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Healthcare Reference Materials

Family Members

Family Members Eligible for Coverage

Employing Office Responsibilities

Your employing office is responsible for making decisions about whether a family member is eligible for coverage. If the carrier of your health benefits plan has any questions about whether someone is an eligible family member, it may ask you or your employing office for more information. The carrier must accept your employing office's decision on your family member's eligibility.

General Eligibility for Coverage

Family members eligible for coverage under your Self and Family enrollment are your spouse (including a valid common law marriage) and children under age 26, including legally adopted children, recognized natural (born out of wedlock) children and stepchildren (including children of same-sex domestic partners). A child is eligible for coverage under your Self and Family enrollment, if a state-issued birth certificate lists you as a parent of that child.

Foster children are included if they meet the requirements listed here:

  • the child must be under age 26 (if the child is age 26 or over, he/she must be incapable of self-support);
  • the child must currently live with you;
  • the parent-child relationship must be with you, not the child's biological parent;
  • you must currently be the primary source of financial support for the child; and
  • you must expect to raise the child to adulthood.

A child age 26 or over who is incapable of self-support because of a mental or physical disability that existed before age 26 is also an eligible family member. In determining whether the child is a covered family member, your employing office will look at the child's relationship to you as the enrollee.

A grandchild is not an eligible family member, unless the child qualifies as your foster child.

Special rules apply to family members if you are enrolled as a survivor annuitant or under the Spouse Equity or temporary continuation of coverage (TCC) provisions.

Defense of Marriage Act

On June 26, 2013, the Supreme Court ruled that Section 3 of the Defense of Marriage Act (DOMA) is unconstitutional. As a result of the Supreme Court’s June 26, 2013 ruling that Section 3 of DOMA is unconstitutional, legally married same-sex spouses will be eligible family members under a Self and Family enrollment.  Coverage is available to any legally married same-sex spouse of any Federal employee or annuitant, regardless of the employee’s or annuitant’s state of residency.

In addition, the children of same-sex marriages will be treated in the same manner as those of opposite-sex marriages and will be eligible family members according to the same eligibility guidelines.  This includes coverage for children of same-sex spouses as stepchildren.

Eligible Family Members Automatically Covered

When you enroll for Self and Family, you automatically include all eligible members of your family. If you don't list an eligible family member on your Health Benefits Election Form (SF 2809) or other enrollment request, that person is still entitled to coverage. If you list a person who is not an eligible family member, your employing office will explain why the person is not eligible for coverage and will remove the name from the list. The listing of an ineligible person on the SF 2809 doesn't entitle him/her to benefits.

Adopted Children

Applicable State law governs whether a child has been adopted. The child is adopted if the adoption decree is final. The child also is considered adopted if the adoption decree is interlocutory and State law provides that the rights of the child generally are the same as those of an adopted child.

Stepchildren

In general, your spouse's child born within or outside marriage or adopted child is considered to be your stepchild. In addition, the child of your same-sex domestic partner (as described below & certified to your agency) is eligible for coverage under a Self and Family enrollment if you would marry your partner but live in a state that does not recognize same-sex marriage. However, your spouse or same-sex domestic partner’s stepchild (by a previous marriage) is not your stepchild.

Children of Same-Sex Domestic Partners

Declaration of Domestic Partnership A domestic partnership is defined as a committed relationship between two adults, of the same sex, in which the partners:

  • Are each other’s sole domestic partners and intend to remain so indefinitely;
  • Maintain a common residence and intend to continue the arrangement indefinitely;
  • Are at least 18 years of age and mentally competent to consent to contract;
  • Share responsibility for a significant measure of each other’s financial obligations;
  • Are not married or joined in a civil union to anyone else;
  • Are not a domestic partner of anyone else;
  • Are not related in a way that, if they were of opposite sex, would prohibit legal marriage in the U.S. jurisdiction in which the domestic partnership was formed.

To cover a child of a same-sex domestic partner, you must provide a Declaration of Domestic Partnership (your employing office or retirement system can give you a copy) establishing fulfillment of the above requirements and in which you certify:

  • that you understand that falsification of the documentation may lead to disciplinary action; and
  • that you would marry your partner but for the failure of your state of residence to permit same-sex marriage.

