Office of Personnel Management

Retirement and Insurance Group

1920

1954

1959

1986	Benefits Administration Letter

Number: 96-207	Date: October 16, 1996

SUBJECT:	Federal Employees Health Benefits Program: New Regulations for Payment of Health Benefit Premiums for Periods of Nonpay Status or Insufficient Pay

I. OVERVIEW

A. Purpose

This letter gives instructions on implementing an interim regulation on the payment of Federal Employees Health Benefits (FEHB) premiums during periods of leave without pay or insufficient pay that was issued by the Office of Personnel Management on July 22, 1996. The regulation was transmitted to employing offices in Benefits Administration Letter 96-601. Section 890.502(b) of the regulation clarifies the responsibilities of both employing offices and employees when employees enter nonpay status or their pay is insufficient to cover their FEHB premium payments.

B. Problem addressed

by the regulation

Current OPM guidance in Subchapter S20-2b(4) of the FEHB Handbook for Personnel and Payroll Offices states that "All employees entering nonpay status or whose salary is insufficient to cover the health benefits premiums should be given a specific notice informing them of the requirement for payment of health benefits premiums for coverage which continues during periods of nonpay status or insufficient salary." We became aware that many Federal employees were not receiving this notice, and were being billed for FEHB coverage that they were not aware they had.

C. Goals of the

regulation

The new regulation has three goals. The first goal is to ensure that all employees who enter nonpay status, or whose pay is insufficient, receive notice of their options to continue or terminate their FEHB coverage. The second goal is to ensure that agencies have the necessary documentation so they can collect premiums from employees who elect to continue their FEHB coverage. The third goal is to not penalize employees who decide to terminate their FEHB coverage during a period of nonpay status or insufficient pay.

D. General notice to

all employees

Because of the importance of the changes made by this regulation for employees, agencies must distribute Attachment 1 to all employees at the earliest possible date. Distribution may be made through hard copy, newsletters, computer bulletin boards, and other available methods.

II. EFFECTIVE DATE AND APPLICABILITY

A. Effective date

The regulation became effective on August 21, 1996. Therefore, it will generally apply to pay periods of nonpay status or insufficient pay that begin on or after August 21, 1996. The regulation does not apply to periods of nonpay status or insufficient pay that began before August 21, 1996.

B. Applicability

The regulation establishes general rules which usually apply to periods of nonpay status or insufficient pay. However, additional or special rules apply when employees enter nonpay status to perform uniformed service; to serve as an officer or employee of an employee organization; to work under the Intergovernmental Personnel Act; or, who are in a leave without pay status in excess of 365 days under the Family and Medical Leave Act.

III. EMPLOYING OFFICES MUST NOTIFY EMPLOYEES

A. Employing office

must identify

employees

Employing offices must have a procedure which identifies all employees whose FEHB premium payments cannot be withheld from their salary because they are in nonpay status or their pay is insufficient to cover the premiums. In order to do this, there needs to be maximum cooperation between personnel, payroll, and employees' supervisors.

Rather than relying on Standard Form (SF) 50's, agencies must rely on time keeping/payroll data. Employing offices cannot rely on SF 50's for this information because they are not issued for employees entering leave without pay for less than 30 days or

when employees have insufficient pay. In addition, in many of the cases we have examined where a SF 50 was required, the SF 50 was never issued, or it was issued after the period of nonpay status ended.

B. Employing office

must notify

employees

Employing offices must give a written notice to employees as soon as possible after the employing office becomes aware that FEHB premium payments cannot be withheld from their salary because they are in nonpay status or their pay is insufficient to cover the premiums. The notice must contain all the necessary information on the options to continue or terminate the enrollment. Attachment 2 is a sample notice that contains all the necessary information.

C. How to notify

employees

If the employing office cannot give the written notice directly to the employee in person, it must send the notice by first class mail.

D. Use of electronic mail

Employing offices cannot use electronic mail at this time to give the written notice to employees. While we are strongly in favor of automating repetitive actions required under the FEHB Program, we are also committed to ensuring that employees receive the written notice. Especially important in this case is the fact that an employee's failure to timely respond results in termination of FEHB coverage. However, we are willing to work with employing offices who want to automate the written notification requirement on a pilot basis. We are convinced that such pilots will result in guidance that can be used by all employing offices.

