Eligibility for Health Benefits
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Temporary Employee's Change in
Employment Status
If your employment status
changes from a temporary employee enrolled under 5 U.S.C. 8906a to a position in which
you become eligible to receive the Government contribution, your employing office will
document the change on the Notice of Change in Health Benefits Enrollment (SF 2810). The
SF 2810 documents the change in premium withholding and when your enrollment begins to
count toward the requirement
for continuation after retirement. (You may change your enrollment
if you wish.)
Your employing office will complete parts A, G, and H of the SF 2810, and enter the
following remark in Part G: "Employee has been converted/appointed to a position in
which (he)(she) participates in a retirement system and is eligible for the Government
contribution to the premium."
Name Change
If your name changes but your enrollment does not, your employing office must report it
to your carrier. Your employing office prepares a Notice of Change in Health Benefits
Enrollment (SF 2810) and notes in the Remarks section the reason and date of the change
(e.g., "Employee married [date])."
Reinstatement of
Enrollment
When your enrollment is reinstated, your employing office will complete parts A, D, and
H of Notice of Change in Health Benefits Enrollment (SF 2810). It will note in the Remarks
section the event permitting reinstatement (e.g., "Returned from military
service", "Employee reinstated", or "Correction of erroneous
termination of enrollment").
Your employing office will send you the enrollee copy, file a copy on the right side of
the Official Personnel Folder, and send the carrier and payroll office copies to the
payroll office for transmission to the carrier and posting to the payroll records,
respectively.
Transfer Between Payroll Offices
Continued Coverage
Your enrollment and coverage continue without change when you transfer from one payroll
office to another without a break in service of more than 3 days. Your employing office
will promptly take action to transfer your enrollment. See "When You Transfer to a Different
Payroll Office (Daily Proration Rule)" for information on each payroll office's
responsibility for withholdings and contributions.
Gaining Employing
Office Actions
Your gaining employing office will perform a record check on SF 75 before you enter on
duty to establish your current enrollment status, enrollment code number, and Social
Security number.
When you enter on duty, your employing office will:
- review SF 75 with you to confirm its accuracy. It will inform you of any opportunities
you may have at that time to change your enrollment
(e.g., if you moved out of your HMO's service area);
- complete a Notice of Change in Health Benefits Enrollment (SF 2810), including parts C
and H, transferring the enrollment to the gaining employing office;
- give you the enrollee copy of the new SF 2810. It will keep a file copy for your
Official Personnel Folder, and send the carrier and payroll office copies to the payroll
office for transmission to the carrier and posting to the payroll records, respectively;
- verify the transfer-in action on the basis of the health benefits documents located in
your Official Personnel Folder. If the action was correct, it will file a copy of SF 2810
on the right side of the Official Personnel Folder (or its equivalent). If the action was
not correct, it will correct the error.
(If the losing office erroneously terminated your enrollment, the gaining employing office
will use part D to show a reinstatement of the enrollment rather than part C to show a
transfer in.)
Mass Transfers
When you are part of a group of 25 or more employees enrolled in the same plan to be
transferred on the same day from one payroll office to another payroll office, your
employing office doesn't need to prepare a separate transfer-in Notice of Change in Health
Benefits Enrollment (SF 2810) for each of you. The gaining employing office may make a
list of all the employees involved in the transfer and attach several copies to only one
SF 2810 documenting the mass transfer in. It will post the change in payroll office number
on the latest SF 2809 in each of your Official Personnel Folders so that the payroll
office number is up to date.
The gaining employing office will prepare the list in three columns, with column 1 for
the employee's name, column 2 for the Social Security Number, and column 3 for the
enrollment code number.
Voiding Health Benefits Actions
When Voiding is
Appropriate
Voiding is appropriate only when an incorrect health benefits action must be withdrawn
and your enrollment status must revert to what it was before the incorrect action was
taken. Voiding has the effect of removing the incorrect action as though it never
occurred.
Procedure
To void an action, your employing office marks "VOID" in bold letters on the
Official Personnel Folder and payroll office copies of the form on which the incorrect
action was taken (either the SF 2809 or SF 2810), and explains the action in the Remarks
section. Additional remarks are required when an erroneous enrollment is voided.
If your employing office had sent the carrier's copy of the form, it will send the
voided payroll office copy to the carrier with the next regular transmittal. If the action being voided is a change in plan, it will send a copy of the
voided SF 2809 to both the old and new carrier. Your employing office will keep a copy in
your Official Personnel Folder (OPF). If a copy had not been sent to the carrier, it will
destroy all but one copy to be retained in your OPF.
