurance coverage to your employing office (or to the OPM in the case of a retiree) by filing a Life Insurance Election form (SF 2817) available from the sources listed in Filing a FEGLI Claim, above. However, there are situations in which your insurance can be discontinued without your consent.

1. Separation from service other than for retirement.

2. After 12 months of non-pay status.

3. Any other employment change that results in your ceasing to be a FEGLI-eligible employee, such as a move to a position excluded from eligibility.

4. Termination of your annuity.

5. At the end of the pay period in which it is determined that your pay, after certain mandatory deductions, is insufficient to cover the required withholding for your insurance. However, you may arrange to continue your insurance coverage by making payments directly to your agency or retirement system. Note: Optional insurance stops when Basic insurance stops.

Converting to an Individual Policy

If your coverage stops except by waiver or cancellation, your coverage automatically continues for an additional 31 days after the termination date. No premiums or government contributions are required during the 31-day extension. This extension does not include accidental death and dismemberment insurance. You have the right to convert your FEGLI coverage under Basic and Options A and B to an individual life insurance policy without medical evidence of insurability.

Generally, only the insured individual has the right to convert coverage when insurance terminates, with exceptions for assignments and designations of powers of attorney. In addition, a family member may convert Option C coverage. Information on how you can convert your insurance is found in the Notice of Conversion Privilege (SF 2819), available from personnel offices and at www.opm.gov/forms. OFEGLI must receive the request for conversion information within 31 calendar days of the date on the conversion notice, or within 60 calendar days after the date of the event, whichever is earlier.
Any insurance policy purchased under the conversion privilege is a private business transaction between you and the insurance company. There will be no government contribution. You will make your payments directly to the insurance company. Premiums will be retroactive to the end of the 31-day extension. The amount of those premiums will depend on four factors:

• the amount of insurance you apply for;

• the type of policy you apply for;

• your age; and

• the class of risk you fall into on the day following the termination of group coverage.

Premiums may well be higher than the group rates available under FEGLI, but no physical exam is required to convert.

If you decide to convert your FEGLI coverage to an individual policy, the following conditions apply:

• The individual policy will be issued by any eligible insurance company you select that has agreed to issue such policies under the provisions of the group policy.

• The individual policy may be in any form customarily issued by the insurance company you select, with the exception of term insurance, universal life insurance, or any other type of life insurance that has an indeterminate premium. It does not include disability or accidental death or dismemberment benefits.

• You may choose to have this individual policy written for an amount equal to or less than the total amount of life insurance you have under the group policy, including all options on the date your insurance stops.

You (or your assignee, if pertinent) must submit the request for conversion information to OFEGLI. OFEGLI must receive the request for conversion within 31 calendar days of the date on the conversion notification from the employing agency (60 days if overseas) or within 60 calendar days after the date of the terminating event (90 days if overseas), whichever is earlier.

For Option C, you can request to have individual policy information for a family member or members (such as children). However, the individual policy is issued to the family member. In the case of a minor child, the parent can apply on the child’s behalf for an individual policy. You can only obtain a conversion policy for family members who exist on the effective date of the conversion policy 32 days after separation.

Family members must submit a request for conversion information to OFEGLI. OFEGLI must receive the request for conversion within 31 calendar days of the date on the conversion notification the employee receives from his or her employing agency (60 days if overseas) or within 60 calendar days after the date of the terminating event (90 days if overseas), whichever is earlier. There is no extension to these time limits. Family members are considered to have refused coverage if they do not request conversion within these time limits.

For both regular mail and overnight deliveries, conversion requests should be sent to: Office of Federal Employees’ Group Life Insurance, 200 Park Ave., New York, NY 10166-0188.

Life Insurance and Workers’ Compensation

If you become entitled to benefits from the Office of Workers' Compensation Programs (OWCP) for a job-related illness or injury that prevents you from working, you may continue your FEGLI coverage as an employee, including accidental death and dismemberment (AD&D) coverage for up to 12 months of non-pay status. Premiums will be withheld from your compensation.

After this 12-month period, your FEGLI coverage may be continued (but without the AD&D) if you are in receipt of benefits from OWCP and are unable to return to duty and have been insured for: (1) the coverages you wish to continue for the five years of service immediately preceding the date of your entitlement to OWCP benefits or (2) the full period of service during which the coverages were available to you (if less than five years).

You must continue Basic life insurance to continue any Optional insurance you might have. Also, the number of multiples of pay you may continue under Optional B and C insurance is limited to the highest number of multiples you had that meet the above requirements.

At the end of 12 months of non-pay status (or at separation, if earlier), you will have the opportunity to convert all or a portion of your FEGLI insurance coverage to an individual (direct-pay) policy. If eligible to continue coverage and you do not convert, premium withholdings will be made from your compensation payment. For the purposes of the FEGLI program, a compensationer is treated as an annuitant.

If compensationers return to federal employment under conditions that allow them to continue receiving compensation, Basic, Option A and Option C insurance held as a compensationer, they are treated as re-employed annuitants. See Life Insurance in Chapter 4, Section 4 and 5 CFR 870.

Life Insurance in Retirement

If you are retiring on an immediate annuity, you may retain your Basic insurance (but not the accidental death and dismemberment coverage) if you have been covered by FEGLI’s Basic life insurance for the five years of service immediately preceding the starting date of your annuity or the full period or periods of service during which the Basic life insurance was available to you, if less than five years. You also may retain all three forms of Optional insurance (but not accidental death or dismemberment coverage) if you are eligible to keep your Basic insurance and you have had that form of Optional insurance in force under those same restrictions. (Note: See Phased Retirement in Chapter 3, Section 1 for policies applying to those in phased retirement.)

The amount of your life insurance will be the amount you had at retirement, until the end of the calendar month that follows your 65th birthday or retirement, whichever is later. It then may begin to reduce in value (as explained below under Retirees and Compensationers: Coverage and Premiums.) An annuitant may elect either full reduction or no reduction for each separate multiple of Option B and Option C. For example, a person with five multiples may elect no reduction on two multiples, while the three remaining multiples reduce fully. Premiums will be set accordingly (see the Monthly Premiums for Annuitants table).

The above conditions also hold true if at the time your Basic life insurance would otherwise stop or OPM determines that you are retiring on an immediate annuity and you did not exercise your right to convert to an individual policy as described above.

The elections regarding Options B and C are made at retirement, with a chance to change them shortly before they would take effect, as described under Retirees and Compensationers: Coverage and Premiums, below.

Canceling Insurance—Unless you have assigned your insurance, you may cancel it at any time. If you cancel your Basic life insurance, you are canceling all your optional insurance as well. If you elected 50 percent reduction or no reduction for your Basic life insurance, you may cancel this additional coverage at any time. You may cancel Option A at any time; it cannot be merely reduced. You may cancel or reduce the amount of your Option B and Option C insurance at any time. To do so, write to Office of Personnel Management, Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045. Provide your civil service retirement claim number (CSA number) and specify what action you want taken. Generally, the reduction or cancellation is effective at the end of the month in which OPM receives your written request. You will not receive a refund of any premiums paid through that month.

Termination of Insurance—FEGLI coverage will terminate if your entitlement to annuity benefits ends. For example, if you are a disability retiree under age 60 and you are found recovered or restored to earning capacity, your disability annuity and life insurance coverage will end. You do not have the 31-day extension of coverage and may not convert the life insurance to an individual policy. If you are a disability retiree whose annuity terminated in that situation, you will retain your life insurance coverage if you are entitled to and apply for an immediate discontinued service annuity.

