Federal Register Editions
Subpart AAdministration and General Provisions
875.102 Where do I send benefit claims?
875.103 Do I need to authorize release of my medical records when I file a claim?
875.104 What are the steps required to resolve a dispute involving benefit eligibility or payment of a claim?
875.105 May OPM correct errors?
875.106 What responsibilities do agencies have under this Program?
875.107 What are OPM's responsibilities as regulator under this Program?
875.108 If the Carrier approves my application, will I get a certificate of insurance?
875.109 Is there a delegation of authority for resolving contract disputes between OPM and the Carrier?
875.201 Am I eligible as a Federal civilian or Postal employee?
875.202 Am I eligible as a Federal annuitant?
875.203 Am I eligible if I separated under the FERS MRA+10 provision?
875.204 Am I eligible as a member of the uniformed services?
875.205 Am I eligible as a retired member of the uniformed services?
875.206 As a new active workforce member, when may I apply?
875.207 What happens if I am in nonpay status during an open season?
875.208 May I apply as a qualified relative if the person on whom I am basing my eligibility status has died?
875.209 How do I demonstrate that I am eligible to apply for coverage?
875.210 What happens if I become ineligible after I submit an application?
875.211 What happens if my eligibility status changes after I submit an application?
875.212 Is there a minimum application age?
875.301 Is there a Government contribution toward premiums?
875.302 What are the options for making premium payments?
875.303 How are premium payment errors corrected?
875.304 How does the Carrier account for FLTCIP funds?
875.401 How do I apply for coverage?
875.402 When will open seasons be held?
875.403 May I apply for coverage outside of an open season?
875.404 What is the effective date of coverage?
875.405 If I marry, may my new spouse apply for coverage?
875.406 May I change my coverage?
875.407 Who makes insurability decisions?
875.408 What is the significance of incontestability?
875.409 Must I provide an authorization to release medical information?
875.410 May I continue my coverage when I leave Federal or military service?
875.411 May I continue my coverage when I am no longer a qualified relative?
875.412 When will my coverage terminate?
875.413 Is it possible to have coverage reinstated?
875.414 Will benefits be coordinated with other coverage?
This part is written as if the reader were an applicant or enrollee. Accordingly, the terms "you," "your," etc., refer, as appropriate, to the applicant or enrollee.
In this part, the terms annuitant, employee, member of the uniformed services, retired member of the uniformed services, and qualified relative have the meanings set forth in section 9001 of title 5, United States Code, and supplement the following definitions:
Abbreviated underwriting is a type of underwriting that asks fewer questions about your health status than with full underwriting to enable the Carrier to determine whether your application for coverage will be approved. The Carrier may also require review of your medical records, a phone interview, or an in-home interview.
Actively at work means:
(1) That as an active workforce member other than a member of the uniformed services you meet all of the following conditions:
(i) You are reporting for work at an approved work location and you work at least one-half of your regularly scheduled hours for that day; and
(ii) You are able to perform all the usual and customary duties of your employment on your regular work schedule.
Carrier means a qualified carrier as defined in section 9001 of title 5, United States Code, with which OPM has contracted to provide long term care insurance coverage under this section. A Carrier may designate 1 or more administrators to perform some of its obligations.
Eligible individual means an annuitant, active workforce member, member of the uniformed services, retired member of the uniformed services or qualified relative, as defined in section 9001 of title 5, United States Code.
Enrollee means an eligible individual whose application for coverage the Carrier has approved and whose coverage is in effect.
FLTCIP means the Federal Long Term Care Insurance Program.
Free look means that within 30 days after you receive the Benefit Booklet, you may cancel your coverage if you are not satisfied with it and receive a refund of any premium you paid. It will be as if the coverage was never issued.
Full underwriting is the more comprehensive type of underwriting under the FLTCIP, which requires that you answer many questions about your health status to enable the Carrier to determine whether your application for coverage will be approved. The Carrier may also require review of your medical records, a phone interview, or an in-home interview.
Stepparent means any person, other than your mother or father, who is currently married to one of your parents, or, if one of your parents is dead, a person who was married to that parent at the time of that parent's death.