Correction of Information on Forms
Your employing office must correct and report to your carrier erroneous information
given on the Health Benefits Election Form (SF 2809) or Notice of Change in Health
Benefits Enrollment form (SF 2810) that would affect your entitlement to benefits.
Significant errors include errors in your name, enrollment code, Social Security number,
the effective date of a health benefits action, or a listing of family members when there
are none.
Your employing office will make a correction on SF 2809 or SF 2810 (depending on which
of these forms contains the erroneous information), and clearly label the form
"CORRECTION." The corrected form must give your name, Social Security number,
and other identifying data. The form may show only the specific item(s) being corrected,
or your employing office may substitute another complete corrected form for the one
previously submitted. Your employing office will send the corrected form to your carrier
with the next regular transmittal. If the erroneous information was sent to both the
old and the new carriers, each will be sent a corrected form.
Reporting Enrollment and Changes in Enrollment to Carriers
Delegation of Authority
Title 6 of the General Accounting Office Manual for Guidance of Federal Agencies, which
provides principles and standards for payroll office operations, delegates to OPM the
authority to prescribe the principles and standards for payroll transactions for the FEHB Program.
Timely Processing of Transmittals to Carriers
On at least a weekly basis, your payroll office will send copies of Health Benefits
Election forms (SF 2809) and Notice of Change in Health Benefits Enrollment forms (SF
2810) to the appropriate carrier with the transmittal document. Your payroll office cannot accumulate health benefits
forms for longer than one week.
Verification
Before transmitting a copy of a health benefits form to a carrier, your payroll office
must verify that the payroll action required by the form can be taken (e.g., that you were
in pay status during the pay period before the effective date, if it is a requirement for
that action). A copy of the form can be released to the carrier before payroll action is
completed to adjust the health benefits control or to note the individual pay record.
Preparing Transmittal Report
Your payroll office will prepare an original and two copies of the transmittal report. It will send the original and
one copy to the carrier with the carrier copies of Health Benefits Election forms (SF
2809) and Notice of Change in Health Benefits Enrollment forms (SF 2810). It will hold the
second copy until the carrier returns a certified copy.
Carrier addresses for fee-for-service plans and HMOs are provided to payroll
offices by OPM before the start of each annual Open Season. The carrier code is the first
two characters of the carrier's enrollment code number.
Payroll Office Number
Each agency payroll office that reports FEHB withholdings and contributions uses a
unique eight digit identification number. The first two digits represent the agency
(assigned by the U.S. Treasury Department) and the last six digits identify the payroll
office within the agency. Agency headquarters must notify OPM of any establishment of or
change in payroll office number.
The payroll office number must be provided on every health benefits form (SF 2809,
2810, and transmittal document). In most cases, the agency office that
maintains the Retirement and Insurance Transfer System (RITS) also maintains the FEHB
enrollment. When different offices are responsible for maintaining RITS and FEHB
enrollment, OPM maintains a payroll office directory, containing the addresses and phone
numbers of agency offices that prepare RITS and FEHB enrollment information. It is
important that agencies promptly report changes to OPM so this directory is kept current.
Carriers must also be notified of changes so they can update their records. This is done
in the same way as a mass transfer.
Report Number
Your payroll office must enter a report number on each Transmittal Report that it prepares. The first two digits
designate the calendar year and the remaining digits run in numerical sequence, starting
with number 1. Thus, 99-1 is the number of the first transmittal sent on or after January
1, 1999; 99-2 is the number of the second transmittal in that year, etc. A new series
starting with number 1 begins each calendar year.
Your payroll office will enter the transmittal report number in the appropriate space
on each Health Benefits Election Form (SF 2809) and Notice of Change in Health Benefits
Enrollment form (SF 2810) sent with that transmittal and on the corresponding payroll
office copies.
Transmittal
Your payroll office will show the number of Health Benefits Election Forms (SF 2809)
and Notice of Change in Health Benefits Enrollment forms (SF 2810) sent with that
transmittal to carrier in the space provided.
Carrier Enrollment Records
OPM does not require a specific enrollment records system for carriers. Carriers must
maintain their records in a way that allows for easy determination of the number and
identity of enrollees served by individual payroll offices for control and statistical
reporting and for reconciliations.