You do not need to meet any further requirements (e.g. state law requirements for registered domestic partners) for a domestic partnership besides those listed above. For employees and annuitants living in states that do not permit same-sex marriage, the completed Declaration of Domestic Partnership establishes employee or annuitant eligibility for this benefit and is considered a Qualifying Life Event.

Tax Treatment

If your stepchild is considered your tax dependent, providing coverage to your stepchild will have no effect on your taxable income.

If your stepchild is not considered your tax dependent, you will be taxed on the fair market value of the coverage provided to your stepchild. Please consult your tax advisor for further information.

To alert your agency or retirement system of the tax status of your stepchild, you must submit a Tax Certification. Contact your employing office or retirement system for a copy of the Tax Certification. A Tax Certification is not a requirement for covering your child; but, failure to submit a Tax Certification will result in taxation of the coverage provided to your stepchild. You need to submit a new Tax Certification to your employing office or retirement system if your stepchild's tax dependent status changes.

Applicable State Law

Because state law concerning same-sex marriage may change during the year, for mid-year enrollments, the determination of the status of the law of the state where you live will be made as of the date you notify your employing agency/retirement system of your desire to cover your stepchild.

For Open Season enrollments, the status of the law of the state where you live as of the day before the beginning of Open Season will determine whether your stepchild is eligible to be covered.

If your state’s law changes to allow same-sex marriage or if you move to a state that allows same-sex marriage in the middle of the year, your child’s continuing eligibility for coverage as a stepchild for the remainder of a particular plan year will not be affected. However, if you marry your same-sex domestic partner mid-year, you should notify your employing office or retirement system; and your child will automatically be considered your tax dependent and there will no longer be any potential tax consequences associated with coverage of the child.

If the law in your state changes to allow same-sex marriage, your stepchild will only be permitted to continue to be covered under your enrollment as a stepchild in following plan years if, on the day before the beginning of Open Season for the following plan year, you live in a state that does not permit same-sex marriage. It is your responsibility to notify your employing office or retirement system if your stepchild is not eligible to be covered in the following year because you 1) move to a new state mid-year or 2) because the law changes in your state.

Please note that if your state law changes to allow same-sex marriage, you can continue to cover your child under a Self and Family enrollment in the following plan year if you and same-sex domestic partner are married.

A list of states that allow same-sex marriage is available on the OPM website.

Coverage of Stepchildren after Divorce

Under the FEHB Program, your stepchild remains a stepchild and an eligible family member after your divorce from, or the death of, the natural parent, provided that the stepchild continues to live with you in a regular parent-child relationship.

If your stepchild stops living with you in a regular parent-child relationship, the child is eligible for coverage under temporary continuation of coverage (TCC) provisions because he/she no longer meets the definition of an eligible child.

If you divorce and your former spouse is eligible to enroll under either the Spouse Equity or TCC provisions, only the natural or adopted children of both you and your former spouse are covered under your former spouse's Self and Family enrollment. Your stepchildren are not covered even though they may have been covered previously by your Self and Family enrollment. However, they may qualify for a TCC enrollment of their own.

Foster Children

Requirements

To be considered a foster child for health benefits purposes:

  • the child must be under age 26 (if the child is over age 26 or over, he/she must be incapable of self-support);
  • the child must currently live with you;
  • the parent-child relationship must be with you, not the child's biological parent;
  • you must currently be the primary source of financial support for the child; and
  • you must expect to raise the child to adulthood.

You don't need to be related to the child nor do you need to legally adopt him/her. As long as the above requirements are met, you may have a foster parent-child relationship even when:

  • the child's natural parents are alive;
  • the child's natural parent lives with you; or
  • the child receives some support from sources other than you (for example, social security payments or support payments from a parent).

Common examples of a foster parent-child relationship are:

  • A child whose parents have died is living with, and being supported by, a close relative who is an enrollee.
  • A child who is living with and financially dependent on a grandparent who is an enrollee. (The natural parent of the child may also be a dependent.)
  • A child living with an enrollee under a preadoption agreement.
  • A child who is in the legal custody of an enrollee.

How to Get a Foster Child Covered

For your foster child to be covered under your FEHB enrollment, you must provide documentation of your regular and substantial support of the child; sign a certification stating that your foster child meets all the requirements

Certification for Foster Children

You may use the following link to the foster child certification to establish your foster child's eligibility for coverage as a family member to your employing office. Your employing office must file the original statement in your Official Personal Folder.