Underwriting requirements means the information about your current health status and history and other information that you must provide to the Carrier with your application for coverage to enable the Carrier to determine your insurability.
Workforce member means a Federal civilian or Postal employee, member of the uniformed services, Federal annuitant, retired member of the uniformed services, or member of any other eligible group, as defined in section 9001 of title 5, United States Code. An active workforce member is one who is currently employed or is on active duty.
You must submit your benefit claims to the FLTCIP Carrier or its designee.
Yes, if you file a claim for benefits, the Carrier needs to have a valid authorization from you to release your medical records.
(a) If you dispute the Carrier's denial of your eligibility for benefits or your claim for payment of benefits, you must first send a written request for reconsideration to the Carrier no later than 60 days from the date of its decision.
(b) The Carrier must provide you with written notice of its review decision no later than 60 days after the date it receives your reconsideration request.
(c) If the Carrier upholds its denial (or does not respond within 60 days), you have the right to appeal its reconsideration decision directly to the Carrier. You must make this appeal in writing within 60 days from the date of the Carrier's notice upholding its decision. You will be notified of the decision on your appeal in writing no later than 60 days from receipt of your appeal request.
(d) If a denial of your eligibility for benefits or a denial of your claim is upheld upon appeal due to the evaluation of your medical condition/functional capacity, the Carrier will inform you that you may request that an independent third party, mutually agreed to by OPM and the Carrier, review the decision. You must make this request in writing within 60 days from the date of the notice informing you of the appeal decision. The independent third party must notify you in writing of its decision no later than 60 days from the Carrier's or its designee's receipt of your request for appeal to the third party. This is the final administrative remedy available to you. The decision of the independent third party is final and binding on the Carrier.
(e) You may seek judicial review of the final administrative denial of a claim. Such action may not be brought prior to exhaustion of the administrative process provided in this section. To pursue such judicial review, you must bring legal action against the Carrier in an appropriate United States district court within 2 years from the date of the final decision. You may not sue OPM, the independent reviewer, or any other entity. If you prevail in court, your recovery is limited to the amount of benefits payable under your benefit booklet and schedule of benefits.
OPM may order correction of administrative errors after reviewing evidence and finding that it would be against equity and good conscience not to do so.
Federal agencies and uniformed services establishments are responsible for:
(a) Providing access to information about the FLTCIP to eligible individuals;
(b) Responding to questions from the Carrier, including questions on the employment status of an applicant or enrollee;
(c) Providing reports as OPM requires;
(d) Complying with Benefits Administration Letters and other OPM issuances/instructions; and
(e) Deducting premiums as authorized by a workforce member and as requested by the Carrier, when possible.
Consistent with the authority and discretion given to OPM by the FLTCIP law, OPM's responsibilities include those functions typically associated with, and preemptive of, State insurance regulatory authorities such as:
(a) Reviewing and approving the content and format of materials associated with the FLTCIP pursuant to section 9008(d) of title 5, United States Code;
(b) Reviewing and approving rates, forms, and marketing materials; and
(c) Determining the qualifications of enrollment personnel and the Program administrator(s).
If the Carrier approves your application for coverage, OPM and/or the Carrier will make available to you a benefit booklet and schedule of benefits with complete coverage information, which will serve as your proof of insurance. You will also get a copy of your approved application for coverage.
For the purpose of making findings of fact and to the extent that conclusions of law may be required under any proceeding conducted in accordance with the provisions of the disputes clause included in the FLTCIP master contract, OPM delegates this function to the Armed Services Board of Contract Appeals.
(a) If you are a Federal civilian or Postal employee whose current position conveys eligibility for Federal Employees Health Benefits under part 890 of this chapter, you are also eligible to apply for coverage, with the following exceptions:
(1) If you are a District of Columbia employee or retiree, you are not eligible to apply for coverage, regardless of whether you are eligible for Federal Employees Health Benefits coverage. There is a related exception, however: D.C. government employees and retirees who were first employed by the D.C. government before October 1, 1987 are eligible to apply for coverage.
(2) If you are a Tennessee Valley Authority employee or retiree, you are eligible to apply for coverage, even though you may not be eligible for Federal Employees Health Benefits coverage.
