U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce
Insurance Services Programs
FEHB Handbook
Family Members
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FAMILY MEMBERS ELIGIBLE FOR COVERAGE (Continued)
The effective date of your foster child's coverage as a family member is the first day of the pay period in which your employing office receives all of the properly completed documents that establish the eligibility of the child as a foster child. When your foster child's mother is an eligible family member under your enrollment, you may request that the effective date be the first day of the pay period in which the child is born.
Your foster child's coverage continues until he/she marries, reaches age 22, becomes capable of self-support if age 22 or over, or is no longer living with and financially dependent on you. If your foster child moves out of your home to live with a biological parent, the child cannot again be covered as your foster child unless:
- the biological parent dies;
- the biological parent is imprisoned;
- the biological parent becomes unable to care for the child due to a disability; or
- you obtain a court order for custody that takes parental responsibility from the biological parent and gives it to you.
Grandchildren are not eligible family members. However, your grandchild can qualify as a foster child if all the requirements are met.
When a Child is Not Considered a Foster Child
A child who has been placed in your home by a welfare or social service agency under an agreement where the agency retains control of the child or pays for maintenance does not qualify as a foster child because there is no regular parent-child relationship. A child living temporarily with you as a matter of convenience does not qualify as a foster child. For example, a child who lives with you only while attending school normally does not qualify as a foster child because this is considered an arrangement of convenience.
Since it is impossible to cover every family situation, it may be necessary for the agency headquarters Benefits Officer to contact OPM for assistance in making difficult determinations.
If your stepchild or foster child temporarily lives elsewhere while attending school or for other reasons, the child is still considered to be an eligible family member if he/she is otherwise living with you in a regular parent-child relationship. Your stepchild or foster child who lives with you at least 6 months of a year under a court order directing shared custody may be considered living with you in a regular parent-child relationship.
A "regular parent-child relationship" means that you are exercising parental authority, responsibility, and control over the child by caring for, supporting, disciplining, and guiding the child, including making decisions about the child's education and health care.
A spouse equity self and family enrollment is limited to natural and adopted children of both you and your former spouse. In this case, a foster child or stepchild is not a covered family member.
Relatives Who are Not Family Members
Your parents and other relatives are not eligible family members, even if they live with and are dependent upon you.
When you have a change in family status, including a change in marital status, you may enroll, change from self only to self and family, or change from one plan or option to another. You must submit your enrollment change from 31 days before to 60 days after the change in family status.
Certain restrictions apply if you are enrolled as a survivor annuitant or as a former spouse under the Spouse Equity or temporary continuation of coverage (TCC) provisions.
Events Considered to be Changes in Family Status
Generally, a change in family status is an event that adds to or decreases the number of your family members. Certain other events are also considered changes in family status. The following events are considered a change in family status for health benefits purposes:
- your marriage, including a valid common law marriage (in accordance with applicable State law);
- birth of your child (but not a stillborn child);
- your legal adoption of a child under age 22 or the acquisition of a foster child under age 22;
- your child under age 22 or spouse enters into or is discharged from military service;
- issuance or termination of a court order granting to you or your spouse a final divorce, interlocutory divorce, limited divorce, legal separation, or separate maintenance;
- issuance of a court decree of annulment, or in the case of a marriage void from its beginning (ab initio) also a declaratory judgment, or conviction of the spouse of bigamy;
- issuance of a court order specifically requiring you to enroll for your children or provide health benefits protection for them;
- the death of your spouse, including a declaration by a court that your missing spouse is presumed dead.
WHEN A COURT ORDER REQUIRES YOU TO PROVIDE COVERAGE FOR YOUR CHILDREN
- Court/Administrative Orders
- Employing Office Review
- If You Don't Have Self and Family Coverage or Coverage that Provides Full Benefits in the Area Where the Children Live
- Sample Notice
- What Happens If I Don't Enroll or Provide Documentation of Other Coverage by the Due Date?
- How an Agency Enrolls You Involuntarily
- What is the Effective Date If I am Enrolled Involuntarily?
- How Does My Employing Office Identify My Eligible Family Members?
- What Happens If I Go into a Nonpay Status or My Pay is Insufficient to Make the Withholdings?
- If My Employing Office Enrolls Me, Can I Later Make Enrollment Changes?
- What Happens If I Make a "Not-Allowed" Enrollment Change by Employee Express?
- How Long Must I Keep the Self and Family Enrollment?
- What Happens When I Retire?
- What If My Employing Office Gets More Than One Court/Administrative Order for Me?
Public Law 106-394 requires mandatory self and family coverage if you are eligible for FEHB coverage and you do not comply with a court or administrative order to provide health benefits for your children. If you are subject to such an order, you must enroll in self and family coverage in a plan that provides full benefits to your children in the area where they live or provide documentation that you have other health coverage for the children.