CERTIFICATION FOR FOSTER CHILDREN

I have been informed of the following requirements for coverage of a foster child under the Federal Employees Health Benefits Program:

  1. The child must be under age 26. (If the child is age 26 or older, he/she can only be covered if he/she is incapable of self-support because of a disabling condition that began before age 26. I must provide documentation of this to my employing office.);
  2. The child must currently live with me;
  3. I must currently be the primary source of financial support for the child;
  4. The parent-child relationship must be with me, not with the biological parent. This means that I am exercise parental authority, responsibility, and control. I care for, support, discipline, and guide the child. I make the decisions about the child's education and health care; and
  5. I must expect to raise the child into adulthood.

I understand that if the child moves out of my home to live with a biological parent, he/she loses coverage and cannot ever again be covered as a foster child unless the biological parent dies, is imprisoned, or becomes incapable of caring for the child due to a disability, or unless I obtain a court order taking parental responsibility away from the biological parent.

This is to certify that: ____________________ (name of child) lives with me; I am the primary source of financial support for this child; I have a regular parent-child relationship with this child, as described above; and I intend to raise this child into adulthood.

I have provided my employing agency proof of my regular and substantial support for ___________________________(name of child).

I will immediately notify both my employing office and the health benefits carrier if this child moves out of my home, or ceases to be financially dependent on me.

(Print name of employee/annuitant)                          (Social Security Number)

(Signature of employee/annuitant)                            (Date)

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Family Members Eligible for Coverage (Continued)

Effective Date

The effective date of your foster child's coverage as a family member is the first day of the pay period in which your employing office receives all of the properly completed documents that establish the eligibility of the child as a foster child. When your foster child's mother is an eligible family member under your enrollment, you may request that the effective date be the first day of the pay period in which the child is born.

When Coverage Ends

Your foster child's coverage continues until he/she reaches age 26, becomes capable of self-support if age 26 or over, or is no longer living with you. If your foster child moves out of your home to live with a biological parent, the child cannot again be covered as your foster child unless:

  • the biological parent dies;
  • the biological parent is imprisoned;
  • the biological parent becomes unable to care for the child due to a disability; or
  • you obtain a court order for custody that takes parental responsibility from the biological parent and gives it to you.

Grandchildren

Grandchildren are not eligible family members. However, your grandchild can qualify as a foster child if all the requirements are met.

When a Child is Not Considered a Foster Child

A child who has been placed in your home by a welfare or social service agency under an agreement where the agency retains control of the child or pays for maintenance does not qualify as a foster child because there is no regular parent-child relationship. A child living temporarily with you as a matter of convenience does not qualify as a foster child. For example, a child who lives with you only while attending school normally does not qualify as a foster child because this is considered an arrangement of convenience.

Since it is impossible to cover every family situation, it may be necessary for the agency headquarters Benefits Officer to contact OPM for assistance in making difficult determinations.

A Child's Temporary Absences

If your foster child temporarily lives elsewhere while attending school or for other reasons, the child is still considered to be an eligible family member if he/she is otherwise living with you in a regular Parent-Child Relationship. Your foster child who lives with you at least 6 months of a year under a court order directing shared custody may be considered living with you in a regular Parent-Child Relationship.

Parent-Child Relationship

A "regular ParentChildRelationship" means that you are exercising parental authority, responsibility, and control over the child by caring for, supporting, disciplining, and guiding the child, including making decisions about the child's education and health care.

A Spouse Equity Self and Family enrollment is limited to natural and adopted children of both you and your former spouse. In this case, a foster child or stepchild is not a covered family member.

Relatives Who are Not Family Members

Your parents and other relatives are not eligible family members, even if they live with and are dependent upon you.

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Change in Family Status

Election Opportunities

When you have a change in family status, including a change in marital status, you may enroll, change from Self Only to Self and Family, or change from one plan or option to another. You must submit your enrollment change from 31 days before to 60 days after the change in family status.

Certain restrictions apply if you are enrolled as a survivor annuitant or as a former spouse under the Spouse Equity or temporary continuation of coverage (TCC) provisions.