(3) If you are a Non-Appropriated Fund (NAF) employee or retiree you are eligible to apply when the Secretary of Defense determines such eligibility for the NAF instrumentality that employs you, and you will be treated the same as a Federal civilian employee or retiree (as applicable) under this Part.
(b) If you are a Federal civilian or Postal employee whose current position is excluded from Federal Employees Health Benefits eligibility under Sec. 890.102 of this chapter, you are excluded from applying for coverage unless paragraph (a)(2) of this section applies.
(c) If you are an annuitant reemployed by the Federal Government, you may apply for coverage as an employee.
If you are a Federal annuitant, including a survivor annuitant, a deferred annuitant, or a compensationer, you are eligible to apply for coverage. Separated Federal employees with title to a deferred annuity may apply for coverage, even if they are not yet receiving that annuity.
If you have separated from service under the FERS Minimum Retirement Age and 10 years of service (MRA+10) provision of 5 U.S.C. 8412(g), and have postponed receiving an annuity under that provision, you are eligible to apply for coverage under this part. For underwriting purposes, you will be considered an annuitant.
(a) You are eligible to apply for coverage if you are on active duty or full-time National Guard duty for more than a 30-day period.
(b) You are eligible to apply for coverage if you are a member of the Selected Reserve, which consists of:
(1) Drilling Reservists and Guardsmembers assigned to Reserve Component Units;
(2) Individual Mobilization Augmentees who are Reservists assigned to Reserve Component billets in Active Component units (you may be performing duty in a pay or non-pay status); and
(3) Active Guard and Reserve members who are full-time Reserve members on full-time National Guard duty or active duty in support of the National Guard or Reserves.
(c) You are not eligible to apply for coverage if you belong to the Individual Ready Reserve. The Individual Ready Reserves includes Reservists who are assigned to a Voluntary Training Unit in the Naval Reserve and Category E in the Air Force Reserve.
(b) You are eligible to apply for coverage if you are a retired reservist who is currently receiving retirement pay.
(c) You are eligible to apply for coverage as a retired ("grey") reservist, even if not yet receiving retirement pay.
(a) As a new, newly eligible, or returning active workforce member, you may apply as follows:
(1) If you are a new active workforce member entering a position that conveys eligibility, you may apply for coverage within 60 days after becoming eligible.
(2) If you are entering a position that conveys eligibility as an active workforce member from a position that did not convey eligibility, you may apply for coverage within 60 days after becoming eligible.
(3) If you return to active service after a break in service of 180 days or more to a position that conveys eligibility, you may apply for coverage within 60 days after becoming eligible.
(b) Your spouse may also apply during that 60-day period after you become eligible.
(c) The underwriting requirements that will be required will be those applicable to active workforce members and their spouses during the last open season for enrollment before the date of your application.
(d) After the 60-day period ends, you may still apply for coverage, as may your spouse, but full underwriting requirements will apply.
(e) If your employing office determines that you were unable, for a cause beyond your control, to submit an application during the initial 60-day period, you may submit an application within 60 days after your employing office advises you of that determination. Similarly, your employing office may make this determination if your spouse is unable to submit an application during the same time period for a cause beyond his/her control. This employing office authority only applies within 6 months after the beginning date of the initial eligibility period. The underwriting requirements will be as specified in paragraph (c) of this section.
(f) Your other qualified relatives may apply for coverage at any time. They will be subject to full underwriting requirements.
(a) If you return to a pay status from nonpay status during the open season, you have 60 days from the date of your return, or until the end of the open season, whichever gives you more time, to apply for coverage pursuant to the open season underwriting requirements for Federal civilian or Postal employees and members of the uniformed services.
(b) If you return to pay status from nonpay status after the open season, you have 60 days from the date of your return to apply for coverage pursuant to the underwriting requirements specified for Federal civilian or Postal employees and members of the uniformed services in the immediately preceding open season.
(c) Paragraphs (a) and (b) of this section apply only when you have been in nonpay status for more than one-half of an open season, unless you went into nonpay status for a reason beyond your control.
You may not apply as a qualified relative if the workforce member on whom you are basing your qualified relative status died prior to the time you apply for coverage, unless you are receiving a survivor annuity as the spouse of a deceased workforce member. In this case, your adult children and your current spouse are also considered to be qualified relatives.