If you do not enroll in an appropriate health plan or provide documentation of other coverage for the children, your agency must enroll you for self and family coverage in the standard option of the Blue Cross and Blue Shield Service Benefit Plan (enrollment code 105).
The court or administrative order can be submitted by anyone, including the custodial parent, an attorney for the custodial parent, and the State administrative agency that issues the order.
If the court order deals only with health benefits, it does not have to be certified. If the court order also deals with life insurance or retirement benefits, then it does have to be certified. Administrative orders come from State child support agencies, and will not be certified.
For it to be considered valid under Pub. L. 106-394, your agency must receive the court/administrative order on or after October 30, 2000.
Anyone who submitted a court/administrative order relating to health benefits for your children before October 30, 2000, would have to resubmit it. The court/administrative order can be issued before October 30, 2000, but it doesn't have any validity for FEHB purposes unless your agency receives it on or after October 30, 2000.
Your employing office must review your records to determine whether you are eligible for FEHB and, if so, whether you are enrolled in a self and family plan that provides full benefits in the location where your children live. If you have such coverage, your employing office will notify whoever sent in the court/administrative order. It will send a copy of your SF 2809 to your health benefits carrier, along with a copy of the court/administrative order to notify the carrier of the additional family members being covered under the self and family enrollment.
Your employing office will file the order in your Official Personnel Folder (OPF), and flag the OPF or other file in some manner that it will know the file contains a court/administrative order relating to health benefits.
If you are eligible for FEHB but don't have the appropriate coverage, you employing office will notify you that it has received a court order requiring you to provide health benefits for your children. Your employing office will give you until the end of the pay period following the one in which you get the notice to enroll in an appropriate health plan or provide documentation that you have other health benefits for the children.
Your employing office may use the following sample notification.
Dear [Employee's name]:
We have received a [court/administrative] order stating that you must provide health benefits for your child[ren]. You are not currently enrolled in self and family coverage under the Federal Employees Health Benefits (FEHB) Program in a health plan that provides full benefits in the area where your child[ren] live[s].
Pub. L. 106-394 requires Federal agencies to ensure that employees comply with the terms of such court and administrative orders. You must enroll in self and family coverage in a plan that provides full benefits where your child[ren] live[s] or provide documentation that you have other health benefits for your child[ren] by [insert date that is the last day of the pay period following the one in which this notice is issued].
If you do not enroll or provide documentation of other coverage for your child[ren] by [repeat date from paragraph above], we will enroll you for self and family coverage under the Blue Cross and Blue Shield Standard Option.
As long as the [court/administrative] order remains in effect and your child[ren] [is/are] eligible under the FEHB Program, you must continue self and family coverage in a plan that provides full benefits where your child[ren] live[s], unless you provide documentation that you have obtained other coverage.
Sincerely,
[Signature, name, and title of appropriate official]
[In addition to sending a copy to the employee, keep a copy in the employee's OPF or other record.]
What Happens If I Don't Enroll or Provide Documentation of Other Coverage by the Due Date?
If you don't enroll in an appropriate plan or provide documentation of other coverage for the children, your employing office will enroll you as follows:
If You Are Not Enrolled at All
If you are not enrolled for any FEHB coverage, your employing office will enroll you for self and family coverage in the standard option of the Blue Cross and Blue Shield Service Benefit Plan (enrollment code 105).
If You Have Self Only Coverage
If you have a self only enrollment in a fee-for-service plan, your employing office will change your enrollment to self and family in the same option of the same plan.
If you have a self only enrollment in an HMO, and the HMO serves the area where your children live, your employing office will change your enrollment to self and family in the same option of the same plan.
If you have a self only enrollment in an HMO, and the HMO does not serve the area where the children live, your employing office will change your enrollment to self and family in the Blue Cross and Blue Shield Standard Option.
If You Have Self and Family Coverage in an HMO That Doesn't Serve the Area Where Your Children Live
If you already have a self and family enrollment, but it's in an HMO that doesn't serve the area where your children live, your employing office will change your enrollment to self and family in the Blue Cross and Blue Shield Standard Option.
How an Agency Enrolls You Involuntarily
If your employing office needs to enroll you involuntarily, it will complete a Health Benefits Election form (SF 2809) with your identifying information. It will use event code 1C (Change in family status). In the signature block in Part G, it will write "See Remarks." In the remarks block in Part H, it will write "Being enrolled for self and family coverage involuntarily under Pub. L. 106-394."
When your employing office sends the SF 2809 to your health plan, it will attach a copy of the court/administrative order. It will send your copy of the SF 2809 to the custodial parent, along with a plan brochure, and make a copy for you.
What is the Effective Date If I am Enrolled Involuntarily?
In most cases, the effective date will be the first day of the pay period following the one in which your employing office completes the SF 2809.