Events Considered to be Changes in Family Status

Generally, a change in family status is an event that adds to or decreases the number of your family members. Certain other events are also considered changes in family status. The following events are considered a change in family status for health benefits purposes:

  • your marriage, including a valid common law marriage (in accordance with applicable State law);
  • birth of your child (but not a stillborn child);
  • your legal adoption of a child under age 26 or the acquisition of a foster child under age 26;
  • your submission of a Declaration of Domestic Partnership to your employing office or retirement system;
  • your child under age 26 or spouse enters into or is discharged from military service;
  • issuance or termination of a court order granting to you or your spouse a final divorce, interlocutory divorce, limited divorce, legal separation, or separate maintenance;
  • issuance of a court decree of annulment, or in the case of a marriage void from its beginning (ab initio) also a declaratory judgment, or conviction of the spouse of bigamy;
  • issuance of a court order specifically requiring you to enroll for your children or provide health benefits protection for them;
  • the death of your spouse, including a declaration by a court that your missing spouse is presumed dead.

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When a Court Order Requires You to Provide Coverage for Your Children (Children's Equity)

Public Law 106-394 requires mandatory Self and Family coverage if you are eligible for FEHB coverage and you do not comply with a court or administrative order to provide health benefits for your children. If you are subject to such an order, you must enroll in Self and Family coverage in a plan that provides full benefits to your children in the area where they live or provide documentation that you have other health coverage for the children.

If you do not enroll in an appropriate health plan or provide documentation of other coverage for the children, your agency must enroll you for Self and Family coverage in the lower option of the Blue Cross and Blue Shield Service Benefit Plan (enrollment code 112).

Court/Administrative Orders

The court or administrative order can be submitted by anyone, including the custodial parent, an attorney for the custodial parent, and the State administrative agency that issues the order.

If the court order deals only with health benefits, it does not have to be certified. If the court order also deals with life insurance or retirement benefits, then it does have to be certified. Administrative orders come from State child support agencies, and will not be certified.

For it to be considered valid under Pub. L. 106-394, your agency must receive the court/administrative order on or after October 30, 2000.

Anyone who submitted a court/administrative order relating to health benefits for your children before October 30, 2000, would have to resubmit it. The court/administrative order can be issued before October 30, 2000, but it doesn't have any validity for FEHB purposes unless your agency receives it on or after October 30, 2000.

Employing Office Review

Your employing office must review your records to determine whether you are eligible for FEHB and, if so, whether you are enrolled in a Self and Family plan that provides full benefits in the location where your children live. If you have such coverage, your employing office will notify whoever sent in the court/administrative order. It will send a copy of your SF 2809 to your health benefits carrier, along with a copy of the court/administrative order to notify the carrier of the additional family members being covered under the Self and Family enrollment.

Your employing office will file the order in your Official Personnel Folder (OPF), and flag the OPF or other file in some manner that it will know the file contains a court/administrative order relating to health benefits.

If You Don't Have Self and Family Coverage or Coverage that Provides Full Benefits in the Area Where the Children Live

If you are eligible for FEHB but don't have the appropriate coverage, you employing office will notify you that it has received a court order requiring you to provide health benefits for your children. Your employing office will give you until the end of the pay period following the one in which you get the notice to enroll in an appropriate health plan or provide documentation that you have other health benefits for the children.

Your employing office may use the following sample notification.

Sample Notice

Dear [Employee's name]:

We have received a [court/administrative] order stating that you must provide health benefits for your child[ren]. You are not currently enrolled in Self and Family coverage under the Federal Employees Health Benefits (FEHB) Program in a health plan that provides full benefits in the area where your child[ren] live[s].

Pub. L. 106-394 requires Federal agencies to ensure that employees comply with the terms of such court and administrative orders. You must enroll in Self and Family coverage in a plan that provides full benefits where your child[ren] live[s] or provide documentation that you have other health benefits for your child[ren] by [insert date that is the last day of the pay period following the one in which this notice is issued].

If you do not enroll or provide documentation of other coverage for your child[ren] by [repeat date from paragraph above], we will enroll you for Self and Family coverage under the lower option of the Blue Cross and Blue Shield Service Benefit Plan.

As long as the [court/administrative] order remains in effect and your child[ren] [is/are] eligible under the FEHB Program, you must continue Self and Family coverage in a plan that provides full benefits where your child[ren] live[s], unless you provide documentation that you have obtained other coverage.

Sincerely,

[Signature, name, and title of appropriate official]

[In addition to sending a copy to the employee, keep a copy in the employee's OPF or other record.]