E. Contents of the

notice

The main purpose of the attached notice is to inform employees of their options in regard to their FEHB coverage so they can make an educated decision. The notice informs employees of their options to continue or terminate their FEHB enrollment. The notice explains the effect of a termination. The notice states that by deciding to continue coverage, the employee agrees to either pay the premium directly or incur a debt. The notice provides a space for employees to continue or terminate their enrollment. The notice also informs employees that if they do not return the notice within 31 days of receiving the notice, (45 days for employees residing overseas), their enrollment will automatically terminate.

F. Tracking receipt and

return of notice

When tracking whether the employee signed and returned the notice within the required time frame note that:

• A notice that is mailed is deemed to be received by the

employee 5 days after the date of the notice.

• When the employee mails the signed form, the date of the

postmark is deemed to be the date the notice is returned to

the employing office.

IV. WHAT HAPPENS IF THE ENROLLMENT TERMINATES?

A. Two ways enrollment

may terminate

Employees' FEHB enrollments will terminate if (1) they fail to sign and return the written notice within 31 days of receiving the notice, (45 days for employees residing overseas), or (2) they return the signed notice, electing to terminate their enrollment.

B. When the employee

elects to terminate

the enrollment

When an employee elects to terminate the enrollment the employing office must prepare an SF 2810 terminating the enrollment. In the remark section include the statement, "Employee elected to terminate the enrollment during a period of...." Conclude the remark with the applicable statement i.e., "nonpay status" or "insufficient pay." Attach the signed notice to the SF 2810 and file in the permanent side of the Official Personnel Folder (OPF). Follow standard procedures for distributing the copies of the SF 2810.

C. When the employee

does not return the

notice within time

frame

When an employee does not return the written notice within 31 days of receiving the notice, (45 days for employees residing overseas), the employing office must prepare an SF 2810 terminating the enrollment. In the remark section include the statement, "Employee did not timely return written notice during a period of...." Conclude the remark with the applicable statement i.e., "nonpay status" or "insufficient pay." Attached the file copy of the notice to the SF 2810 and file in the permanent side of the Official Personnel Folder (OPF). Follow standard procedures for distributing the copies of the SF 2810.

D. Effective date of

termination

The effective date of a termination under IV.B or IV.C is retroactive to the end of the last pay period in which the premium was withheld from pay.

V. WHAT IS THE EFFECT OF A TERMINATION?

A. Terminations are

different from

cancellations

Previously, employees who decided not to continue their coverage during nonpay status or insufficient pay had to cancel their enrollment. Now, employees terminate their enrollment if they decide not to continue their coverage. The three major differences between cancellations and terminations are explained below.

B. Temporary extension

of coverage and

conversion

When an enrollment is terminated, FEHB coverage continues temporarily for 31 days, and the employee and any covered family members may convert to nongroup coverage. Temporary extension of coverage and conversion are not available when the enrollment is cancelled.

C. Opportunity to

reenroll

As explained below in section VII, when an enrollment is terminated, the employee does not have to wait until the next open season to reenroll. When employees cancel their FEHB enrollment, they must usually wait until the next open season to enroll.

D. Satisfying 5-year rule

for continuing

coverage during

retirement

A termination is not considered a break in the continuous coverage necessary for continuing FEHB coverage during retirement. The period during which the termination is in effect does not count toward satisfying the required 5 years of continuous coverage. A cancellation is considered a break in the continuous coverage necessary for continuing FEHB coverage during retirement.

E. Not eligible for TCC

Temporary Continuation of Coverage (TCC) is not available to employees whose FEHB coverage terminates during nonpay status or insufficient pay. TCC is only available to employees whose FEHB coverage terminates because of separation from employment.

VI. RETROACTIVE REINSTATEMENT OF TERMINATED FEHB COVERAGE

A. Circumstances

beyond control

When employees' enrollments are terminated because circumstances beyond their control, (such as a serious injury or similar circumstances), prevented them from timely returning the notice, they may request reinstatement of their FEHB coverage by writing to their employing office. Employees must file the request within 30 calendar days from the date the employing office gave them notification of the termination. Employees must include with the request a description of the circumstances beyond their control that prevented timely return of the notice.

When making a reinstatement request, employees must also include the signed written notice electing to continue FEHB coverage and agreeing to either pay the premium directly or incur a debt.

B. Employing office

procedures when

request is granted

When the employing office decides reinstatement of the enrollment is appropriate, it must take the following action. Complete parts A, D, and H of the SF 2810; note in the remarks section "Employee reinstated"; and, follow standard procedures for distributing the copies of the SF 2810.

