FEHB Handbook

Termination, Conversion and Temporary Continuation of Coverage
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Move from an HMO's Service Area

If you are enrolled in an HMO and you move or become employed outside the HMO's service area (or, if already living or working outside this area, move or become employed further away), you may change your enrollment. You must notify your employing office of the change.

You Become Eligible for Medicare

You may change your enrollment from one plan or option to another at any time beginning on the 30th day before you become eligible for Medicare. You may make an enrollment change under this event only once in a lifetime.

Termination of TCC Enrollment or Coverage

Your Temporary Continuation of Coverage (TCC) enrollment will end either because your eligibility period ends or you cancel your enrollment (this includes cancellation when you don't pay your premiums). If your enrollment ends because your TCC eligibility period ends, you are entitled to the 31-day extension of coverage for conversion to an individual contract.

Your family member's coverage ends when your enrollment ends or when he/she no longer is eligible for coverage as a family member. If your family member loses TCC coverage for any reason other than your cancellation (this includes cancellation when you don't pay your premiums), he/she is entitled to the 31-day extension of coverage for conversion to an individual contract. If you are a former employee, your family member that loses coverage is also eligible for TCC in his/her own right.

Your enrollment ends when your premiums remain unpaid 60 days (90 days if you live overseas) after the date of your employing office's notice of nonpayment.

If your enrollment ends because you didn't pay your premiums, it is considered to be a voluntary cancellation effective with the last day of the pay period for which you made payment. Your servicing employing office must complete a Health Benefits Election Form (SF 2809) for you. In part G, which normally would have your signature, your employing office will enter "Canceled due to nonpayment of premiums." In part H, it will enter "N/A" in item 2, and in item 3 it will enter the effective date of the cancellation. In cases where you never made payment, it enters the same effective date as on the original SF 2809 enrolling you. In the Remarks section it enters "This cancellation voids the prior SF 2809 enrolling this individual in your plan on the date in item 3." This voiding action has the same effect as a cancellation for nonpayment of premiums.

31-Day Extension of Coverage and Conversion to an Individual Contract

If you lose your Temporary Continuation of Coverage (TCC) other than by cancellation (including cancellation by nonpayment of premiums) or discontinuance of the plan, your coverage is automatically extended for 31 days, at no cost to you. You are also entitled to convert to an individual contract with your health benefits carrier, without providing evidence of insurability. You are eligible for the 31-day extension of coverage and have the right to convert even if you are eligible to elect TCC in your own right (e.g., you are a child of a former employee and you lose TCC coverage because you are no longer considered a covered family member).

Denial of TCC because of Involuntary Separation for Gross Misconduct

Under the law, you are not eligible for Temporary Continuation of Coverage (TCC) when you are involuntarily separated from Federal service because of gross misconduct.

Your employing office must determine whether the offense for which you are being removed constitutes gross misconduct. The determination must be made on a case-by-case basis by employing office staff (employee relations, Office of General Counsel, etc.) with a knowledge of case law involving gross misconduct.

General Guidelines for Gross Misconduct Determination

Generally, an offense punishable as a felony is considered gross misconduct. Lesser offenses may also be gross misconduct, depending on the circumstances. Other elements that must be considered are:

• There must be a connection between the offense and your job. Also, some individuals, such as judges, are held to a higher standard of conduct than others.
• You must have the ability to understand the gravity of your conduct.
• Your offense must be affirmative and willful, not simply negligent.

An adverse action procedure (5 CFR Part 752) does not result in a specific finding of gross misconduct. There are some offenses for which you can be removed under adverse action procedures that are not considered gross misconduct or are even considered disciplinary in nature (e.g., your refusal to transfer with your function).

Removal Must Result from Gross Misconduct

In order to be denied Temporary Continuation of Coverage (TCC) eligibility for gross misconduct, your removal (or resignation in lieu of removal) must be a direct result of your gross misconduct. If you resign before your employing office initiates adverse action procedures, your separation is considered voluntary and you are entitled to TCC. If you resign after receiving notice of your employing office's proposal to remove, but before you are removed, your separation is considered to be involuntary and you are not entitled to TCC. If you commit an offense that would be considered gross misconduct, but you are removed on another basis (e.g., unsatisfactory performance), your removal is not due to the gross misconduct and you are entitled to TCC.

Example

Simon was found to have embezzled money from his employing office's imprest fund. His employing office notifies him that it will begin an adverse action procedure to have him removed from service. Simon resigns the next day. He is not entitled to TCC since this is considered an involuntary separation.

Notification Requirements

When your employing office determines that your offense constitutes gross misconduct, it must notify you in writing that it intends to deny you TCC eligibility. The notice must:

• give the reason for the denial;
• give you at least 7 days to respond;
• be given to you no later than the date of your separation.

This notification may be combined with other notifications required for adverse action procedures or other procedures for actions based on misconduct.

