INITIAL DECISION AND RECONSIDERATION

• Initial Decision
• Reconsideration Right
• Who Does the Reconsideration?
• How to Request Reconsideration
• Time Limit
• Final Decision
• Effective Date of Reconsideration Enrollment

Initial Decision

Your employing office has the responsibility for determining whether you are eligible to enroll or change your enrollment in the FEHB Program or in the premium conversion plan. Its initial decision that you can not enroll is given in writing and will inform you of the right to an independent level of review (reconsideration) by the appropriate agency office. The written initial decision will include the address of the office making reconsideration decisions, the time limit for requesting reconsideration, and a statement that you should include a copy of the initial decision with your reconsideration request.

See "Opportunities to Enroll or Change Enrollment" for the events that allow enrollment or changes in enrollment and the time frames within which changes may be made.

Reconsideration Right

You have the right to ask your employing office to reconsider its initial decision denying FEHB enrollment or the opportunity to change your enrollment, or your participation in the premium conversioin plan. The reconsideration determines whether your employing office properly applied law and regulations in making its initial decision. This reconsideration is your final level of administrative review for enrollment decisions under the FEHB Program.

Who Does the Reconsideration?

The office that makes the reconsideration decision must be at either a higher level or in a different office than the office that made the initial decision. Employing offices that make initial decisions must be made aware of the identity of the agency office making reconsideration decisions because they must include that information with the initial decision.

How to Request Reconsideration

You must request reconsideration in writing. The request must include:

• Your name and address
• Your date of birth
• Your Social Security Number
• The reason(s) for the request
• A copy of the initial decision.

Time Limit

You must request reconsideration within 30 calendar days from the date of the initial decision. Exception: you must request reconsideration of a carrier's disenrollment decision within 60 calendar days after the date of a carrier's disenrollment notice.

This time limit may be extended when you show that you were not notified of the time limit and were not otherwise aware of it or that you were unable to make the request within the time limit for reasons beyond your control.

Final Decision

The reconsidering office will issue a final decision. This decision will be in writing and fully state the findings. Initial decisions that comply with law and regulations cannot be overturned by reconsideration.

Example 1

Henry lists parents who live with and are dependent on him as family members under his family enrollment. His employing office denies coverage of his parents. This initial decision cannot be overturned by reconsideration because the FEHB law does not provide for coverage of an employee's parents.

Example 2

John marries. Three months later he requests a change of enrollment from Self Only to Self and Family based on the marriage. The employing office denies his request because the time frame for making a change due to marriage is 31 days before to 60 days after the marriage. This initial decision cannot be overturned because the time frame is a regulatory requirement.

(If John claimed that he didn't make the change timely for reasons beyond his control, his employing office could allow a late election on that basis either at the initial decision level or at the reconsideration level.)

Effective Date of Reconsideration Enrollment

If on reconsideration your employing office decides that you should have been allowed to enroll or change enrollment, it accepts a Health Benefits Election Form (SF 2809) from you making the change. Generally, changes made upon reconsideration are effective prospectively. Under FEHB regulations, the change is normally effective on the first day of the first pay period beginning after the employing office receives the SF 2809.

In some cases, the law or regulations provide for retroactive effective dates, so your employing office doesn't need to decide whether a retroactive effective date is appropriate.

When the late election was the result of an administrative error, you may request that your employing office make the change retroactive to an earlier date, generally the date it would have been effective if you had been able to make a timely election.

If on reconsideration your employing office decides that you are entitled to continued enrollment in a plan from which you were disenrolled by the carrier, the disenrollment is void and coverage is reinstated retroactively.

CORRECTION OF ERRORS

• Employing Office
• OPM

Employing Office

Your employing office can make corrections of administrative errors regarding eligibility to enroll or changes in enrollment at any time. Your employing office may retroactively correct an enrollment code error if you report the error by the end of the second pay period after you received written documentation showing the error (for example, a pay statement or enrollment change confirmation).

When retroactive corrections are made, your employing office must determine whether the proper amount of health benefits deductions were made from your pay. Your employing office must submit any uncollected deductions and Government contributions to OPM for deposit in the Employees Health Benefits Fund.

Exception: If the administrative error was made before January 1, 1995, your employing office does not have the authority to make a retroactive correction. Instead, you must request a retroactive correction from OPM, Retirement and Insurance Service, Office of Insurance Programs, P.O. Box 436, Washington, D.C. 20044.

OPM

OPM can order correction of an administrative error after reviewing evidence that it would be against equity and good conscience not to do so. A request for review should be sent to OPM, Retirement and Insurance Service, Office of Insurance Programs, P.O. Box 436, Washington, D.C. 20044.

IMPAIRED RELATIONSHIP

OPM may order a change in your enrollment from a particular HMO when you can show that you cannot receive adequate medical care because you (or a family member) and your HMO's health care providers have a seriously impaired relationship. You should submit your request and documentation of the impaired relationship to OPM, Retirement and Insurance Service, Office of Insurance Programs, P.O. Box 436, Washington, DC 20044.

PROCESSING ELECTIONS

• PROCESSING ELECTIONS
• Prompt Action on Elections
• Health Benefits Forms
• Remarks
• SF 2809
• Employing Office Review of SF 2809
• Processing an Election not to Enroll
• Processing an Election Change
• SF 2810
• Temporary Employee's Change in Employment Status
• Name Change
• Reinstatement of Enrollment

Generally, the responsibility for processing health benefits actions is divided between the personnel and payroll offices.