If you are under age 60 and your disability annuity is reinstated due to loss of earning capacity or a recurrence of the disability for which you retired, you will be given an opportunity to have your life insurance coverage reinstated. Only coverage of the type and up to the amount you had in effect at the time your disability annuity was terminated can be reinstated. If you are entitled only to a deferred annuity after your disability annuity terminates, you cannot retain your life insurance coverage as a retiree, and you cannot convert it to an individual policy.

Retirees and Compensationers: Coverage and Premiums

Federal retirees and workers’ compensation recipients have the following options regarding FEGLI coverage and premiums.

Basic Insurance—Prior to retiring or receiving compensation, you must make a written election as to the amount of post-65 Basic life insurance coverage you want to retain. You can obtain this election form, Continuation of Life Insurance Coverage as an Annuitant or Compensationer (SF 2818) from your employing office or at www.opm.gov/forms. Unless you have elected a partial living benefit, you have three choices: a 75 percent reduction, a 50 percent reduction or no reduction. If you elect a partial living benefit, you have only two choices: termination of the insurance and conversion to an individual policy, or no reduction. The percentage reduction choices operate as follows:

• 75 Percent Reduction—Coverage is reduced by 2 percent a month beginning at age 65, with an ultimate reduction to 25 percent of the basic policy value. The premium is $.325 per month per $1,000 of coverage until the calendar month in which the retiree becomes 65, at which point the coverage is free.

• 50 Percent Reduction—Beginning at age 65, coverage is reduced by 1 percent a month until it reaches 50 percent of the basic policy value. The premium is $1.035 per month per $1,000 of coverage until age 65 and $.71 a month per $1,000 of coverage thereafter.

• No Reduction—The basic policy value remains unchanged at a premium cost of $2.455 per month per $1,000 of coverage until age 65 and $2.13 per month per $1,000 of coverage thereafter.

Unless you elected a partial living benefit, failure to make a written choice will result in OPM concluding that you have elected the 75 percent reduction.

Generally, all premiums will be withheld from your annuity or compensation payments. However, you may pay the premiums directly to the retirement system, if your annuity is insufficient to withhold the premiums.

If you have not assigned your insurance and decide to cancel your increased post-retirement coverage under the second or third options above, the amount of your Basic insurance coverage and the premiums would immediately drop to the level they would have been if you had originally elected the 75 percent reduction. You must elect No Reduction if you previously elected a partial living benefit, and your election may not be changed at a later date.

Optional Insurance—The face value of any optional life insurance will be the same as the amount carried at retirement (or if a compensationer, the date your insurance would otherwise have terminated, as explained above). You must pay the full amount for any optional insurance coverage you retain until you reach age 65. However, you may elect to keep up to the full amount of the Option B and C insurance in force and continue to pay the pertinent premiums. Unless the insurance has been assigned, such an election may be canceled at a later date. Generally, the cost of optional insurance premiums will be withheld from your annuity or compensation payments.

At the end of the calendar month that follows your 65th birthday or your retirement, whichever is later, your Option A life insurance will be reduced by 2 percent each month until it reaches 25 percent of its face value. Option B and Option C insurance will continue to be reduced for 50 months, at which time coverage ceases, unless you elected to continue paying the premiums. Those retiring before age 65 are given a second chance on turning that age to make their election under Options B and C; for those retiring at or after that age, the second chance comes as soon as the retirement processing period is completed,

Direct Payment of Premiums

Employees who have insufficient pay on an ongoing basis to cover their insurance premiums may pay those premiums directly. Insufficient pay on an ongoing basis means that the employing agency expects that during the next six months or more, an employee’s regular pay, after all other deductions, will not be enough to cover the required withholdings.

The direct pay provision does not apply to employees in a non-pay status. Those employees are entitled to continue their FEGLI coverage for free for up to 12 months (unless they are receiving workers’ compensation benefits, in which case the coverage is not free). In general, at the end of 12 months in a non-pay status, FEGLI terminates. Note: Military reservists called to active duty may elect to continue FEGLI coverage after their initial 12 month free period while in non-pay status. Reservists can continue coverage for an additional 12 months but must pay the full cost.

Annuitants and compensationers whose payments are not large enough to cover their insurance premiums similarly may pay those premiums directly to the retirement system.

For More Information

Although OPM has overall responsibility for administering the FEGLI program, each federal agency is responsible for day-to-day operations of the program with respect to its own employees. Therefore, questions about life insurance policies should be addressed to the local personnel office or the agency insurance benefits officer at agency headquarters.

The FEGLI Program Handbook and additional information is at www.opm.gov/
healthcare-insurance/life-insurance
.

Section 3
Federal Long-Term Care Insurance Program

The Federal Long-Term Care Insurance Program covers services that individuals may need because they are unable to care for themselves due to a chronic mental or physical condition. Included are services such as nursing home care, home health care, assisted living facilities, adult day care and personal/homemaker care. The coverage is provided by LTC Partners, LLC, and underwritten by the John Hancock Life & Health Insurance Company under contract with the Office of Personnel Management.

Coverage is voluntary and enrollees pay the entire cost of the premiums; there is no government contribution.

The FLTCIP is “guaranteed renewable”—as long as you pay your premiums, it cannot be changed because you have aged, due to personal health changes or for any other reason related solely to you (except if you request and are approved for a higher level of benefits as described in Benefit Choices, below). However, premiums may increase, with OPM’s consent, for those within a group of enrollees whose premiums are determined to be inadequate to cover projected costs of benefits. See Changes in Benefits and Premiums, below.

Eligible persons may apply to enroll at any time, subject to underwriting. Full underwriting applies to all but newly hired or newly eligible employees and spouses except during an open season, when abbreviated underwriting applies to all employees and spouses. See Underwriting, below. The FLTCIP has had only two open seasons, however, one at the program’s introduction in 2002 and one in 2011. The “enrollee decision period” held in mid-2016 was not an open season because it allowed only changes in benefit elections by persons already enrolled.

Eligibility

Individuals eligible to apply for this insurance coverage are:

• Federal employees, including employees of the U.S. Postal Service and Tennessee Valley Authority. In general, an employee in a position eligible for Federal Employees Health Benefits program coverage is eligible for FLTCIP (whether enrolled in FEHB or notthe key is eligibility). TVA employees are eligible for FLTCIP even though they may not be eligible for FEHB.

• Federal annuitants, surviving spouses of deceased federal or postal employees or annuitants who are receiving a federal survivor annuity, individuals separated from the federal service who are eligible for a deferred annuity, individuals separated from the federal service who are receiving compensation from the Department of Labor.

• Members of the uniformed services who are on active duty or full-time National Guard duty for more than 30 days, active members of the Selected Reserve (but not members of the Individual Ready Reserve), former members of the uniformed services and retired military reservists who are entitled to retired or retainer pay, regardless of whether they are currently receiving military retired pay.

• Current spouses of employees, annuitants and survivor annuitants, and spouses in common law marriages recognized by the state of residence.

Domestic partners (both same-sex and opposite-sex) of federal and postal employees and annuitants and active and retired members of the uniformed services (see below).

• Adult children (at least 18 years old, including natural children, adopted children and stepchildren but not foster children) of living employees, annuitants and survivor annuitants.

• Parents, parents-in-law, and stepparents of living employees and their spouses (but not of domestic partners or annuitants).

There is no upper age limit for who can apply for this insurance but there is a minimum age; you must be at least 18 years old at the time you submit your application.

