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FEHB Handbook

Former Spouses Page 6 of 7

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INFORMATION FOR EMPLOYING OFFICES (Continued)

ENROLLMENT (Continued)

Health Benefits File

You must establish and maintain a health benefits file for the former spouse, even when you have denied eligibility for coverage. The file must be set up in the former spouse's name and must be separate from the employee's Official Personnel Folder. The front cover of the file will show the name and date of birth of the employee on whose service the spouse equity benefits are based.

Disclosure of the contents of the health benefits file must be consistent with OPM regulations concerning access to the OPM/CENTRAL-1, Civil Service Retirement and Insurance Records, system of records under the Privacy Act of 1974 [5 CFR, part 297]. The System Manager for this system of records is: Associate Director of Retirement and Insurance, Office of Personnel Management, 1900 E Street, NW., Washington, DC 20415.

File Contents

You must keep the following documents in the former spouse's health benefits file:

Documentation that the former spouse applied in writing or in person (this may be a brief statement signed by the former spouse, with the receipt date noted by the employing office) within the 60-day time limit;

  • A copy ( provided by the former spouse) of the court order used by the retirement system to determine eligibility;
  • A copy of the retirement system's written notification verifying that the court order is acceptable;
  • the employing office's letter approving or denying eligibility for health benefits coverage along with the documents it used to make its decision;
  • the Official Personnel Folder copies of the Health Benefits Election Form (SF 2809) or other enrollment request for enrollment documenting the former spouse's enrollment, enrollment changes, or cancellation;
  • the former spouse's certification that he/she will notify the employing office within 31 days of an event that terminates eligibility;
  • the notice of premium amount and payment schedule;
  • the Official Personnel Folder copy of the Notice of Change in Health Benefits Enrollment (SF 2810) terminating the enrollment;
  • the employing office's copy of the letter transferring the enrollment to the retirement system;
  • Any other correspondence regarding eligibility or enrollment, such as a letter requesting payment of overdue premium prior to terminating coverage; documentation of a child's disability existing before age 22; a court order terminating entitlement to a portion of a retirement annuity or a former spouse survivor annuity; a letter from the former spouse canceling enrollment; or a retirement system notice that a refund has been paid to the former employee or that he/she has died and no survivor annuity is payable.

File Disposition

You must keep the former spouse's health benefits file for as long as you maintain his/her spouse equity enrollment. (If he/she becomes a Federal employee eligible for an employee enrollment, his/her employing office maintains the enrollment as an employee, and you will continue to maintain the inactive former spouse enrollment.)

If the former spouse did not qualify for coverage under the spouse equity provisions, you must keep the file containing the records for at least one year from the date of notice stating that he/she did not qualify. You may then either destroy the file contents or return it to the former spouse.

Transfer to Retirement System

You will transfer the former spouse's health benefits file to the appropriate retirement system when:

  • the former spouse cancels the enrollment;
  • you terminate his/her enrollment;
  • he/she begins receiving an annuity payment (a portion of the employee's retirement annuity or a former spouse survivor annuity). At that time the retirement system begins to withhold premiums from the annuity check and becomes the former spouse's employing office.

You will send the former spouse's health benefits file to the applicable retirement system address shown below:

Retirement System

Address

Civil Service Retirement System

Office of Personnel Management, Retirement and Insurance Service, Office of Retirement Programs, P.O. Box 45, Boyers, PA 16017

Federal Employees Retirement System

Federal Employees Retirement System, P.O. Box 200, Boyers, PA 16017

Foreign Service Retirement and Disability System

Department of State, Retirement Division, Room 1251, Washington, DC 20520

CIA Retirement and Disability System

Central Intelligence Agency, P.O. Box 1925, Washington, DC 20505

Effective Date

The effective date of the former spouse's enrollment is the first day of the first pay period after you receive the Health Benefits Election Form (SF 2809) and you have approved eligibility.

If the former spouse requests immediate coverage, and you receive the Health Benefits Election Form (SF 2809) and satisfactory proof of eligibility within 60 days after the date of the divorce, you may make the enrollment effective on the same day that temporary continuation of coverage would otherwise take effect.

Except as specified in this section, an enrollment change is effective on the first day of the first pay period beginning after the date you receive the SF 2809.

OPPORTUNITIES TO ENROLL OR CHANGE ENROLLMENT

When you determine that the former spouse is eligible, he/she may enroll at any time.

Belated Enrollment

When you determine that the former spouse wasn't able to enroll or change enrollment within the required time frame for reasons beyond his/her control, you may permit the former spouse to do so within 60 days after your determination.

Enrollment by Proxy

The former spouse's representative may enroll or change enrollment for the former spouse with his/her written authorization.

Change to Self Only

The former spouse may change his/her enrollment from self and family to self only at any time. A change to a self only enrollment is effective on the first day of the first pay period beginning after you receive the Health Benefits Election Form (SF 2809). At the former spouse's written request and with proof that there was no family member eligible for coverage, you may make the change retroactive to the first day of the pay period following the one in which there were no remaining eligible family members.

Open Season

During Open Season, the former spouse may change enrollment from self only to self and family, from one plan or option to another, or make any combination of these changes. With a self and family enrollment, the only eligible family members are the natural or adopted children of the former spouse and the Federal employee or annuitant on whose service coverage is based.

If the former spouse:

  • previously informed you that he/she suspended the spouse equity enrollment to enroll in a Medicare managed care plan or Medicaid (or a similar State-sponsored program of medical assistance for the needy); and
  • later voluntarily disenrolls,

he/she may reenroll under the spouse equity provisions during Open Season provided he/she still qualifies for a spouse equity enrollment. (If the former spouse involuntarily loses the Medicare managed care plan or Medicaid coverage, he/she can immediately reenroll.)