Example
Chester's employing office receives an administrative order on November 14, 2000, saying that he must provide health benefits for his two children. Chester doesn't have any FEHB coverage. His employing office notifies him that he has until December 2, 2000 (the end of the following pay period) to enroll or provide documentation that he has other coverage for them. He doesn't respond. On December 4, 2000, Chester's employing office completes an SF 2809 enrolling him for self and family coverage in the Blue Cross and Blue Shield standard option. The effective date would be December 17, 2000 (the first day of the next pay period).
Exception: There is one instance in which the enrollment would be retroactive, and that's if the court/administrative order specifies an effective date. In this case, your employing office must make the enrollment retroactive to the beginning of the pay period that includes that effective date, but no further back than 2 years.
How Does My Employing Office Identify My Eligible Family Members?
Usually the court/administrative order will have the names and birthdates of the children. If the order does not have this information, your employing office will leave item 2 on the SF 2809 blank. The health plan will obtain the information from the custodial parent.
What Happens If I Go into a Nonpay Status or My Pay is Insufficient to Make the Withholdings?
The provisions of 5 CFR 890.502(b) apply (see "Leave Without Pay Status and Insufficient Pay"). However, in this case, you do not have the option of terminating coverage. You must continue the coverage and either make direct premium payments or incur a debt to the Government.
If My Employing Office Enrolls Me, Can I Later Make Enrollment Changes?
It depends on the enrollment change you want to make. During open season or when you have an event that allows an enrollment change, you can change to a different fee-for-service plan or to an HMO that provides full benefits where your children covered under the court/administrative order live.
However, you cannot (even during open season):
- cancel your enrollment,
- change to self only, or
- change to an HMO that doesn't provide coverage in the area where your children live,
as long as the court/administrative order is still in effect and the children are eligible under the FEHB Program (unless you provide documentation that you have other coverage for the children). This applies whether you are enrolled voluntarily or involuntarily. If you submit an SF 2809 making such an enrollment change, your employing office will not process it. If it gets processed by mistake, your employing office will void it. Your employing office will notify you that you cannot make the change and that your existing self and family enrollment will remain in effect.
What Happens If I Make a "Not-Allowed" Enrollment Change by Employee Express?
Your payroll office should flag the records for all employees subject to a court/administrative order for health benefits. You will then not be able to make an enrollment change through Employee Express.
If your agency has its own electronic system for FEHB enrollments, it will take similar action.
How Long Must I Keep the Self and Family Enrollment?
If the court/administrative order doesn't specify a time limit on the coverage, you must keep the self and family enrollment until the last child marries or reaches age 22.
If the court/administrative order states that coverage must continue until a specific age--and that age is over age 22--the coverage must continue until the last child reaches age 22. Unless they meet the requirements for being incapable of self support, children cannot continue FEHB coverage beyond age 22, regardless of what the court/administrative order says.
If the court/administrative order states that the coverage must continue until a specific age--and that age is below age 22--you may cancel the coverage or change to self only as follows:
If You Participate in Premium Conversion
You may cancel or change to self only during the next open season after the last child reaches the age stated in the court/administrative order.
If You Waived Premium Conversion
You may cancel or change to self only at any time after the last child reaches the age stated in the court/administrative order.
If you are eligible to carry FEHB coverage into retirement, you must continue the self and family coverage after retirement to provide coverage for the children covered under the court/administrative order. As long as the court/administrative order remains in effect, you cannot:
- cancel coverage,
- change to self only, or
- change to an HMO that doesn't provide full benefits where the children live.
What If My Employing Office Gets More Than One Court/Administrative Order for Me?
A self and family enrollment automatically covers all eligible family members. If you are subject to a court/administrative order, and another court/administrative order is filed relating to a different child (or children), that child is automatically covered under your existing self and family enrollment.
Your employing office will send your health plan a copy of the subsequent court/administrative order, along with a copy of the SF 2809 marked "Duplicate."
If you are enrolled in an HMO, and the children mentioned in the subsequent court/administrative order live in an area that the HMO doesn't serve, your employing office will notify you and give you a chance to choose a different health plan. If you don't change plans, your employing office will change your enrollment to the Blue Cross and Blue Shield standard option. It will attach copies of all court/administrative orders to the SF 2809.
CHANGES THAT DO NOT AFFECT ENROLLMENT
Family Members
You don't need to report to your employing office any change in the number of family members that doesn't affect your health benefits enrollment. However, the carrier of your plan may request this information, including evidence of family relationship.
Your enrollment is not affected when:
- your child is born when you already have a self and family enrollment;
- your spouse dies or you divorce and you have children still covered under your self and family enrollment;
- your child reaches age 22 or marries, and you have other children or a spouse still covered under your self and family enrollment. (If you want temporary continuation of coverage (TCC) or a conversion contract for your child, you must inform your employing office of your child's loss of FEHB eligibility within 60 days.)