Domestic Partners—Under 5 CFR 875, domestic partners of FLTCIP-eligible federal and U.S. Postal Service employees and annuitants are eligible to enroll if they meet standards that define “domestic partner” for this purpose as a committed relationship between two adults, of either the opposite or the same sex, in which the partners:

• are each other’s sole domestic partner and intend to remain so indefinitely;

• have a common residence, and intend to continue the arrangement indefinitely;

• are at least 18 years of age;

• share responsibility for a significant measure of each other’s financial obligations (including where one is the sole earner);

• are not married to anyone else;

• are not a domestic partner of anyone else; and

• are not related in a way that would prohibit legal marriage in the jurisdiction in which they resided when the partnership was formed.

A Declaration of Domestic Partnership form is at www.ltcfeds.com/epAssets/documents/Declaration_of_SSDP.pdf. Use of the form is not mandatory but is recommended since any substitute would have to include the same information required on the form. An employee or his or her partner must file their declaration with the employee’s agency and it will be kept in the employee’s official personnel folder or equivalent. Annuitants or their partners must file their declaration with their retirement system, typically through OPM. Both must certify they understand that willful falsification of information within the documentation may lead to disciplinary action, loss of insurance coverage and/or the recovery of the cost of benefits received related to any falsification. The employee or annuitant must be eligible for FLTCIP coverage, although need not be enrolled, for a partner to apply. Partners undergo the same underwriting as other eligible applicants and similarly are not guaranteed coverage. Dissolution of a partnership must be disclosed to the employing agency or to OPM but does not affect coverage already in place. Also see Benefits Administration Letter 15-901 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Enrollment

Eligible individuals may apply at any time.

Newly hired employees and their spouses have 60 days to apply and use abbreviated underwriting. Afterward, they must undergo full underwriting.

If you are an active employee eligible for the program and have newly married, your spouse is eligible to apply within 60 days and be subject only to abbreviated underwriting. You, however, are not eligible for abbreviated underwriting because of your marriage; full underwriting will be required for you if you choose to apply. After 60 days, your spouse may apply for coverage but will be subject to full underwriting. Your new qualified relatives (such as parents-in-law) may apply for coverage with full underwriting at any time following the marriage.

Application forms are available through personnel offices, by calling (800) 582-3337, TTY (800) 843-3557, and at www.ltcfeds.com/apply; online application also is available at that site.

Underwriting

Abbreviated underwriting applies to newly hired employees and their spouses within the first 60 days of the hiring or to a spouse newly married afterward, as described above. The abbreviated underwriting application has seven health-related questions designed to determine who may be immediately eligible for benefits or eligible for benefits within a short time. Newly eligible spouses must answer two additional questions regarding their mobility and any need for help with everyday tasks. All other applicants are subject to full underwriting at all times (other than during one of the rare open seasons, when abbreviated underwriting applies to all employees and spouses). This means that they must answer numerous health-related and lifestyle-related questions in addition to the questions asked in abbreviated underwriting. (Note: Domestic partners and adult children of domestic partners are eligible as “qualified relatives” and therefore must complete a full underwriting application.)

Changes in Benefits and Premiums

The original seven-year contract in the FLTCIP program expired April 30, 2009. At its expiration, OPM awarded a new seven-year contract to the original benefit provider, LTC Partners LLC, although only one of the original two underwriting insurance companies, John Hancock, chose to continue.

The second contract provided for several changes in benefits effective October 1, 2009. Terms of the original contract remained available for new enrollments up to that point, with the new provisions effective for those enrolling afterward. Because of benefit enhancements in certain areas (such as home health care reimbursements and coverage for informal care provided by family members under certain conditions), premiums overall were slightly higher for coverage elected under the second contract than under the original contract for an equivalent package of benefit options and age at purchase.

In addition, under the second contract, premiums increased as of March 2010 for most enrollees on grounds that trends and claims experience indicated that the prior premiums would not be sufficient to meet the future projected costs of the benefits. The increases affected those with automatic compound inflation protection elected before the enrollee turned age 70, regardless of whether the enrollment was under the original or the second contract.

Those enrolling after October 1, 2009, may not elect several options that were available under the original design, including a choice of facilities-only coverage and an option for a 30-day waiting period. Those who enrolled before that date were given an opportunity to continue, reduce or cancel their coverage, or elect from the new benefit options with no underwriting required unless they chose to increase the value of their benefits.

Rates increased for those enrolling after July 31, 2015, again on grounds that existing premiums would not cover projected costs. Those increases applied to all options but did not affect those already enrolled as of that date.

Upon the expiration of the second contract, OPM entered a third seven-year contract with the same provider effective May 1, 2016, with premium increases, for the same reason, effective November 1, 2016 for most enrollees. Not affected were those enrolled in the Alternative Insurance Plan (see below); those who had enrolled at or after age 80; or anyone enrolling after July 31, 2015.

An “enrollee decision period” was held in July through September 2016 giving those affected by the increases the choice of: accepting a reduction in benefits to fully offset the premium increase; accepting roughly half the premium increase along with a lesser reduction in benefits; accepting the full premium increase while retaining existing benefits; or, if eligible, stopping premiums and keeping paid-up coverage with reduced benefits (see Benefit Choices, below). No underwriting was required for those choices. Affected enrollees also could revise their benefit selections in other ways, subject to full underwriting for increases in coverage. For those who made no election by the deadline, existing coverage continued subject to the higher premium rates.

Benefit Choices

Enrollees can choose a maximum benefit, the length of the policy, and the type and level of inflation protection. Those factors, plus the age at application, affect premium levels. A calculator for determining premiums is at www.ltcfeds.com under Planning Tools. That site also has information on the average costs of care by location.

Note: As explained above, those who were enrolled before October 2009 could retain certain options elected under the original contract that have not been available for those enrolling since that time.

Benefit Amount—Your maximum daily benefit can range from $100 to $450 a day in $50 increments. (Under the original contract, benefits ranged from $50 to $300 a day in $25 increments, and weekly benefits were allowed.)

Length of Policy—The length of your policy can be two years, three years, five years, or lifetime coverage. (Under the original contract, no two-year option was available). For other than lifetime coverage, the period and the maximum benefit create a pool of money. The insurance will pay benefits until your pool of money is exhausted, a process that may be shorter or longer than the length of the policy depending on your actual expenses. A lifetime benefit has a limitless pool of money.

Inflation Protection—Two inflation-protection features are available.

Under automatic compound inflation protection, you choose to have your benefit increase by either 4 percent or 5 percent every year, compounded annually. The increases are effective at the anniversary of the effective date of that coverage, regardless of actual inflation. (Under the original contract, only a 5 percent level was available).

Under the future purchase option, every two years you have the option to increase your benefits based on a medical inflation index. Your premiums increase as your benefit increases; they further are based on the age you are at the time of election, not the age at which you first took out the policy. You can switch from the future purchase option to the automatic compound inflation-protection option without proof of good health at the time of a notification if you have not declined more than two notifications in the past and are not eligible for benefits at that time. Premiums for those who make this change will be based on their age at that time and premiums already paid in, not on the rates for new enrollees. If you decline more than two offers, you still can apply for future inflation increases but would have to show satisfactory evidence of insurability.


Waiting Period—The waiting period—also called an elimination period or deductible—is the number of days of covered care that you (or other insurance coverage you may have) must pay for before the insurance begins to pay. The period is 90 calendar days, with no incurred expenses required. Days need not be consecutive or related to the same condition. (Under the original contract, a 30-day waiting period was available, and waiting periods for coverage elected then and retained are measured in days during which you are eligible for benefits and receiving covered services.)

Home Health Care—Home health care is reimbursable at up to 100 percent of the daily benefit amount (75 percent for coverage elected under the original contract and retained).