C. Employing office

procedures when

request is denied

When the employing office decides reinstatement of the enrollment is not appropriate it must notify employees of their right to request a review of the decision from the employing agency. The reconsideration process must follow the requirements of 5 CFR 890.104, which include the condition that the reconsideration review must be an independent review designated at or above the level at which the initial decision was rendered.

VII. WHEN CAN EMPLOYEES REENROLL FOR FEHB COVERAGE?

A. Determining factor

The triggering event that allows employees who terminated their FEHB enrollment to reenroll is determined by whether the termination occurred during a period of nonpay status or insufficient pay.

B. Nonpay status

Employees who terminated their enrollment while they were in nonpay status may reenroll within 31 days of returning to pay and duty status.

C. Insufficient pay

Employees who terminated their enrollment while their pay was insufficient may reenroll within 31 days after the end of the first pay period their pay becomes sufficient to cover their FEHB premium.

D. Effective date

Reenrollments under VII.B and VII.C take effect the first day of the first pay period that begins after the date the employing office receives an appropriate request to reenroll and that follows a pay period during any part of which the employee is in pay status.

E. Can choose any plan

or option

Employees can reenroll into any plan or option available to them under the FEHB Program. They are not restricted to enrolling into the same plan and option they had when their coverage was terminated.

F. Effect of failure to

reenroll

Employees who fail to reenroll during the 31-day time period must wait for an open season until they can enroll for FEHB coverage, unless another qualifying event, such as a change in marital status, occurs before the next open season. The break in coverage which results from the failure to reenroll is taken into account when determining whether the employee has satisfied the continuous coverage requirement for continuing FEHB coverage during retirement.

G. Future change in

time period to

reenroll

On July 9, 1996, OPM published in the Federal Register a proposed regulation entitled, "Federal Employees Health Benefits Program: Opportunities to Enroll and Change Enrollment" (61 FR 35973). This regulation will most likely be finalized in the near future. When the regulation does take effect, one of the changes it will make is to expand the time frame for employees to reenroll under VII.B and VII.C from 31 to 60 days.

VIII. WHAT HAPPENS IF THE ENROLLMENT CONTINUES?

A. Two options

Employees who elect to continue coverage during nonpay status or insufficient pay can choose between paying the premiums directly or incurring a debt.

B. Filing election in

OPF

When employees return the written notice electing to continue FEHB coverage, the employing office must add a copy of the signed notice to the permanent side of the Official Personnel Folder.

C. Employing office's

responsibilities

The new regulations, like the previous regulations on this subject, require agencies to establish a method for accepting direct payment of FEHB premiums from an employee in nonpay status or insufficient pay. Employing offices must tell employees who elect to pay premiums directly how to make the payments. Employees who do not pay all the premiums that become due incur a debt for past-due FEHB premiums. Employing offices are responsible for determining the debt incurred by employees during nonpay status or insufficient pay, and collecting and forwarding to OPM the appropriate past-due health benefits premiums.

IX. COLLECTING PAST-DUE FEHB PREMIUMS FOR PAY PERIODS BEGINNING

BEFORE SEPTEMBER 30, 1996

A. Withholding debt

from salary

Employing offices must give a written notice to employees indebted for past-due FEHB premiums while on nonpay status when they return to pay and duty status, (and to employees who incurred the debt because their salary was insufficient when their salary becomes sufficient to pay FEHB premiums). The notice much state that the amount due will be withheld by deducting the regular premium and an additional premium per pay period until the debt is paid. The notice must include the employing office's contact person for employees who have questions about the notice. Attachment 3 is a sample notice that contains all the necessary information.

B. Final payment of

salary and accrued

annual leave

If employees separate from service before repaying the debt, the full amount of any final payment of salary or accrued annual leave is available for offset.

C. Notice to separating

employees

Employing offices must give a written notice to employees who separate from the employing office before collection of any past-due FEHB premiums are completed. Because the debt should generally be recovered promptly when employees return to duty, and because the full amount of any final checks to employees may be offset to settle the debt, it is expected that this notice will be

used primarily in the case of employees who do not return to duty after a period of nonpay status or insufficient pay. Attachment 4 is a suggested notice to be used for this purpose.

D. Refund of retirement

deductions and

annuity payments

If separated employees apply for withdrawal of their accumulated retirement deductions or receive annuity payments, the refunds or annuity payments are available for offset. An employee's SF 2806, "Individual Retirement Record" for the Civil Service Retirement System (CSRS), (or SF 3100 for the Federal Employees Retirement System (FERS)), must be noted when forwarded to OPM to show that the employee is indebted. In the remarks column enter, "Indebted in Amt of $ for FEHB, OPM 1522 (Will be Fwd)(is Attached)." In this way, the amount necessary to settle the debt may be offset from any refund of retirement deductions or annuity payments.