What Happens If I Don't Enroll or Provide Documentation of Other Coverage by the Due Date?

If you don't enroll in an appropriate plan or provide documentation of other coverage for the children, your employing office will enroll you as follows:

If You Are Not Enrolled at All

If you are not enrolled for any FEHB coverage, your employing office will enroll you for Self and Family coverage in the lower option of the Blue Cross and Blue Shield Service Benefit Plan (enrollment code 112).

If You Have Self Only Coverage

If you have a Self Only enrollment in a fee-for-service plan, your employing office will change your enrollment to Self and Family in the same option of the same plan.

If you have a Self Only enrollment in an HMO, and the HMO serves the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan.

If you have a Self Only enrollment in an HMO, and the HMO does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the lower option of Blue Cross and Blue Shield Service Benefit Plan.

If You Have Self and Family Coverage in an HMO That Doesn't Serve the Area Where Your Children Live

If you already have a Self and Family enrollment, but it's in an HMO that doesn't serve the area where your children live, your employing office will change your enrollment to Self and Family in the lower option of Blue Cross and Blue Shield Service Benefit Plan.

How an Agency Enrolls You Involuntarily

If your employing office needs to enroll you involuntarily, it will complete a Health Benefits Election form (SF 2809) with your identifying information. It will use event code 1C (Change in family status). In the signature block in Part G, it will write "See Remarks." In the remarks block in Part I, it will write "Being enrolled for Self and Family coverage involuntarily under Pub. L. 106-394."

When your employing office sends the SF 2809 to your health plan, it will attach a copy of the court/administrative order. It will send your copy of the SF 2809 to the custodial parent, along with a plan brochure, and make a copy for you.

What is the Effective Date If I am Enrolled Involuntarily?

In most cases, the effective date will be the first day of the pay period following the one in which your employing office completes the SF 2809.

Example

Chester's employing office receives an administrative order on November 14, 2010, saying that he must provide health benefits for his two children. Chester doesn't have any FEHB coverage. His employing office notifies him that he has until December 2, 2010 (the end of the following pay period) to enroll or provide documentation that he has other coverage for them. He doesn't respond. On December 4, 2010, Chester's employing office completes an SF 2809 enrolling him for Self and Family coverage in the lower option of Blue Cross and Blue Shield Service Benefit Plan. The effective date would be December 17, 2010 (the first day of the next pay period).

Exception: There is one instance in which the enrollment would be retroactive, and that's if the court/administrative order specifies an effective date. In this case, your employing office must make the enrollment retroactive to the beginning of the pay period that includes that effective date, but no further back than 2 years.

How Does My Employing Office Identify My Eligible Family Members?

Usually the court/administrative order will have the names and birthdates of the children. If the order does not have this information, your employing office will leave item 12 on the SF 2809 blank. The health plan will obtain the information from the custodial parent.

What Happens If I Go into a Nonpay Status or My Pay is Insufficient to Make the Withholdings?

The provisions of 5 CFR 890.502(b) apply (see "Leave Without Pay Status and Insufficient Pay"). However, in this case, you do not have the option of terminating coverage. You must continue the coverage and either make direct premium payments or incur a debt to the Government.

If My Employing Office Enrolls Me, Can I Later Make Enrollment Changes?

If you are involuntarily enrolled and your employing office finds that circumstances beyond your control prevented you from making your own enrollment election, you may change the enrollment prospectively within 60 days after your employing office advises you of its finding. Otherwise, it depends on the enrollment change you want to make. During Open Season or when you have an event that allows an enrollment change, you can change to a different fee-for-service plan or to an HMO that provides full benefits where your children covered under the court/administrative order live.

However, you cannot (even during Open Season):

  • cancel your enrollment,
  • change to Self Only, or
  • change to an HMO that doesn't provide coverage in the area where your children live,

as long as the court/administrative order is still in effect and the children are eligible under the FEHB Program (unless you provide documentation that you have other coverage for the children). This applies whether you are enrolled voluntarily or involuntarily. If you submit an SF 2809 making such an enrollment change, your employing office will not process it. If it gets processed by mistake, your employing office will void it. Your employing office will notify you that you cannot make the change and that your existing Self and Family enrollment will remain in effect.

What Happens If I Make a "Not-Allowed" Enrollment Change by Employee Express?