Informal Care—Under the comprehensive plan, informal care provided by family members who do not normally live with the insured at the time of claim is covered up to 500 days at 75 percent of the elected daily benefit amount (for coverage elected under the original contract and retained, only 365 days of coverage is available).

Bed Reservations—Charges incurred for bed reservations are reimbursed at 100 percent of the daily benefit amount for up to 60 days (up to 30 days for coverage elected under the original contract and retained).

Catastrophic Coverage—For coverage elected under the original contract and retained, benefits may be reduced if a war (declared or undeclared), act of war, or act of terrorism is determined to be a catastrophic event. Coverage elected under the later contracts has no catastrophic event provision.

Changing Coverage Levels—You can request a decrease in your coverage at any time to anything currently available under the program, and your premiums (which will be based on your age at time of original enrollment) will also decrease. For example, if you have the five-year benefit period, you can decrease to a three-year benefit period. You do not have to undergo new underwriting in order to decrease your coverage. However, you don’t get paid-up benefits.

At any time, you also may request an increase in your coverage by contacting LTC Partners. To receive approval of a request for an increase outside an open season, you must provide, at your expense, evidence of your good health that is satisfactory to LTC Partners. The amount of an increase is subject to what is then available under the program. If you request and LTC Partners approves an increase in your daily benefit amount (not counting any increase due to inflation protection), your additional premium will be based on your age and the premium rates in effect at the time the increase takes effect. Other coverage increases you request that LTC Partners approves will cause your entire premium to be based on your age and the premium rates in effect at the time the increase takes effect.

The Coverage Change Application is available through personnel offices and at www.ltcfeds.com/apply.

Canceling Coverage—You may cancel your coverage at any time. If you cancel during the initial “free look” period, your premiums will be refunded to you. If you cancel your coverage at any other time, cancellation will take effect on your requested cancellation date or at the end of the period covered by your last premium payment, whichever occurs first. You will not receive any refund of premiums paid, other than any premiums paid in advance for the period following the effective date of your cancellation of coverage, and you will not have to pay any more premiums unless you owed retroactive premiums.

The FLTCIP program doesn’t provide paid-up benefits for those who cancel coverage. However, a paid-up benefit feature can apply if the insurer increases a premium by more than a fixed percentage above the premium on initial purchase. The percentage varies according to the enrollee’s age at enrollment and the applicable percentages are at www.ltcfeds.comsearch for “contingent benefit upon lapse.” In such a case the enrollee can stop paying premiums and the coverage will be converted into a paid-up policy with a maximum lifetime benefit that is the larger of: the total amount of premiums the enrollee has paid; or 30 times the daily benefit amount. This option was available to most enrollees affected by the 2016 increase in premiums as described in Changes in Benefits and Premiums, above.

Coverage Termination—Your coverage will terminate on the earliest of the following dates:

• the date you specify to the carrier that you wish your coverage to end;

• the date of your death;

• the end of the period covered by your last premium payment if you do not pay the required premiums when due, after a grace period of 30 days; or

• the date you have exhausted your maximum lifetime benefit, if applicable. (However, in this event, care coordination services will continue.)

Reinstating Coverage—Under certain circumstances, your coverage can be reinstated. The carrier will reinstate your coverage if it receives proof satisfactory to it, within six months from the termination date, that you suffered from a cognitive impairment or loss of functional capacity before the grace period ended that caused you to miss making premium payments. In that event, you will not be required to submit to underwriting. Your coverage will be reinstated retroactively to the termination date but you must pay back premiums for that period. The premium will be the same as it was prior to termination.

If your coverage has terminated because you did not pay premiums or because you requested cancellation, the carrier may reinstate your coverage within 12 months from the termination date at your request. You will be required to reapply based on full underwriting, and the carrier will determine whether you are still insurable. If you are insurable, your coverage will be reinstated retroactively to the termination date and you must pay back premiums for that period. The premium will be the same as it was prior to termination.

Premiums

Premiums are based on your age when you buy the coverage, the benefit amount, the length of the policy, the type of inflation protection chosen, and, for coverage elected under the original contract and retained, the length of the waiting period and the choice of facilities-only versus comprehensive coverage.

Premiums cannot be increased on an individual basis but can be increased, with Office of Personnel Management approval, for a group whose premiums are determined to be inadequate to cover expected future claims. See Changes in Benefits and Premiums, above. Enrollees pay the entire premium cost; there is no government contribution. A premium calculator is at www.ltcfeds.com under Planning Tools.

Note: FLTCIP premiums, including premiums for the Alternative Plan or the Service Package, cannot be paid with pretax money from a flexible spending account, although certain expenses not reimbursed by the FLTCIP related to long-term care are reimbursable from an FSA. Long-term care insurance premiums and certain long-term care costs are payable from a health savings account that is part of a high-deductible health plan (see FEHB Plan Options in Section 1 of this chapter).

Tax Break for Some Retirees—Section 845 of the Pension Protection Act of 2006 allows pretax payment of FLTCIP premiums (among certain other forms of insurance) for retired “public safety officers.” OPM in Benefits Administration Letter 07-201 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters, determined that the Civil Service Retirement System and the Federal Employees Retirement System are eligible retirement plans under the act and that retired public safety officers are deemed to have made an FLTCIP premium conversion election for this purpose.

As a result, retired public safety officers whose CSRS or FERS annuity payments include a direct premium payment to the FLTCIP carrier may self-identify eligibility for, and self-report, a tax exclusion to the Internal Revenue Service. To qualify, the distribution must be paid directly from the retirement system to the insurance provider. Premiums of up to $3,000 for coverage of the enrollee, spouse or dependents can be excluded, but only for amounts that otherwise would be included in taxable income, and the amount excluded cannot be used to claim a medical expense deduction.

IRS Publication 721, Tax Guide to U.S. Civil Service Retirement Benefits, defines public safety officers as including law enforcement officers, including those of the Capitol Police and Supreme Court Police, firefighters, Customs and Border Protection officers, air traffic controllers, nuclear materials couriers, and diplomatic special security agents of the State Department. That publication, at www.irs.gov/pub/irs-pdf/p721.pdf, also contains additional information on this tax advantage. Consult a tax adviser for guidance.

Transferring or Retiring—If you are paying FLTCIP premiums via payroll deduction and transfer to a new agency, contact LTC Partners as soon as you know where and when you will be transferring in order to arrange payroll deductions there. Depending on the timing of the premiums and the payroll cycles, a payment might be missed; in this case LTC Partners will send a bill directly to you. Payroll deductions cannot be adjusted to catch up for missed payments.

If you do not let LTC Partners know about the transfer, it will continue to request deductions from the previous payroll location until three deductions have been missed. At that point, you will be taken off payroll deduction and switched to direct billing of premiums. If premiums are not paid on a timely basis, it will cancel the coverage. Note: When there is a mass transfer that the servicing payroll location has communicated to LTC Partners, individuals do not need to report the transfer.

Similarly, if you are retiring, deductions will not transfer automatically from payroll deductions to annuity deductions; you must contact LTC Partners to make the needed arrangements. Also, deductions cannot be taken from “interim” payments received until an annuity is finalized. During this period (which may last a number of months after retirement until full benefits begin), you will be billed directly for premiums due. Annuity deductions cannot be adjusted to catch up for missed payments.

If you are paying FLTCIP deductions through direct billing or through automatic bank withdrawal, you do not need to contact LTC Partners if you transfer agencies, retire, or leave the government, unless a change affecting those payment arrangements is involved.