Employing offices must use OPM Form 1522, "Request for Offset for Past-Due Health Benefits Premiums From Monies Payable Under the Civil Service Retirement System (in Lieu of SF 2805)", to request the offset of any outstanding past-due FEHB premiums from any amounts to be paid to the former employee from the CSRS or FERS. The employing office must submit the OPM Form 1522 to OPM after giving the separated employee the notice required by IX.C.

If the debt is settled before an offset is processed by OPM and sent to the employing office, the employing office must notify OPM to prevent a duplicate recovery of the debt and the consequent need for a refund to the former employee.

E. Subsequent federal

employment

When an indebted employee separates, the employing office must document the Official Personnel Folder (right hand side) to alert the next employing office, if any, that the amount of the debt must be withheld from pay and forwarded to the former employing office which is still responsible for forwarding the amount due to OPM on an SF 2812. Such documentation may consist of the file copy of the notice required by IX.A or IX.C, appropriately noted. In such a case, the new employing office must contact the former employing office to verify the debt and to make the necessary arrangements for forwarding any amounts collected.

F. Any other source

In addition to the above methods to collecting past-due FEHB premiums, this debt can also be collected from any other source normally available for the recovery of a debt due the United States. Therefore, employing offices should also utilize other available methods to collect past-due health benefits premiums.

G. Remitting

payments to OPM

The procedures for remitting premiums to OPM are unchanged. The amounts forwarded for coverage during nonpay status or insufficient pay, including amounts collected for past-due FEHB premiums, must be incorporated in the employing office's regular SF 2812. OPM will not accept individual payment and/or separate documents concerning payments of this type.

X. SPECIAL CIRCUMSTANCES

A. Employees who pay

their FEHB

premiums over less

than 12 months

Some employees normally pay their total health benefits premiums for the year over a period of less than 12 months, such as teachers on a 10-month contract. Accordingly, when the employee is in nonpay status during the expected nonpay period (for which the premiums taken during pay status have been adjusted), such as the teacher's summer break, the employee does not pay any additional premiums. However, if the employee enters a nonpay status during the normal working period so that the health benefits withholding is not made for a pay period in which it otherwise would have been made, the employee is responsible for the premiums for that period of nonpay status in the same way as employees on a regular year-round withholding system.

B. Part-time employees

Career part-time employees who receive a prorated Government share are responsible, for periods of nonpay status, for the same health benefits premiums which would be withheld from pay if they were in pay status with their regularly scheduled tour of duty.

C. Temporary

employees

Temporary employees with one year of current continuous employment can enroll for FEHB coverage and must pay both the employee and Government contribution. For periods of nonpay status, temporary employees remain responsible for both contributions.

D. Discharges in

bankruptcy

An individual is no longer required to repay any past-due FEHB premiums if the debt is discharged in bankruptcy. When an employing office is notified of a discharge in bankruptcy they must inform OPM of the discharge so OPM does not make an offset

from an individual's refund of retirement contributions or annuity payment.

XI. PAYMENT OF THE GOVERNMENT CONTRIBUTION

Rule

Employing offices must in any and all circumstances, on a current basis, pay their share of the cost of an enrollment under the FEHB Program for every pay period during which an employee's enrollment continues whether the employee is in a pay or nonpay status. The employing office must submit the Government contribution as soon as it becomes due, that is, with the other deductions and contributions forwarded on the SF 2812, Report of Withholdings and Contributions, for the same pay period in which the coverage continued.

XII. COORDINATION WITH RETIREMENT OR WORKERS' COMPENSATION CASES

A. Purpose

The purpose of this section is to inform employing offices when and how to coordinate the collection of past-due FEHB premiums with deductions from Federal retirement and workers' compensation benefit payments.

B. General Information

When an individual applies for disability retirement or workers' compensation benefits, the annuity or compensation is generally payable from the day following the last day of pay. If the enrollee is eligible to continue coverage during receipt of annuity or compensation, the appropriate premium is withheld from the benefits retroactive to the beginning date of the payments. Therefore, if an employee's application for annuity or compensation is approved, the amounts due for health benefits are withheld from these benefits.

C. When premium is

not paid

If the FEHB premium has not been paid, either directly by the employee or through collection of the debt, for the same period for which FEHB withholdings are made from annuity or compensation no action is necessary by the former employing office.