(a) When you submit your application for coverage, you must make known your status as a member of an eligible group.
(b) If the Carrier finds that you misrepresented your eligibility status, the Carrier has the right to void your coverage and return to you any premiums you paid, without interest. The incontestability provisions in Sec. 875.409 do not apply to this section.
(a) You must be eligible at the time of your application and at the time your coverage is scheduled to go into effect. Except as noted in paragraph (b) of this section, if you lose your status as part of an eligible group before your coverage goes into effect, you are no longer eligible for FLTCIP coverage. You are required to inform the Carrier that you are no longer eligible.
(b) In two instances, you will continue to be eligible for coverage even if you lose your status as part of an eligible group after you submit an application for coverage, but before your coverage becomes effective. The two instances are:
(1) When you are involuntarily separated from Federal civilian service (except for misconduct) or from the uniformed services (except for a dishonorable discharge). In either of these events, your qualified relatives will continue to be eligible.
(2) When you are the qualified relative of a workforce member who dies.
(a) If you applied as an active workforce member, and separate from service under the MRA+10 provisions of 5 U.S.C. 8412(g), or retire after you submit an application for coverage, but before your coverage becomes effective, you must reapply as an annuitant and submit to full underwriting requirements.
(b) If you applied as an active workforce member, and otherwise separate from service, but you are a qualified relative of another workforce member, you must reapply based on the additional underwriting requirements specified for that type of qualified relative.
Yes, there is a minimum application age. You must be at least 18 years old at the time you submit an application for coverage.
There is no Government premium contribution toward the cost of long term care insurance.
(a) Premium payments may be made by Federal payroll or annuity deduction, uniformed services retirement pay deduction, by pre- authorized debit, or by direct billing.
(b) You must continue to make premium payments when they are due for your coverage to stay in effect.
(a) If the Carrier finds that you have underpaid the premium rate for your age and/or level of coverage, you must pay retroactive premiums to the Carrier for the amount due. If you fail to pay back premiums within the time provided by the Carrier to correct the error, the Carrier may terminate your coverage.
(b) If the Carrier finds that you have overpaid premiums, the Carrier will either reimburse you or reduce a future premium payment(s) by the amount of the overpayment.
(c) If you die while you have coverage, any premiums paid for the period beyond the date of your death will be refunded to your estate or to an alternate payee. If there is no estate, the Carrier will determine whether to pay the refund to an alternate payee. If you cancel your coverage, any premiums paid in advance for the period following the effective date of your cancellation will be refunded to you.
(d) Any premiums you paid will be returned if you cancel coverage within the "free look" period specified in the benefit booklet.
The Carrier must keep account of all funds received under this section separate from all other funds. The Carrier may use FLTCIP funds only for purposes specifically related to the FLTCIP.
(a) To apply for coverage, you must complete the application in a form appropriate for your eligibility status as prescribed by the Carrier and approved by OPM.
(b) If you are the qualified relative of a workforce member, you may apply for coverage even if the workforce member does not apply for coverage.
(a) The first open season for enrollment under this section began July 1, 2002, as described in a Federal Register Notice (67 FR 43691, June 28, 2002), including the open season ending date(s) and which eligible individuals may apply based on abbreviated underwriting.
(b) There are no regularly scheduled open seasons for long term care insurance. OPM will announce any subsequent open seasons via a Federal Register Notice. The Notice will include the requirements for applicants during the open season.
(c) In situations where new eligibility groups are added to the Program, and OPM determines that it is appropriate to have an open season, OPM will provide notice and set the requirements for a special open season limited to those eligible individuals.
If you are eligible for coverage, you may submit an application at any time outside of an open season. You will be subject to full underwriting requirements. The only exceptions to the full underwriting requirements outside of an open season are described in �5.206 and �5.405.
(a) The effective dates of coverage under open season enrollments will be announced in a Federal Register Notice that announces open season dates.
(b)(1) If you enroll at any time outside of an open season, your coverage effective date is the 1st day of the month after the date your application is approved.