Leave Without Pay—If you go on extended leave without pay (including due to furlough; see Furloughs in Chapter 9, Section 1), you may change from payroll deduction to direct billing or to payment via electronic funds transfer. If LTC Partners does not receive premium for one or two pay periods, it will adjust future premium deductions, increasing by no more than $50 per pay period to recover the missed premiums. Three consecutive pay periods of missed premiums will result in a direct billing. If premiums are not collected or a final bill is not paid within a 30-day grace period, it will send a termination letter. You would have 35 days from the date of the letter to pay the premium; otherwise you will be disenrolled retroactively to the last pay period in which the premium was paid.

Military Duty—If you are called to active military duty, you can keep FLTCIP coverage but must keep your premium payments current; you cannot incur a debt for the premiums during the time in a non-pay status. If you will be deployed overseas, it may not be feasible for you to receive and pay direct bills on a timely basis, which risks cancellation of coverage. If you have payroll deduction of premiums, you can have premiums deducted from active duty pay by contacting LTC Partners. If you currently pay premiums through automatic bank withdrawal or direct bill, you will need to complete a billing change form to get premiums deducted from your military pay.

Alternative Insurance Plan/Service Package

Some applicants who are not approved to enroll in the insurance they originally applied for will be offered an Alternative Insurance Plan. It offers nursing home only coverage with a 180 day waiting period and two-year benefit period. The Alternative Insurance Plan also has higher premiums. This plan is not available to those who use the full underwriting application. If you apply for and are denied the standard insurance and are not offered the Alternative Insurance Plan, you will be offered a Service Package. This is true for everyone who applies—those using the abbreviated underwriting application and those using the full underwriting application. The Service Package is not insurance. It provides access to a care coordinator, general information and referral services, and access to a discounted network of long-term care providers and services. It costs $59 per year for an individual or a couple.

Individuals who are offered both can decide which, if either, they wish to purchase.

Types of Care Covered

Comprehensive coverage under the FLTCIP includes:

• nursing home care, assisted living facility care, and hospice care at up to 100 percent of the chosen daily benefit amount;


• respite care (temporary care if your normal caregiver needs time off) at up to 100 percent of the chosen daily benefit amount (limited to 30 times your daily benefit amount per calendar year, but the waiting period does not apply);

• bed reservations at up to 100 percent of the chosen daily benefit amount (limited to 60 days per calendar year);

• home care, adult day care, formal caregiver services, and hospice care at up to 100 percent of the chosen daily benefit amount (the waiting period does not apply to hospice care);

• informal caregiver services by people who didn’t normally live in the enrollee’s home at the time the enrollee became eligible for benefits (benefits for care provided by family members are limited to 500 days lifetime); and

• a stay-at-home benefit covering services such as care planning visits, home modifications, emergency medical response systems, durable medical equipment, caregiver training, and home safety checks (limited to 30 times the daily benefit amount, but the waiting period does not apply).

Note: Those electing coverage under the original contract had the option for a facilities-only coverage plan; also, different coverage levels applied to some benefits under that contract. See Benefit Choices, above.

The FLTCIP does not cover:

• illnesses, treatments, or medical conditions arising out of participation in a felony, riot, or insurrection; from an attempted suicide while sane or insane; or from self-inflicted injuries;

• care or treatment for alcoholism or drug addiction;

• care or treatment provided in a government facility unless required by law;

• care received in a hospital except in designated nursing home or hospice units;

• any service or supply reimbursable under Medicare;


• services or supplies for which you are not obligated to pay in the absence of insurance; or

• services provided by any person who normally lives in your home at the time you become eligible for benefits.

Benefit Eligibility Determination and Appeals

You are eligible for benefits if, after your coverage becomes effective:

• a licensed health care practitioner has certified within the last 12 months that you are unable to perform, without substantial assistance from another person, at least two activities of daily living for an expected period of at least 90 days due to a loss of functional capacity; or you require substantial supervision due to your severe cognitive impairment;

• LTC Partners agrees with that certification; and 


• LTC Partners approves a written plan of care established for you by a licensed health care practitioner or its care coordinator.

Activities of daily living include eating, toileting, transferring (as from bed to chair), bathing, dressing, and bowel and bladder control. A cognitive impairment is impairment in short-term or long-term memory, orientation as to person, place and time, or deductive or abstract reasoning such that the person needs substantial supervision by another person to prevent him from harming himself or others.

In general, benefits will not be paid for care received in a government facility, such as a Department of Defense or Department of Veterans Affairs medical center. The “catastrophic coverage” limitation under policies elected under the original contract and retained might affect benefits paid in the event of war.

You will not have to pay premiums after you have met a condition for eligibility and you use the care coordination program during the waiting period you select. If you do not use the care coordination program, you will pay premiums during your waiting period, but will stop paying them after you satisfy your waiting period.

To apply for benefits, call (800) 582-3337, TTY (800) 843-3557; a representative will provide information about the procedures and the needed documentation. Also see www.ltcfeds.com/claims/claims_filing_claim.html.

After you apply, LTC Partners may contact you, your physician or other persons familiar with your condition, may access medical records and may have you examined by a licensed health care professional and/or conduct an on-site assessment.

LTC Partners will send you written notice of its decision on whether you are eligible for benefits no later than 10 business days after it receives all the information it needs. If LTC Partners determines that you are eligible, the notice will state the effective date and will include claim forms. At least once a year, but no more often than every 30 days, LTC Partners will reassess whether you continue to be eligible for benefits.

If LTC Partners determines that you are not eligible for benefits, the notice will provide the reason(s) for the denial and will let you know how to request a review, which must be filed within 60 days from the date of the denial. If the denial is upheld—an answer will be provided within 60 days after LTC Partners receives the review request—you may appeal to an appeals committee whose members are agreed upon by OPM and LTC Partners.

If the appeals committee upholds the denial, that denial may be eligible for review by an independent third party. For example, appeal to an independent third party is available when the appeals committee upholds a denial of your eligibility for benefits because its review indicates that you can perform at least five out of six activities of daily living. However, appeal to an independent third party is not available for example when the appeals committee upholds a denial of your claim for benefits because you exhausted your maximum lifetime benefit.

The decision by the independent third party is final and binding on LTC Partners.

After you have gone through this administrative review process, you may seek judicial review of a final denial of eligibility for benefits or a claim. The amount of recovery available is limited to the benefit payable; no punitive, compensatory or other damages are allowed.

Note: These procedures apply only if you have valid coverage under the FLTCIP. If the carrier determines that your coverage was based on an erroneous application and voids the coverage, these provisions do not apply. The carrier will provide you with information on your review rights in its letter voiding your coverage.

Tax Treatment

The FLTCIP meets the requirements of the Health Insurance Portability and Accountability Act (HIPAA). This means you can deduct the premiums to the extent that your total qualified medical expenses exceed 7.5 percent of your annual adjusted gross income (up to dollar limits determined by age) and that the benefits you receive are not considered income for tax purposes.

Some states offer tax incentives designed to encourage the purchase of long-term care insurance. Check with your state’s insurance department.

For More Information

Further information on the program can be obtained from LTC Partners, phone (800) 582-3337 or TTY (800) 843-3557 and at www.ltcfeds.com and at www.opm.gov/
healthcare-insurance/long-term-care
.


Section 4
Federal Employees Dental and Vision
Insurance Program

The Federal Employees Dental and Vision Insurance Program provides vision and dental benefit benefits for employees, annuitants and certain family members apart from the limited coverage in those areas provided in the Federal Employees Health Benefits program. FEDVIP is voluntary for eligible persons. Enrollees pay the full cost; there is no government contribution toward the premiums. Benefits are provided by insurers under contract to the Office of Personnel Management.