References in this section to Standard Forms 2809 and 2810 apply to the August 1992 and June 1995 editions respectively.

Prompt Action on Elections

Your personnel and payroll offices must process your election within one week after their receipt. This is very important to protect your eligibility for benefits (especially when you are enrolling in an HMO), to keep health plan carriers fully informed of the status of its enrollments, and to avoid retroactive adjustments in withholding and contributions.

Health Benefits Forms

Health benefits actions are taken on either the Health Benefits Election Form (SF 2809) or the Notice of Change in Health Benefits Enrollment (SF 2810). Each of these forms contains instructions explaining its use.

Remarks

Both the SF 2809 and SF 2810 contain space for remarks. Your employing office will use this space to give information needed to support any action that is not apparent from the completed form. For example, to show that as a new employee, you are enrolling on a timely basis, your employing office will note "Appointed (date)", or "Converted to eligible type of appointment (date)". It should not include information that is not relevant to your health benefits, such as the reason for separation, or title and grade of your position.

Special entries in the Remarks section are required if you are a temporary continuation of coverage (TCC) enrollee or a temporary employee eligible under 5 U.S.C. 8906(a).

SF 2809

The Health Benefits Election Form (SF 2809) is used to enroll, to decline enrollment, to change your enrollment, or to cancel your enrollment. The SF 2809 may be in either paper or electronic format. Whenever the use of the SF 2809 is discussed in this section, it refers to either the paper or electronic format.

Employing Office Review of SF 2809

Upon its receipt of your Health Benefits Election Form (SF 2809), your employing office will:

• note in part H the date it received the completed form;
• make sure that you are eligible to enroll;
• check that you are not already covered as a family member under another FEHB enrollment;
• review the form for completeness, consistency, signature, accuracy, and legality of the action, and check all copies for legibility;
• discuss with you any inconsistencies or situations not permitted by the law or regulations (e.g., not filed within the required time limits; enrollment in a plan not serving your area; name of plan and enrollment code do not agree; code number indicating Self Only enrollment when family members are listed; listing of persons not eligible for family coverage.) If you are enrolling in an employee organization plan, your employing office must accept your enrollment but also advise you that you must become a member of the organization, if you are not already a member;
• obtain a medical certificate from you if you have listed a child age 22 or over as a family member. Your employing office will record its determination of capability for self-support in the Remarks section on all copies of the form (e.g.,"[name] is incapable of self-support--permanent" or "certificate expires on [date])", and will attach the documentation to the Official Personnel Folder copy of SF 2809 (in a sealed envelope if preferred). If coverage is approved for a limited period of time, your employing office will prepare a follow-up notice to remind you in writing, at least 60 days before the certificate expires, that it must be renewed. If your employing office doesn't approve coverage, it will remove the child's name from the listing of family members;
• if you are a temporary employee enrolling under 5 U.S.C. 8906a, enter in the Remarks section: "Temporary employee eligible under 5 U.S.C. 8906a; must pay the full premium amount with no Government contribution.";
• if you have properly completed the SF 2809 and you are eligible to enroll, enter in part H the effective date of your enrollment, payroll office number (or the agency location code, if different from the payroll office number), and the name, title, address, signature, and telephone number of the authorized agency official. These entries may be made by rubber stamp, overprint, or facsimile signature;
• file a copy on the right or permanent side of the Official Personnel Folder (or its equivalent);
• send the new carrier and payroll office copies of SF 2809 to the payroll office for transmission to the carrier and for posting to the payroll records, respectively. (If it prefers, your employing office may send all copies except the enrollee copy to the payroll office for its action and later return of the Official Personnel Folder copy for filing.) It will discard the old carrier copy if it is a new enrollment;
• give you the enrollee copy, so you can use it as proof of enrollment until the carrier sends you an identification card.

Processing an Election not to Enroll

Your employing office will process your election not to enroll in the FEHB Program by following the applicable instructions under "Employing Office Review of SF 2809," except that the carrier copies should be destroyed.

Processing an Election Change

Your employing office will process your election change as outlined in "Employing Office Review of SF 2809" and take these additional steps:

• if you are changing from one option or type of enrollment to another in the same plan, your employing office will use the new carrier copy of SF 2809 to notify your carrier of the change. It will discard the old carrier copy;
• if you are changing plans, your employing office will use the new carrier copy of SF 2809 to notify the gaining carrier, and the old carrier copy to notify the losing carrier;
• if you are changing plans, the correct transmittal document report number must be entered on each carrier's copy.

SF 2810

Your employing office uses the Notice of Change in Health Benefits Enrollment form (SF 2810) to record certain changes in an enrollment not requiring your signature. It is used for an enrollment termination (but not a cancellation), reinstatement, change in payroll office, and a name change. In case of an enrollment termination, the back of the original (enrollee) copy of the SF 2810 serves as your official notice of the 31-day extension of coverage and conversion right. The back of the form also explains other rights you may have (continuation of enrollment on transfer, retirement, death, or entitlement to compensation under the Federal Employees' Compensation law).

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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

• Search the Handbook
• Handbook Changes