If you change your name for any reason, your employing office must report the change to the carrier of your plan. If no other changes are involved (e.g., you legally change your name, or you change your name upon your marriage but keep your self only enrollment), your employing office reports the name change on the Notice of Change in Health Benefits Enrollment (SF 2810).
You are also eligible to change your enrollment upon your marriage. (Note: If your spouse is a Federal employee with a self and family enrollment, you are automatically covered as a family member under that enrollment, and you generally must cancel your enrollment to avoid dual enrollment.) If you change your enrollment, you must submit a new Health Benefits Election Form (SF 2809) under your new name, showing your former name in the Remarks section of the form.
When a family member loses coverage because he/she is no longer an eligible family member, he/she will be entitled either to temporary continuation of coverage or to convert to an individual policy with your carrier. If you are divorcing, your former spouse may be eligible for coverage under the spouse equity provisions.
When a Family Member is no Longer Eligible
Your family member immediately loses eligibility for coverage under your self and family enrollment when:
- Your divorce decree is final (according to State law);
- Your child reaches age 22, unless he/she is incapable of self support;
- Your child marries; or
- Your stepchild or foster child stops living with you in a regular parent-child relationship.
CHILD INCAPABLE OF SELF SUPPORT
- Coverage
- Requirements
- Financial Dependency
- Determination of Incapacity for Self-Support
- When Employing Office Must Make Determination
- When Carrier May Approve Coverage
- Medical Certificate
- When to Submit Certificate
- Use of Physicians
- Duration and Approval of Incapacity for Self Support
- Renewal of Medical Certificate
- Late Certificates
Your self and family enrollment covers your unmarried dependent child age 22 or over who is incapable of self-support because of a physical or mental disability that existed before the child reached age 22.
Your child age 22 or over may be considered incapable of self-support only if his/her physical or mental disability is expected to continue for at least one year and, because of the disability, he/she isn't capable of working at a self-supporting job.
A disability such as blindness or deafness isn't qualifying in itself because it doesn't necessarily make someone incapable of self-support. The onset of a disease before age 22 that doesn't result in incapability for self-support until age 22 or after doesn't qualify a child for continued coverage as a family member.
Your child incapable of self-support because of a mental or physical disability that existed before age 22 must also be dependent upon you to qualify for health benefits coverage. In addition, your stepchild or foster child incapable of self-support must live with you in a regular parent-child relationship to qualify.
Determination of Incapacity for Self-Support
When Employing Office Must Make Determination
Your employing office is responsible for determining whether your dependent child age 22 or over is incapable of self-support because of a mental or physical disability that began before age 22 and for notifying the carrier of your plan of its determination. If your child's medical condition is listed below, the carrier may also approve coverage.
Your dependent child is incapable of self-support when:
- he/she is certified by a state or federal rehabilitation agency as unemployable;
- he/she is receiving: (a) benefits from Social Security as a disabled child; (b) survivor benefits from CSRS or FERS as a disabled child; or (c) benefits from OWCP as a disabled child;
- a medical certificate documents that: (a) your child is confined to an institution because of impairment due to a medical condition; (b) your child requires total supervisory, physical assistance, or custodial care; or (c) treatment, rehabilitation, educational training or occupational accommodation has not and will not result in a self-supporting individual;
- a medical certificate describes a disability that appears on the list of medical conditions; or
- you submit acceptable documentation that the medical condition is not compatible with employment, that there is a medical reason to restrict your child from working, or that he/she may suffer injury or harm by working.
If your child earns some income (generally no more than the equivalent of the GS 5, step 1), it doesn't necessarily mean that he/she is capable of self support. Your employing office will take both your child's earnings and condition or prognosis into consideration when determining whether he/she is incapable of self-support.
When Carrier May Approve Coverage
If your child has a medical condition listed, and he/she had the condition before reaching age 22, you don't need to ask your employing office for approval of continued coverage after your child reaches age 22. The carrier of your health benefits plan may approve continued coverage to your child without referring you to your employing office.
When the carrier determines your child's incapacity for self support, it sends the approval notice to you and advises you to give a copy of the notice to your employing office. Your employing office must file it with your other health benefits enrollment documentation in your Official Personnel Folder.
Handbook Contents
- Introduction
- Cost of Insurance
- Health Plans
- Eligibility for Health Benefits
- Enrollment
- Leave Without Pay Status and Insufficient Pay
- Termination, Conversion, and Temporary Continuation of Coverage
- Annuitants and Compensationers
- Military Service
- Family Members
- Former Spouses
Appendices
- Forms and Brochures
- Glossary
- Table of Permissible Changes
- Chapter 89 of title 5, United States Code
- Part 890 of title 5, Code of Federal Regulations
Other
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