Individuals eligible to enroll in both the FEDVIP and FEHB programs can choose to enroll in FEHB only, FEDVIP only, both, or neither. They can also choose different enrollment types for each program—enrolling, for example, in self and family coverage under FEHB, but self-only coverage under FEDVIP. Eligible persons may enroll or change coverage for the following calendar year during an annual open season from the Monday of the second full workweek in November through the Monday of the second full workweek in December. If they make no changes, the previous choice continues.

Other key features of FEDVIP are:

• Premiums are deducted from enrollees’ pay or annuity when possible.

• Employees (but not retirees) pay the premiums from pretax payroll dollars and may not opt out of this premium conversion arrangement. (Note: Those in phased retirement status remain eligible for premium conversion because they do not separate from service; see Phased Retirement in Chapter 3, Section 1.)

• Employees may use money in health care flexible spending accounts to pay co-payments and deductibles (but not premiums) of either vision or dental care.

• There are no pre-existing condition limitations on care, although there are waiting periods for orthodontic benefits under the dental benefits plans, and a dental plan carrier may refuse to cover treatments related to teeth missing as of the date of enrollment.

• Where a FEDVIP carrier is also an FEHB carrier, those enrolled in the carrier’s FEHB plan need not choose its dental or vision plan.

• Employees enrolled in FEDVIP who retire on an immediate annuity or for disability under a federal retirement system may continue FEDVIP enrollment into retirement with no requirement to have been enrolled for the prior five years, as applies in the FEHB and Federal Employees’ Group Life Insurance programs. Further, unlike in those programs, retirees may newly enroll in FEDVIP during the annual open season.

A link to each FEDVIP plan’s site, a provider search function and other information is at www.opm.gov/healthcare-insurance/dental-vision/plan-information. The FEDVIP general information number is (877) 888-3337, TTY (877) 889-5680. Enrollment and related information is at www.benefeds.com. The mailing address is BENEFEDS, P.O. Box 797 Greenland, NH 03840-0797.

Coordination of BenefitsSome FEHB plans cover some dental and vision services. If a FEDVIP enrollee’s FEHB plan does provide any benefits for dental and vision services, the FEHB plan will be the first payer of any benefits. FEDVIP plans are responsible for coordinating benefits with the primary payer.

FEDVIP plans also coordinate benefit payments with other group health, dental or vision benefits coverage that enrollees may have, and with the payment of dental or vision costs under no-fault insurance.

FEDVIP plans may request that enrollees verify or identify their health insurance plan(s) annually or at the time of service. Enrollees who change FEHB plans during an open season after enrolling should communicate that change to BENEFEDS. Providing FEHB information may reduce enrollees’ out-of-pocket costs.


Disputed ClaimsEach plan has its own policies for reviewing disputed claims, which are explained in its brochure. An enrollee who has completed the plan’s claims dispute process and still disagrees with the plan’s decision may request that an independent third party, mutually agreed to by the plan and OPM, review the decision. The decision of the independent third party is final and binding. OPM does not review disputed FEDVIP claims.

Eligibility

EmployeesExecutive Branch and U.S. Postal Service employees are eligible to enroll in FEDVIP if they are eligible to enroll in the FEHB program regardless of whether they actually are enrolled in that program, except that those who are eligible for FEHB only through enrollment in temporary continuation of coverage are ineligible under FEDVIP. See FEHB Eligibility and Enrollment Rules in Section 1 of this chapter.

AnnuitantsFederal annuitants are eligible to enroll in FEDVIP if they retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the government, including retirement for disability.

Employees separating with eligibility only for a deferred annuity cannot continue FEDVIP enrollment and are not eligible to enroll once their annuity benefits begin.

Employees enrolled in FEDVIP who retire on a FERS Minimum Retirement Age +10 annuity and elect to postpone receipt of their annuity lose FEDVIP coverage upon separation from service. Such individuals can again enroll in FEDVIP within 60 days of when they start receiving their annuity. They do not have to enroll in the same plan, option or same enrollment type they had when they separated.

Survivor AnnuitantsIf you are a survivor of a deceased federal/Postal Service employee or annuitant, you may enroll or continue an existing enrollment only if you are receiving a survivor annuity (unless you are otherwise eligible, such as through your own federal employment).

Compensationers—Injury compensationers are eligible to enroll in FEDVIP or continue enrollment into compensation status. A family member receiving monthly compensation from the Office of Workers’ Compensation Programs as the surviving beneficiary of an employee who dies as a result of illness or injury sustained while in performance of duty can enroll or continue the deceased’s enrollment.

Family MembersUnder FEDVIP, eligible family members (see www.opm.gov/
healthcare-insurance/dental-vision/eligibility)
are:

• a spouse, including a common law spouse in states where such marriages are recognized (note: eligibility does not apply to domestic partnerships, civil unions or other arrangements not formally recognized as a marriage);

• unmarried dependent children under age 22, including adopted children and recognized children born out of wedlock who meet certain dependency requirements, stepchildren and foster children who live with the enrollee in a regular parent-child relationship; and children age 22 or over who are incapable of self-support because of a mental or physical disability that existed before reaching age 22.

Note: Children of a same-sex domestic partner were eligible for coverage under certain conditions during 2014-2015; that coverage generally ended effective in 2016 due to a 2015 U.S. Supreme Court ruling requiring all states to conduct and recognize same-sex marriages. A temporary extension of eligibility for children of a same-sex domestic partnership when the enrollee was stationed overseas expired September 30, 2018.

Former spouses are not eligible, even if they are receiving an apportionment of an annuity or a survivor annuity, nor are parents and other relatives who are not eligible under FEHB, even if they live with and are dependent upon the enrollee. FEHB temporary continuation of coverage enrollees also are ineligible, as are insurable interest annuity recipients unless they qualify otherwise.

You self-certify the eligibility of dependents to be covered under self plus one or self and family coverage. FEDVIP plans may ask you to provide documentation that confirms a family member’s eligibility (such as a marriage certificate or adoption papers) when you initially enroll or when you add a family member to an existing enrollment. If your employing agency or retirement system has already made a determination regarding a child’s eligibility under the FEHB program or the Federal Employees’ Group Life Insurance program as a foster child or as a child incapable of self-support because of a mental or physical disability, provide the FEDVIP plan with a copy of that determination. If such a determination has not been made, you must request that determination from your agency or retirement system and then submit a copy to the FEDVIP plan.

Note: P.L. 114-328 of 2016 eliminated the Tricare Retiree Dental Plan effective with calendar year 2019 and made most military retirees and their family members eligible for FEDVIP, as well as members of the Retired Reserve, non-active Medal of Honor recipients, and survivors, Most family members of active duty personnel are eligible for vision coverage only, and also must be enrolled in a Tricare health plan.

End of CoverageYour coverage ends when you:

• no longer meet the definition of an eligible employee or annuitant;

• begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;

• are making direct premium payments to BENEFEDS and you stop making the payments; or

• cancel the enrollment (see Canceling Enrollment under Enrollment, below).

Coverage for a family member ends when:

• you as the enrollee lose or cancel coverage; or

• the family member no longer meets the definition of an eligible family member.

Under FEDVIP, there is no 31-day extension of coverage, temporary continuation of coverage, spouse equity coverage, or right to convert to an individual policy as in FEHB.