D. When premium is

paid

If the FEHB premium has been paid, either directly by the employee or through collection of the debt, for the same period for which FEHB withholdings are made from annuity or compensation these amounts must be refunded to the employee by the employing office, to avoid double payments by the employee.

E. Coordination with

retirement cases

In retirement cases except for the case noted below, the employing office must refund the amounts received directly from the employee for periods after the last day of pay because these periods will be covered by withholdings from annuity. When the employee does not meet the requirements for an annuity on the day after the last day of pay, such as when the employee has not completed 5 years of civilian service until a later date, the annuity will not begin until a later date. In such cases, the employing office must only make a refund for periods of nonpay status after the annuity began.

F. Coordination with

disability retirement

cases

The employing office must refund amounts received directly from an employee when it receives OPM's approval form for disability retirement applications, unless the employing office does not have sufficient information on file to determine that all periods of nonpay status after the last day of pay will be covered by withholdings from annuity. If the employing office is unable to determine the period to be covered by a refund of premiums, a request for verification of the correct period for which annuity withholdings will be made must be requested by letter attached to the documents transferring the employee's health benefits to OPM.

G. Coordination with

workers'

compensation cases

In workers' compensation cases, the employing office must receive verification from the Office of Workers' Compensation Programs of the dates for which health benefit premiums have been withheld from benefits before refunding any amounts paid directly to the agency.

XIII. RECENTLY ENACTED LEGISLATION

A. Summary

Section 422 of the Treasury, Postal Service and General Government Appropriations, 1997, as incorporated in Section 101(f) of the Omnibus Consolidated Appropriation Act of 1997, Public Law 104-208, requires that agencies advance salary to employees in nonpay status in the amount of the employee contribution for their FEHB coverage. Agencies are also required to forward the full FEHB premium (both Government and employee contributions) for employees in nonpay status on a current basis for each pay period FEHB coverage continues. The Act was enacted on September 30, 1996, and became effective for pay periods beginning on or after September 30, 1996.

B. Further guidance

Once we fully evaluate this provision we will provide further guidance, including instructions on how to collect the debt resulting from the advancement of salary.

Abby L. Block, Chief

Insurance Policy and

Information Division

4 Attachments

IMPORTANT CHANGES

IN THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

This notice provides information about revised rules effective August 21, 1996, for employees who are enrolled in the Federal Employees Health Benefits (FEHB) Program and who enter nonpay status (including leave without pay), or whose pay otherwise becomes insufficient to cover premiums.

Employees who are enrolled in the FEHB Program are responsible for payment of their regular premium for each pay period they are enrolled. When an employee enters nonpay status, or when pay is insufficient to cover the cost of the premium, the employing office must provide the employee written notification of the following options:

•	continuing the enrollment and agreeing to pay the premium or incur a debt; or

•	terminating the enrollment.

If an employee chooses to continue the enrollment, payment of the premiums may be made either on a current basis, or when the employee returns to work. If an employee chooses to terminate the enrollment and avoid the indebtedness for the premium, the revised rules provide that:

•	the termination is subject to the 31-day temporary extension of coverage;

•	the employee and any covered family members may convert to a nongroup contract;

and

•	the employee may re-enroll in any FEHB plan upon returning to pay and duty status,

without having to wait for an open season or other enrollment event.

Also, under the revised rules, if an employee fails to make an election within the 31-day time frame, (45 days for employees residing overseas), the FEHB enrollment will automatically terminate.

A termination under the revised rules is not considered a break in the continuous coverage necessary for continuing health insurance into retirement. However, the period during which the termination is in effect does not count toward satisfying the required 5 years of continuous coverage.

Additional or special rules apply when employees enter nonpay status to perform uniformed service; to serve as an officer or employee of an employee organization; to work under the Intergovernmental Personnel Act; or, who are in leave without pay status in excess of 365 days under the Family and Medical Leave Act.

For full details, contact your employing organization. (Please try to give a specific person or office, and a phone number.)

FEDERAL EMPLOYEE HEALTH BENEFITS (FEHB) OPTIONS WHILE IN NONPAY STATUS

Name of Employee: Date:

You must respond within 31 days, (45 days for employees residing overseas), of this notice or your FEHB enrollment will automatically terminate.

Each pay period you are enrolled in the FEHB Program, you are responsible for payment of the employee share of the premium. When you enter nonpay status, or your pay is insufficient to cover the premium, you must:

•	terminate the enrollment; or

•	continue the enrollment and agree to pay the premium or incur a debt.