An Open Season reenrollment or change in enrollment is effective on the first day of the first pay period beginning in January of the following year. When you accept a late Open Season reenrollment or change in enrollment it takes effect on the date it normally would have been effective if it had been received on time.

Change in Family Status

The former spouse may change from self only to self and family, from one plan or option to another, or make any combination of these changes from 31 days before to 60 days after the birth or acquisition of a natural or adopted child of the former spouse and the Federal employee or annuitant on whose service coverage is based. The change to self and family coverage is effective on the first day of the pay period in which the child is born or becomes an eligible family member.

Loss of Other FEHB Coverage or Coverage under Another Group Insurance Plan

The former spouse may change from self only to self and family, from one plan or option to another, or make any combination of these changes when the former spouse or an eligible child loses other FEHB coverage or coverage under another group health benefits plan. Unless stated otherwise, he/she must change the enrollment from 31 days before to 60 days after the loss of coverage.

Examples of loss of coverage include:

  • Loss of coverage under another FEHB enrollment because the covering enrollment was terminated, canceled, or changed to self only;
  • Loss of coverage under another federally-sponsored health benefits program;
  • Loss of coverage because membership in an employee organization sponsoring or underwriting an FEHB plan was terminated;
  • Loss of coverage because an FEHB plan was discontinued in whole or in part. If the discontinuation is at the end of the contract year, he/she must change the enrollment during the Open Season, unless OPM sets a different time frame. If the discontinuation is at a time other than the end of the contract year, OPM will set the time and effective date for changing the enrollment. If the whole plan is discontinued and he/she doesn't change within the set time frame, he/she is considered to have canceled the enrollment. If only one option of a two-option plan is discontinued and he/she doesn't change within the set time frame, he/she is considered to be enrolled in the remaining plan option.
  • Loss of coverage under the Medicaid program (or similar State-sponsored program of medical assistance for the needy);
  • Loss of coverage under a non-Federal health plan.

Move from an HMO's Service Area

If the former spouse is enrolled in an HMO and moves or becomes employed outside the plan's service area (or, if already outside this area, moves or becomes employed further away) he/she may change the enrollment. If a covered family member moves outside the plan's service area (or if already outside this area, moves further away), the former spouse may also change the enrollment. The enrollment change is effective on the first day of the pay period beginning after you receive the Health Benefits Election Form (SF 2809) or other enrollment request.

On Becoming Eligible for Medicare

The former spouse may change enrollment from one plan or option to another at any time beginning 30 days before becoming eligible for Medicare coverage. An enrollment change based on becoming eligible for Medicare may be made only once.

Annuity Insufficient to Pay Withholdings

If the former spouse's employing office is a retirement system:

If the former spouse's annuity is insufficient to pay the premiums, you must provide him/her with information and give the former spouse to either:

  • pay premiums directly to the retirement system; or
  • enroll in a plan with a premium less than the annuity amount.

If the former spouse elects to change to a lower cost plan, make the change effective immediately upon loss of coverage in the prior plan.

If the former spouse is enrolled in the high option of a two-option plan and does not make one of the elections noted above, change the enrollment to the standard option of the same plan (unless the annuity won't cover the cost of the standard option). If the former spouse is enrolled in a one-option plan, and doesn't make one of the elections, terminate the enrollment.

Former Spouses with Other FEHB Coverage

Once the former spouse has established eligibility for FEHB coverage, he/she may defer enrolling under spouse equity provisions if he/she is already enrolled in FEHB.

When the former spouse loses regular coverage under FEHB, he/she may enroll under spouse equity provisions from 31 days before to 60 days after the covering enrollment terminates, as long as he/she continues to meet the eligibility requirements. The former spouse may enroll in any available plan.

When Both Spouses have FEHB Enrollments

If both spouses have their own FEHB enrollments and divorce, it is important for each to establish his/her eligibility for FEHB coverage under spouse equity provisions within the required time frame. In this way each can protect a future entitlement to FEHB coverage under spouse equity provisions if one loses his/her own FEHB coverage. Each spouse must apply to his/her former spouse's employing office for the determination, not his/her own employing office.

If you determine that a Federal employee is eligible for coverage under spouse equity provisions, advise the employee that he/she must provide a copy of your determination to his/her current employing office. The current employing office must note on his/her Individual Retirement Record that he/she is eligible for FEHB coverage under spouse equity provisions. You must maintain a health benefits file for the former spouse and note that he/she is deferring enrollment under spouse equity provisions until he/she loses enrollment as an employee.

When an Employee Loses Coverage and Enrolls as a Former Spouse

When the former spouse's enrollment as an employee terminates, the current employing office must terminate his/her enrollment on the Notice of Change in Health Benefits Enrollment (SF 2810) and note the time limits for enrolling as a former spouse with other FEHB coverage. The former spouse then must notify you of his/her intent to enroll under spouse equity provisions. If he/she is still eligible as a former spouse, accept the enrollment based on the submission of a Health Benefits Election Form (SF 2809). Give the former spouse a certification to sign and date and a premium payment schedule.

Note on the SF 2809 that the former spouse was previously covered as an employee and is now enrolling under the same Social Security number under spouse equity provisions. Once the spouse equity coverage begins, you must collect both the employee and Government shares of the premium from the former spouse.

If you determine that the former spouse is no longer eligible to enroll under spouse equity provisions, deny the enrollment, explain his/her right to request reconsideration, and place a copy of the request for enrollment and your denial in the former spouse's health benefits file.

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