Enrollment

Eligible individuals can enroll in dental care, vision care or both:

• during the annual open season that runs concurrent with the annual FEHB open season in mid-November through mid-December;

• within 60 days after first becoming eligible as a new employee, as a previously ineligible employee who transferred to a covered position, or as a survivor annuitant (if not already covered under FEDVIP);

• within 60 days of when you return to service following a break in service of at least 30 days;

• from 31 days before you or an eligible family member lose other dental/vision coverage to 60 days after a qualifying life event that allows you to enroll (see below);

• from 31 days before you get married to 60 days after; or

• within 60 days after returning to federal employment after being on leave without pay if you did not have federal dental or vision coverage prior to going on leave without pay, or your coverage was terminated or canceled during your period of leave without pay.

Newly hired eligible employees and newly eligible employees have one opportunity to enroll for vision coverage and one opportunity to enroll for dental coverage in their first 60 days. Once they enroll in either type of plan, the opportunity for that type of enrollment ends, even if the period hasn’t elapsed. They cannot change or cancel that enrollment until the next open season, unless they experience a qualifying life event that allows such a change or cancellation.

Enrollment typically is done at www.benefeds.com or by phone at (877) 888-3337 (TTY (877) 889-5680). In limited circumstances a paper form election is allowed. Enrollment is not allowed through the FEHB election form (SF 2809) or through agency self-service pay and benefits systems, although some of those systems provide links to BENEFEDS.

OptionsAn eligible individual may choose one of the following enrollment options:

• Self-Only. A self-only enrollment covers only the enrolled employee or annuitant. An eligible individual may enroll in self-only even though he or she has one or more family members eligible to be covered.

• Self Plus One. A self plus one enrollment covers the enrolled employee or annuitant plus one person who is eligible as a family member. Eligible individuals may enroll in self plus one even though they have more than one eligible family member, but the additional family members are not covered. The enrollee must specify during the enrollment process which eligible family member he or she wishes to cover under a self plus one enrollment. The enrollee may change the covered family member to another eligible family member during an open season or because of a qualifying life event, consistent with that event.

• Self and Family. A self and family enrollment covers the enrolled employee or annuitant and all persons who are eligible as family members (see above). Enrollees should list all eligible family members when they enroll in order to ensure timely claim payments. All of the enrollee’s eligible family members are automatically covered, even if the enrollee fails to list all of them when enrolling, but claim payments may be delayed for family members who were omitted. An eligible individual may enroll in self and family coverage in anticipation of gaining an eligible family member, as described under Qualifying Life Events, below. The family member (such as a newly adopted child or a new spouse) is automatically covered by a self and family enrollment from the date he or she becomes eligible as a family member. However, enrollees should still add new family members to existing self and family enrollments to ensure timely payment of claims.

The type of enrollment need not be the same as the type chosen in the FEHB, if applicable. Those enrolled in both vision and dental plans further can choose different enrollment types for each. In addition, they can choose a different eligible family member for each if enrolled as self plus one in each.

For both self plus one and self and family enrollments, when an eligible family member on an existing enrollment loses eligibility (for example, a non-disabled child reaches age 22) and there is at least one other eligible family member remaining on the enrollment, the enrollee should remove the ineligible family member. Failure to remove ineligible family members does not make them eligible.

Dual enrollment” is when an individual is covered under more than one FEDVIP dental enrollment or more than one FEDVIP vision enrollment, for example when two eligible persons, each having children covered under self and family coverage, marry each other. Generally, dual enrollment is prohibited except when elimination of the dual enrollment would cause an enrollee or an eligible family member to lose coverage. Guidance on situations that are considered to be dual enrollment that must be rectified and the steps to be taken are in Benefits Administration Letter 10-202 at www.opm.gov/retirement-services/publications-forms/benefits-administration-letters.

Canceling EnrollmentEnrollment can be canceled only during an open season, except that:

• If BENEFEDS and/or a FEDVIP plan discover an unauthorized dual enrollment, one of the enrollments must be canceled. This is done prospectively from the date the dual enrollment was discovered. (Note: The premiums paid for the canceled enrollment will not be refunded to you, but you are not required to refund any benefits paid under the canceled enrollment.)


• If you take an enrollment action based on experiencing a qualifying life event (QLE), you may cancel that action within the time limit allowed for the QLE.

• If you change enrollment in anticipation of a permitted QLE and that event does not occur, you can cancel the change.

• You may cancel enrollment if you transfer to an eligible position with a federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premiums.

• You may cancel enrollment upon your deployment or your spouse’s deployment to active military duty.

These cancellations will become effective at the end of the pay period that you submit your request. An eligible family member’s coverage also ends upon the effective date of a cancellation.

Re-Enrollment—An existing enrollment renews automatically each year in the open season unless you make a change or your plan’s participation ends.

Belated Enrollments or Changes—The time limit for enrolling or changing an enrollment may be extended for up to six months after you first becomes eligible, or have a qualifying life event, or after the end of open season, if you provide evidence to BENEFEDS that you were unable to enroll or change enrollment timely for reasons beyond your control. If BENEFEDS allows a belated enrollment or change in enrollment, you must enroll or change enrollment within 30 days after BENEFEDS notifies you. BENEFEDS will allow belated enrollments and changes only in exceptional circumstances, and its decisions cannot be appealed.

Changes Outside Open Season—Outside the annual open season, new enrollments and changes in existing enrollments are allowed consistent with certain qualifying life events. If you do not act within the pertinent time, you must wait until the next open season.

You may newly enroll up to 60 days after:

you marry;

you or an eligible family member lose other dental/vision coverage;

your annuity or injury compensation is restored after having been terminated;

you return to pay status after being on leave without pay due to deployment to active military duty; or

you return to federal employment after being on leave without pay if you did not have federal dental or vision coverage prior to going on leave without pay, or your coverage was terminated or canceled during your period of leave without pay.

In the case of marriage or loss of other coverage, you also can enroll up to 31 days before the event.

If you already are enrolled, within 31 days before to 60 days after you may:

increase enrollment type (such as from self-only to self plus one) and/or change plan/plan options within a plan upon marriage;

• increase enrollment type upon acquiring an eligible family member or when an eligible family member loses other vision/dental coverage;

• decrease enrollment type on the loss of, or loss of eligibility of, a covered family member;

• change plans/plan options on returning to federal employment after being on leave without pay if you did not have FEDVIP coverage prior to going on leave without pay, or your coverage was terminated or canceled during your period of leave without pay.

You also may change plans/plan options at any time after moving out of a regional plan’s service area.

Retirees and injury compensationers may make enrollment changes under the same circumstances as active employees (although not all of the conditions that apply to active employees, such as going on leave, apply to retirees).

Effective DateThe effective date of open season enrollments is the start of the succeeding calendar year. Generally, enrollments and changes to enrollments that occur outside of open season become effective the first day of the pay period or annuity cycle following the one in which BENEFEDS receives the enrollment or change. For belated enrollments or belated changes in enrollments, the effective date will be retroactive to the date the enrollment or change in enrollment would have been effective if made timely.

Vision Benefits

Premiums vary according to whether the enrollee chooses the high or standard option and whether the enrollee chooses self-only, self plus one or self and family coverage. Premium rates, a plan comparison tool and other plan information are at www.opm.gov/healthcare-insurance/dental-vision/plan-information.

There are four vision plans, each of them national and each with standard and high options: Aetna Vision, FEP BlueVision, UnitedHealthcare Vision, and Vision Service Plan. Each offers comprehensive vision services, including annual examinations, lenses and frames, discounts on laser vision correction, and coverage for elective or medically necessary contact lenses. See plan brochures for specific coverage terms.