TERMINATING THE ENROLLMENT

If you elect to terminate your enrollment (or the enrollment automatically terminates), the termination will take effect at the end of the last pay period in which premiums were withheld from pay. FEHB coverage will continue at no cost to you for an additional 31 days. During the 31 days, you and your covered family members may convert to a nongroup contract. The termination is not considered a break in the continuous coverage necessary for continuing FEHB coverage into retirement. However, the period during which the termination is in effect does not count toward satisfying the required 5 years of continuous coverage. When you return to pay and duty status, or at the end of the first pay period your pay becomes sufficient to cover your premium, you must reenroll within 31 days if you want FEHB coverage.

CONTINUING THE ENROLLMENT AND AGREEING TO PAY THE PREMIUM

If you elect to continue your coverage, you must elect to pay the premiums directly or to incur a debt in the amount of the unpaid premiums. If you elect to pay directly, mail a check or money order payable to . Include on the check your name, social security number, a note that the payment is for "FEHB premium", and the pay period for which the payment is being made. Mail to: (address) .

If you elect to incur a debt, or if you elect to pay directly but fail to pay the entire amount due, you will receive a notice stating the total amount due. The notice will be sent when you return to pay status, your pay becomes sufficient, or you separate from employment. By electing to continue coverage you agree that the amount due will be withheld from salary by deducting the regular premium and an additional premium per pay period until the debt is paid. If the amount due cannot be withheld in full from salary, it will be recovered from a lump sum payment of accrued leave, income tax refunds, amounts payable under the Civil Service Retirement System or Federal Employees Retirement System, or any other source normally available for the recovery of a debt due the United States.

Please check the appropriate space(s) below, sign, and return this notice to your employing office at: (address) .

After reading and understanding the above, I elect to:

Continue the enrollment (Check one): Submit direct payments Incur a debt

(Signature) (Date)

Terminate the enrollment. (Signature) (Date)

Refer questions to: (Name) (Telephone)

Notice of Intent to Recover Past-Due Health Benefits Premiums From Salary

Name of Employee:	Date:

Employees enrolled in the Federal Employees Health Benefits (FEHB) Program are responsible for payment of the employee share of the cost of their enrollment for every pay period during which their enrollment continues. When you entered nonpay status, or your pay became insufficient to cover the FEHB premium, you signed a notice electing to continue your FEHB enrollment and agreed that any unpaid premiums for this period of coverage would be withheld from salary. The amount due will be withheld by deducting your regular premium and an additional premium per pay period until the debt is paid.

Our records show that you are indebted as described below. Please note that a recovery action from your salary will start soon. If you believe the amount of the indebtedness is incorrect, or if you have any questions regarding this notice, please contact the person mentioned below as soon as possible. Unless you pay the amount due in full, these withholdings will begin automatically as shown. If you should separate from service before the full amount due is recovered, your final salary payment will be used to complete recovery of the indebtedness. The remaining amount due, if any, will be recovered from a lump sum payment of accrued leave, income tax refunds, amounts payable under the Civil Service Retirement System or Federal Employees Retirement System, or any other source normally available for the recovery of a debt due the United States.

Name of FEHB plan and enrollment code:

Pay periods not covered by withholdings:

Total premiums required for these pay periods:

Amounts you paid directly to agency:

Total amount due to date:

Recovery from salary begins on:

Amount of each installment:

Number of installments:

Name, address and telephone number of contact person:

Notice of Intent to Recover Past-Due Health Benefits Premiums

Name of Employee:	Date:

Employees enrolled in the Federal Employees Health Benefits (FEHB) Program are responsible for payment of the employee share of the cost of their enrollment for every pay period during which their enrollment continues. When you entered nonpay status, or your pay became insufficient to cover the FEHB premium, you signed a notice electing to continue your FEHB enrollment and agreed that any unpaid premiums for this period of coverage would be recovered from any source normally available for the recovery of a debt due the United States.

Our records show that you are indebted as described below. You may pay the full amount due by check or money order made payable to . However, if you believe that the amount due is incorrect, or if you have any questions about this indebtedness please contact the person mentioned below within 15 days. If we do not hear from you, we will take action to recover the amount due from a lump sum payment of accrued leave, income tax refunds, amounts payable under the Civil Service Retirement System or Federal Employees Retirement System, or any other source normally available for the recovery of a debt due the United States.

Name of FEHB plan and enrollment code:

Pay periods not covered by withholdings:

Total premiums required for these pay periods:

Amounts you have already paid:

Total amount due:

Name, address and telephone number of contact person: