Code

Event

From Not Enrolled to Enrolled

From Self Only to Self and Family

From One Plan or Option to Another

When You Must File Health Benefits Election Form With Your Employing Office

4

Temporary Continuation of Coverage (TCC) For Eligible Former Employees, Former Spouses, and Children.

Note: Former spouse may change to Self and Family only if family members are also eligible family members of the employee or annuitant.

4A

Opportunity to enroll for continued coverage under TCC provisions:

Within 60 days after the qualifying event, or receiving notice of eligibility, whichever is later.

• Former employee

Yes

Yes

Yes

• Former spouse

Yes

N/A

N/A

• Child who ceases to qualify as a family member

Yes

N/A

N/A

4B

Open Season:

As announced by OPM.

• Former employee

No

Yes

Yes

• Former spouse

No

Yes

Yes

• Child who ceases to qualify as a family member

No

Yes

Yes

4C

Change in family status (except former spouse); for example, marriage, birth or death of family member, adoption, legal separation, or divorce.

No

Yes

Yes

From 31 days before through 60 days after event.

4D

Change in family status of former spouse, based on addition of family members who are eligible family members of the employee or annuitant.

No

Yes

Yes

From 31 days before through 60 days after event.

4E

Reenrollment of a former employee, former spouse, or child whose TCC enrollment was terminated because of other FEHB coverage and who loses the other FEHB coverage before the TCC period of eligibility (18 or 36 months) expires.

May Reenroll

N/A

N/A

From 31 days before through 60 days after the event. Enrollment is retroactive to the date of the loss of the other FEHB coverage.

4F

Enrollee or eligible family member loses coverage under FEHB or another group insurance plan; for example:

• Loss of coverage under another FEHB enrollment due to termination, cancellation, or change to Self Only of the covering enrollment (but see event 4E);
• Loss of coverage under another federally-sponsored health benefits program;
• Loss of coverage due to termination of membership in the employee organization sponsoring the FEHB plan;
• Loss of coverage under Medicaid or similar State-sponsored program;
• Loss of coverage under a non-Federal health plan.

No

Yes

Yes

From 31 days before through 60 days after loss of coverage.

4G

Enrollee or eligible family member loses coverage due to the discontinuance, in whole or part, of an FEHB plan.

N/A

Yes

Yes

During open season, unless OPM sets a different time.

4H

Enrollee or covered family member in a Health Maintenance Organization (HMO) moves or becomes employed outside the geographic area from which the carrier accepts enrollments, or if already outside this area, moves or becomes employed further from this area.

N/A

Yes

Yes

Upon notifying the employing office of the move or change of place of employment.

4I

On becoming eligible for Medicare.
(This change may be made only once in a lifetime.)

N/A

No

Yes

At any time beginning on the 30th day before becoming eligible for Medicare.