Reconciliation
OPM requires the quarterly reconciliation of carrier enrollment records with agency
personnel and payroll records. These reconciliations are critical to ensure that enrollees
receive the health benefits to which they are entitled.
Joint
Payroll Office-Carrier Reconciliations
Each payroll office will reconcile the names and numbers of enrollees in a particular plan with the carrier's records through the National Finance Center (NFC). OPM urges payroll offices and carriers to fully cooperate to maintain accurate and up-to-date enrollment files.
Each payroll office and carrier is required to submit an electronic listing of those enrolled in a FEHB health plan to the NFC on a quarterly basis. The data submitted is to be "as of" March 1, June 1, September 1, or December 1, or as close to those dates as the closest pay period allows. The data is to be submitted in a format designed by NFC and approved by OPM. The social security number is the principal identifying number and must be submitted by all parties. NFC will conduct a computer match of records submitted by payroll offices versus records submitted by carriers and identify discrepancies. These discrepancies are then posted on a secure website known as the Centralized Enrollment Reconciliation Clearinghouse, or CLER for short. Payroll offices are then to resolve the discrepancies with the carriers. Carriers may also contact payroll offices to request resolution of specific discrepancies.
For those enrollments that are reported to CLER only by the carriers, the carriers may use the FEHB Disenrollment Procedures to unilaterally resolve these discrepancies.
The carrier must keep the reconciliation results and work papers for inspection by OPM and the General Accounting Office.
Use of Social Security Numbers in Reconciling Enrollments
Your carrier is required to use your Social Security number to reconcile
enrollments. Social Security numbers must be clearly shown on any Health Benefits Election
forms (SF 2809) and Notice of Change in Health Benefits Enrollment forms (SF 2810)
processed and forwarded to the carriers. Social Security numbers must be available for use
in the reconciliation process either within the payroll office or during the joint payroll
office-carrier reconciliations.
If you object to giving your carrier your Social Security number, your employing office
may make special provisions to accommodate your wishes. However, it may be difficult for
the carrier to pay your claims or provide services without using your Social Security
number as an identifier.
Disenrollment
When a carrier can not reconcile
its records of your enrollment with the employing office's enrollment records, or when it
does not receive the necessary documentation from the employing office to resolve the
discrepancy within 31 days from its request, the carrier may proceed with your
disenrollment.
The carrier must provide you with written notice that the employing office of record
does not show you as enrolled in the carrier's plan and that you will be disenrolled 31
calendar days after the date of the notice unless you can provide documentation of your
enrollment. This documentation may include:
- a copy of the Health Benefits Enrollment Form (SF 2809) or a letter confirming an
electronic transaction;
- a Notice of Change in Health Benefits Enrollment (SF 2810) (or the equivalent electronic
submission) transferring your enrollment;
- copies of earnings and leave statements or annuity statements showing withholdings for
the plan; or
- a document or other credible information from your employing office stating that you are
entitled to continued enrollment in the plan and that premiums are being paid.
After receiving your documentation, the carrier must notify you and your employing
office of its decision on your information. If the carrier does not receive documentation
of your enrollment within 31 calendar days from its notice, you will be disenrolled from
its plan, without further notice.
You may request that your employing office reconsider
the carrier's disenrollment decision. Your reconsideration request must be filed within 60
calendar days of the date of the carrier's disenrollment notice. Your employing office
must notify the carrier when it receives such a request.
If, at any time after disenrollment, your employing office or OPM determines that you
should be enrolled under another coverage provision, or if the carrier receives
appropriate documentation showing that you should be enrolled, the disenrollment is void
and coverage is reinstated retroactively.
Other Disenrollment
Actions
A carrier also has the right to disenroll:
- an individual with a Self Only enrollment when it receives reliable information that the
person has died;
- a child survivor annuitant with a Self Only enrollment when he/she reaches age 26,
unless the carrier's records indicate that the child is incapable of self-support due to a
physical or mental disability;
- an enrollee who notifies the carrier that he/she has separated from Federal employment
and is no longer eligible for FEHB enrollment.
Notice of disenrollment must be provided to a child survivor annuitant or a former
employee. The notice must be provided to the child survivor annuitant prior to the
disenrollment date.
A child survivor annuitant has the right to request that the retirement system reconsider the disenrollment decision.
If, at any time after disenrollment, the employing office or OPM determines that
coverage should be extended under another coverage provision, or if the carrier receives
appropriate documentation of the enrollment, the disenrollment is void and coverage is
reinstated retroactively.