To contact vision plans:

Dental Benefits

There are 10 dental carriers. Six are nationalAetna, Delta Dental, FEP BlueDental, GEHA, MetLife and United Concordiaand four are regionalDominion Dental (District of Columbia, Delaware, Maryland, Pennsylvania and parts of New Jersey and Virginia); EmblemHealth (state of New York and parts of Connecticut, New Jersey and Pennsylvania); Humana Dental Company (Alabama, Arizona, Arkansas, California, Colorado, District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Missouri, Mississippi, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and parts of Maryland); and Triple-S Salud (Puerto Rico).

Dental coverage includes (see plan brochures for specific coverage terms):

• Basic services, such as oral examinations, prophylaxis, diagnostic evaluations, sealants, and X-rays.

• Intermediate services, such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.

• Major services, such as root canals, gingivectomy, crowns, oral surgery, bridges, and complete dentures.

• Orthodontic services, subject to a waiting period of up to 24 months of continuous enrollment in the same plan before eligibility for benefits begins.

Standard reimbursement rates are for in-network services. Costs to enrollees for using out of network providers are higher. Premiums vary according to whether the enrollee chooses the high or standard option (where applicable), whether the enrollee chooses self-only, self plus one or self and family coverage, and according to geographic rating areas established by the plans. Premium rates, a plan comparison tool and other plan information are at www.opm.gov/healthcare-
insurance/dental-vision/plan-information.

To contact dental plans:

2019 Federal Employees Almanac

Chapter 2—Insurance

2019 Federal Employees Almanac

Chapter 2—Insurance

2019 Federal Employees Almanac

Chapter 2—Insurance

2019 Federal Employees Almanac

Chapter 2—Insurance

2019 Federal Employees Almanac

Note: For special policies affecting employees not participating in premium conversion, former spouses, those under temporary continuation of coverage and others not listed in this table, see Standard Form 2809 at www.opm.gov/forms. That form also specifies whether employees may elect or waive premium conversion due to these events.

Table of Permissible Changes in FEHB Enrollment for Employees Participating in Premium Conversion

Qualifying Life Events (QLEs) that

FEHB Enrollment Change that May Permit Change in FEHB Enrollment or Premium Conversion Election

Time Limits in which Change May Be Permitted

Code

Event

From Not Enrolled to Enrolled

Increase From Enrollment Type*

Cancel or One Plan or Option to Another

When You Must File Decrease Enrollment Type**

Health Benefits Election Form With
Your Employing Office

1A

Initial Opportunity to Enroll, for example: • New employee • Change from excluded position • Temporary employee who completes 1 year of service and is eligible to enroll under 5 USC 8906a

Yes

N/A

N/A

N/A

Within 60 days after becoming eligible

1B

Open Season.

Yes

Yes

Yes

Yes

As announced by OPM

1C

Change in family status that results in increase or decrease in number of eligible family members, for example: •Marriage,divorce, annulment, legal separation • Birth, adoption, acquiring foster child or stepchild, issuance of court order requiring employee to provide coverage for child • Last eligible child loses coverage, for example, child reaches ages 26, disabled child becomes capable of self-support, child acquires other coverage by court order • Death of spouse or dependent

Yes

Yes

Yes

Yes

Within 60 days after change in family status

1D

Any change in employee’s employment status that could result in entitlement to coverage, for example: • Re-Employment after a break in service of more than three days; • Return to pay status from non-pay status, or return to receiving pay sufficient to cover premium withholdings, if coverage terminated (If coverage did not terminate, see 1G.)

Yes

N/A

N/A

N/A

Within 60 days after employment status change

1E

Any change in employee’s employment status that could affect cost of insurance, including:

• Change from temporary appointment with eligibility for coverage under 5 USC 8906a to appointment that permits receipt of government contribution • Change from full time to part-time career or the reverse

Yes

Yes

Yes

Yes

Within 60 days after employment status change

1F

Employee restored to civilian position after serving in uniformed services

Yes

Yes

Yes

Yes

Within 60 days after return

1G

Employee, spouse or dependent:

• begins non-pay status or insufficient pay or

• ends non-pay status or insufficient pay if coverage continued

(If employee’s coverage terminated, see 1D.)

• (If spouse’s or dependent’s coverage terminated, see 1M.)

No

No

No

Yes

Within 60 days after employment status change

1H

Salary of temporary employee insufficient to make withholdings for plan in which enrolled.

N/A

No

Yes

Yes

Within 60 days after receiving notice from employing office to civilian position

1I

Employee (or covered family member) enrolled in FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollments or, if already outside the area, moves further from this area.

N/A

Yes

Yes

N/A

Upon notifying employing office of move

1J

Transfer from post of duty within a State of the United States or the District of Columbia to post of duty outside a State of the United States or District of Columbia, or reverse.

Yes

Yes

Yes

Yes

Within 60 days after arriving at new post

1K

Separation from federal employment when

the employee or employee’s spouse is pregnant.

Yes

Yes

Yes

N/A

During employee’s final pay period

1L

Employee becomes entitled to Medicare and wants to change to another plan or option.

No

No

Yes

N/A

Any time beginning on the 30th day before becoming eligible for Medicare

1M

Employee or eligible family member loses coverage under FEHB or another group insurance plan including the following:

• Loss of coverage under another FEHB enrollment due to termination, cancellation, or change to Self-Only of the covering enrollment

• Loss of coverage due to termination of membership in employee organization sponsoring the FEHB plan

• Loss of coverage under another federally-sponsored health benefits program, including: TRICARE, Medicare, Indian Health Service

• Loss of coverage under Medicaid or similar State-sponsored program of medical assistance for the needy

• Loss of coverage under a nonfederal health plan, including foreign, state or local government, private sector

• Loss of coverage due to change in worksite or residence (Employees in an FEHB HMO, also see 1I.)

Yes

Yes

Yes

Yes

Within 60 days after loss of

coverage

1N

Loss of coverage under a nonfederal group health plan because an employee moves out of the commuting area to accept another position and the employee’s nonfederally employed spouse terminated employment to accompany the employee.

Yes

Yes

Yes

Yes

From 31 days before the employee leaves the commuting area to 180 days after arriving in the new commuting area

1O

Employee or eligible family member loses coverage due to discontinuance in whole or part of FEHB plan.

Yes

Yes

Yes

Yes

During open season, unless OPM sets a different time

1P

Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan, including the

following:

• Medicare (employees who become eligible for Medicare and want to change plans or options, see 1L.)

• TRICARE for Life, due to enrollment in Medicare.

• TRICARE due to change in employment status, including: (1) entry into active military service, (2) retirement from reserve military service under Chapter 67, title 10.

• Medicaid or similar State-sponsored program of Medical assistance for the needy

•Health insurance acquired due to change of worksite or residence that affects eligibility for coverage

• Health insurance acquired due to spouse’s or dependent’s change inemployment status (includes state, local, or foreign government or private sector employment).

No

No

No

Yes

Within 60 days after QLE

1Q

Change in spouse’s or dependent’s coverage under a nonfederal health plan, for example:

• Employer starts or stops offering a different type of coverage (If no other coverage is available, also see 1M.)

• Change in cost of coverage

• HMO adds a geographic service area that makes spouse ineligible for coverage under that HMO, but other plans or options are available (if no other coverage is available, see 1M)

No

No

No

Yes

Within 60 days after QLE

1R

Employee or eligible family member becomes

eligible or assistance under Medicaid or a State

Yes

Yes

Yes

Yes

Within 60 Days after the date the employee of family member

Children's Health Insurance Program (CHIP). becomes eligible for assistance.

* Change from self-only to self plus one or to self and family, or change from self plus one to self and family
** Change from self and family to self plus one or to self-only, or change from self plus one to self-only

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