(2) If you are an active workforce member and you are applying for coverage under abbreviated underwriting, you also must be actively at work at least 1 day during the calendar week immediately before the week which contains your coverage effective date for your coverage to become effective. You must inform the Carrier if you do not meet this requirement. In the event you do not meet this requirement, the Carrier will issue you a revised effective date, which will be the 1st day of the next month. You also must meet the actively at work requirement for any revised effective date for coverage to become effective, or you will be issued another revised effective date in the same manner.
(1) If you are a Federal civilian or Postal employee or member of the uniformed services and you have married, your spouse is eligible to submit an application for coverage under this section within 60 days from the date of your marriage, and will be subject to the underwriting requirements in force for the spouses of civilian employees and members of the uniformed services during the most recent open season. You, however, are not eligible for abbreviated underwriting because of your marriage. You may apply for coverage along with your spouse, but full underwriting will be required for you.
(a) You may make the following changes to your coverage:
(1) You may apply to increase your coverage at any time. Full underwriting is required, except when an open season allows abbreviated underwriting.
(2) If you increase your coverage by adding to your daily benefit amount, the premiums for the additional coverage will be based on your age, prevailing premium rates, and coverage rules in effect at the time you purchase the additional coverage.
(3) For other types of coverage increases, your entire premium will be based on your age, prevailing premium rates, and coverage rules in effect at the time you purchase the increased coverage. Any increase in coverage will take effect on the 1st day of the month following the date the Carrier approves your request for an increase.
(b) You may decrease your coverage at any time, although any decrease will be subject to coverage rules at the time of the decrease. Decreased coverage takes effect on the 1st day of the month after the Carrier receives your request. You will not receive any refund of premiums paid for coverage you held before the decrease; however, your subsequent premiums will be reduced based on your new, lower level of coverage. The Carrier will refund or credit any portion of premium paid in advance for the period following the date on which you decrease your coverage.
(1) If you cancel during the free look period, your premiums will be refunded to you.
(2) If you cancel your coverage at any time other than during the free look period, 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 Carrier determines the insurability of all applicants. The Carrier's decision may not be appealed to OPM.
(a) Incontestability means coverage issued based on an erroneous application may remain in effect. Such coverage will not remain in effect, and your claim may be denied, under any of the following conditions:
(1) If your coverage has been in force for less than 6 months, the Carrier may void your coverage or deny a claim upon a showing that information on your signed application that was material to your approval for coverage is different than what is shown in your medical records.
(2) If your coverage has been in force for at least 6 months but less than 2 years, the Carrier may void your coverage or deny a claim upon a showing that information on your signed application that was material to your approval for coverage is different than what is shown in your medical records, and pertains to the condition for which benefits are sought.
You must provide the Carrier with an authorization to release medical information when requested. The Carrier may deny a claim for benefits or void your coverage if the Carrier does not receive an authorization to release medical information within 3 weeks after its request (4 weeks for those outside the United States).
If you are a Federal civilian or Postal employee or member of the uniformed services, your coverage will automatically continue when you leave active service, as long as the Carrier continues to receive the required premium when due. However, once you leave active service, you are no longer eligible for any abbreviated underwriting provided during any future open season.
If you are already enrolled as a qualified relative, you may continue your FLTCIP coverage if you subsequently lose qualified relative status (such as upon divorce), as long as the Carrier receives the required premium when due.
Your coverage will terminate on the earliest of the following dates:
(a) The date you specify to the Carrier that you wish your coverage to end;
(b) The date of your death;
(c) 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
(d) The date you have exhausted your maximum lifetime benefit.
(However, in this event, care coordination services will continue.)
(a) Under certain circumstances, your coverage can be reinstated. The Carrier will reinstate your coverage if it receives proof satisfactory to it, within 6 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.
(b) 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.
Yes, benefits will be coordinated with other plans, following the coordination of benefits (COB) guidelines set by the National Association of Insurance Commissioners. The total benefits from all plans that pay a long term care benefit to you should not exceed the actual costs you incur. The other plans that are considered for COB purposes include government programs, group medical benefits, and other employer-sponsored long term care insurance plans. Medicaid, individual insurance policies, and association group insurance policies are not taken into consideration under this provision.