Your payroll office should flag the records for all employees subject to a court/administrative order for health benefits. You will then not be able to make an enrollment change through Employee Express.

If your agency has its own electronic system for FEHB enrollments, it will take similar action.

How Long Must I Keep the Self and Family Enrollment?

If the court/administrative order doesn't specify a time limit on the coverage, you must keep the Self and Family enrollment until the last child marries or reaches age 26.

If the court/administrative order states that coverage must continue until a specific age--and that age is over age 26--the coverage must continue until the last child reaches age 26. Unless they meet the requirements for being incapable of self-support, children cannot continue FEHB coverage beyond age 26, regardless of what the court/administrative order says.

If the court/administrative order states that the coverage must continue until a specific age--and that age is below age 26--you may cancel the coverage or change to Self Only as follows:

If You Participate in Premium Conversion

You may cancel or change to Self Only the Open Season following when the child reaches the age stated in the court/administrative order.

If You Waived Premium Conversion

You may cancel or change to Self Only at any time after the last child reaches the age stated in the court/administrative order.

What Happens When I Retire?

If you are eligible to carry FEHB coverage into retirement, you must continue the Self and Family coverage after retirement to provide coverage for the children covered under the court/administrative order. As long as the court/administrative order remains in effect, you cannot:

  • cancel or suspend coverage,
  • change to Self Only, or
  • change to an HMO that doesn't provide full benefits where the children live.

If your retirement becomes insufficient to make the premium withholdings, you may not choose to terminate the enrollment. Instead, you must continue the coverage and make direct premium payments for as long as the order remains in effect and the child or children continues to be eligible.

What If My Employing Office Gets More Than One Court/Administrative Order for Me?

A Self and Family enrollment automatically covers all eligible family members. If you are subject to a court/administrative order, and another court/administrative order is filed relating to a different child (or children), that child is automatically covered under your existing Self and Family enrollment.

Your employing office will send your health plan a copy of the subsequent court/administrative order, along with a copy of the SF 2809 marked "Duplicate."

If you are enrolled in an HMO, and the children mentioned in the subsequent court/administrative order live in an area that the HMO doesn't serve, your employing office will notify you and give you a chance to choose a different health plan. . If you don't change plans, your employing office will change your enrollment to the lower option of Blue Cross and Blue Shield Service Benefit Plan. It will attach copies of all court/administrative orders to the SF 2809.

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Changes that Do Not Affect Enrollment

Family Members

You don't need to report to your employing office any change in the number of family members that doesn't affect your health benefits enrollment. However, the carrier of your plan may request this information, including evidence of family relationship.

Your enrollment is not affected when:

  • your child is born when you already have a Self and Family enrollment;
  • your spouse dies or you divorce and you have children still covered under your Self and Family enrollment;
  • your child reaches age 26, and you have other children or a spouse still covered under your Self and Family enrollment. (If you want temporary continuation of coverage (TCC) or a conversion contract for your child, you must inform your employing office of your child's loss of FEHB eligibility within 60 days.)

Name Changes

If you change your name for any reason, your employing office must report the change to the carrier of your plan. If no other changes are involved (e.g., you legally change your name, or you change your name upon your marriage but keep your Self Only enrollment), your employing office reports the name change on the Notice of Change in Health Benefits Enrollment (SF 2810).

You are also eligible to change your enrollment upon your marriage. (Note: If your spouse is a Federal employee with a Self and Family enrollment, you are automatically covered as a family member under that enrollment, and you generally must cancel your enrollment to avoid dual enrollment.) If you change your enrollment, you must submit a new Health Benefits Election Form (SF 2809) under your new name, showing your former name in the Remarks section of the form.

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Loss of Family Member Status

When a family member loses coverage because he/she is no longer an eligible family member, he/she will be entitled either to temporary continuation of coverage or to convert to an individual policy with your carrier. If you are divorcing, your former spouse may be eligible for coverage under the spouse equity provisions.

When a Family Member is no Longer Eligible

Your family member immediately loses eligibility for coverage under your Self and Family enrollment when:

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Child Incapable of Self-Support

Coverage

Your Self and Family enrollment covers your child age 26 or over who is incapable of self-support because of a physical or mental disability that existed before the child reached age 26.

Requirements

Your child age 26 or over may be considered incapable of self-support only if his/her physical or mental disability is expected to continue for at least one year and, because of the disability, he/she isn't capable of working at a self-supporting job.

