Eligibility for Health Benefits
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Initial Decision and Reconsideration
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
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
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).