Response

Your response may be oral or in writing. You are entitled to be represented by an attorney or other representative. Your employing office must designate an official who has the authority to either make or recommend a final decision to hear your oral answer. If you respond to the notice of denial, your employing office must issue a final decision that fully describes its findings and conclusion.

The final decision is not subject to OPM reconsideration. If you want to challenge the decision, you may file suit against your employing office in a district court.

Coordination with the Office of Workers' Compensation Programs (OWCP)

Your employing office is responsible for providing notification to eligible family members who lose family member status, for accepting their enrollments, and for collecting their premiums.

When you are a covered compensationer and you aren't entitled to continue your FEHB coverage as a compensationer upon your separation from service, your employing office must provide you with notification of your right to elect Temporary Continuation of Coverage (TCC), accept your enrollment, and collect your TCC premiums in the same way as for any other separating employee.

If your enrollment has been transferred to OWCP, your employing office must contact OWCP to determine whether you are enrolled and, if the person seeking continued coverage is a family member, whether the enrollment is for self and family. If your child is seeking continued coverage and his/her date of birth is not available, OWCP can supply that information.

If you are a compensationer who is no longer an employee, OWCP is responsible for providing notification to eligible family members who lose family member status, for accepting their enrollments, and for collecting their premiums.

Coordination with Spouse Equity Provisions

If you are a former spouse of a Federal employee or annuitant and you don't qualify for FEHB coverage under spouse equity provisions, you may be eligible for Temporary Continuation of Coverage (TCC).

Coverage under the spouse equity provisions is often delayed because the retirement system must determine whether you have a qualifying court order. Coverage does not begin until the pay period after the employing office receives the determination that the court order is qualifying (although you may request retroactive enrollment). You may be eligible for TCC while you are waiting for coverage under the spouse equity provisions to begin (but not beyond 36 months after your divorce or annulment).

Your coverage under the spouse equity provisions will end if you remarry before you reach age 55. If you remarry during the 36 months following your divorce or annulment, you are eligible for TCC. Your TCC will expire 36 months after the date of your divorce or annulment from the Federal employee.

Example

Nick and Nora's divorce becomes final on June 1, 1998. Nora applies for FEHB coverage under the spouse equity provisions and under TCC. She is covered under TCC until her spouse equity application is approved. Nora remarries on October 15, 1999, and since she is under age 55, her spouse equity coverage ends. She reenrolls under TCC provisions, and her coverage expires on June 1, 2001.

Health Benefits File

When you become enrolled under Temporary Continuation of Coverage (TCC), your servicing employing office will establish a health benefits file in your name. If you are a former employee, this file must be separate from your personnel records. If you are a former spouse or child, the name of the employee on whose service your TCC coverage is based must be noted on the front cover of your file.

Your servicing employing office must keep the following documents in your health benefits file:

• The Official Personnel Folder (OPF) copy of the Health Benefits Election forms (SF 2809) documenting your enrollment and any changes in enrollment;
• The OPF copy of the Notice of Change in Health Benefits Enrollment (SF 2810) terminating your enrollment; and
• Copies of any correspondence or other documents related to your enrollment (e.g., employing office notice of the premium amount and payment schedule; any notice of overdue premiums; documentation of a child's mental or physical disability before age 22; a cancellation request).

The contents of your file are subject to the provisions of the Privacy Act [5 U.S.C. 552a(b)]. Your health benefits file may be destroyed 2 years after the end of the calendar year in which your TCC eligibility period expires.

If you are a former spouse who elects TCC after you lose coverage under the spouse equity provisions, your servicing employing office must forward your spouse equity health benefits file to the employee's (on whose service your TCC coverage is based) retirement system. It must prepare a new health benefits file for your TCC enrollment.

When You have TCC Coverage and you become Employed by the Federal Government

When you have Temporary Continuation of Coverage (TCC) and you become employed by the Federal government, your TCC coverage stops when you enroll for regular FEHB coverage. Either you or your new employing office must send a copy of the Health Benefits Election Form (SF 2809) documenting your new enrollment to the employing office that maintains your TCC enrollment, with a cover letter instructing it to stop your TCC enrollment.

If your regular FEHB coverage ends before the expiration of your TCC eligibility, you may resume your previous TCC enrollment. You will likely be eligible for a new TCC enrollment period based on your separation from service. In some cases, it may be more beneficial to continue your previous TCC enrollment. This would happen when your previous TCC enrollment was for 36 months and it extends beyond the 18-month eligibility period after your separation from service.

Example

Janice is covered as a family member under her mother's FEHB enrollment. She turns age 22 on May 15, 1998, and elects TCC coverage. Her eligibility period under TCC ends on May 14, 2001 (36 months). She later becomes employed by the Federal government and elects to carry regular FEHB coverage, so her TCC coverage is terminated. She leaves Federal service on April 20, 1999, and is eligible to elect TCC as a separated employee. Her eligibility period would end on October 20, 2000 (18 months). She chooses instead to resume her original TCC coverage since this would give her a longer eligibility period.

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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