A disability such as blindness or deafness isn't qualifying in itself because it doesn't necessarily make someone incapable of self-support. The onset of a disease before age 26 that doesn't result in incapability for self-support until age 26 or after doesn't qualify a child for continued coverage as a family member.

Determination of Incapacity for Self-Support

When Employing Office Must Make Determination

Your employing office is responsible for determining whether your dependent child age 26 or over is incapable of self-support because of a mental or physical disability that began before age 26 and for notifying the carrier of your plan of its determination. If your child's medical condition is listed below, the carrier may also approve coverage.

Your dependent child is incapable of self-support when:

  • he/she is certified by a state or federal rehabilitation agency as unemployable;
  • he/she is receiving: (a) benefits from Social Security as a disabled child; (b) survivor benefits from CSRS or FERS as a disabled child; or (c) benefits from OWCP as a disabled child;
  • a medical certificate documents that: (a) your child is confined to an institution because of impairment due to a medical condition; (b) your child requires total supervisory, physical assistance, or custodial care; or (c) treatment, rehabilitation, educational training or occupational accommodation has not and will not result in a self-supporting individual;
  • a medical certificate describes a disability that appears on the list of medical conditions; or
  • you submit acceptable documentation that the medical condition is not compatible with employment, that there is a medical reason to restrict your child from working, or that he/she may suffer injury or harm by working.

If your child earns some income (generally no more than the equivalent of the GS 5, step 1), it doesn't necessarily mean that he/she is capable of self-support. Your employing office will take both your child's earnings and condition or prognosis into consideration when determining whether he/she is incapable of self-support.

When Carrier May Approve Coverage

If your child has a medical condition listed, and he/she had the condition before reaching age 26, you don't need to ask your employing office for approval of continued coverage after your child reaches age 26. The carrier of your health benefits plan may approve continued coverage to your child without referring you to your employing office.

When the carrier determines your child's incapacity for self-support, it sends the approval notice to you and advises you to give a copy of the notice to your employing office. Your employing office must file it with your other health benefits enrollment documentation in your Official Personnel Folder.

List of Medical Conditions that would Cause a Child to be Incapable of Self-Support During Adulthood

If your child has one of the following disabilities noted in the medical certificate, and the disability began before age 26, your employing office or health benefits carrier can automatically extend continued coverage.

  • AIDS - CDC classes A3, B3, C1, C2, and C3 (not seropositivity alone)
  • Advanced Muscular Dystrophy
  • Any malignancy with metastases or which is untreatable
  • Chronic Hepatic Failure
  • Chronic neurological disease, whatever the reason, with severe mental retardation or neurologic impairment, for example:
    • Cerebral Palsy
    • Ectodermal Dysplasia
    • Encephalopathies
    • Uncontrollable Seizure Disorder
  • Chronic Renal Failure
  • Inborn errors of Metabolism with complications such as the following:
    • Adrenoleukodystrophy
    • Gaucher disease
    • Glycogen storage diseases
    • Homocysteinuria
    • Lesch-Nyhan disease
    • Mucopolysacharide disease
    • Nieman-Pick disease
    • Phenylketonuria
    • Primary hyperoxaluria
    • Tay-Sachs disease
  • Mental Retardation with IQ of 70 or less
  • Osteogenesis Imperfecta
  • Severe acquired or congenital Heart Disease with decompensation which is not correctable
  • Severe Autism
  • Severe Juvenile Rheumatoid Arthritis
  • Severe Mental Illness requiring prolonged or repeated hospitalization
  • Severe Organic Mental Disorder
  • Xeroderma Pigmentosa

This list doesn't include all the disabilities that would cause a child to be incapable of self-support.

Medical Certificate

Your child's doctor must complete a medical certificate for the employing office to make its determination of incapacity of self-support. The certificate must state that your child is incapable of self-support because of a physical or mental disability that existed before he/she became age 26 and that can be expected to continue for more than one year.

  • your child's name and birth date;
  • the type of disability;
  • the period of time the disability has existed and the date the impairment began;
  • diagnosis and history of the specific medical condition(s), references to findings from previous examinations, treatment and responses to treatment;
  • clinical findings from the most recent physical examination, including objective findings of physical examination, results of laboratory tests, x-rays, EKG's and other special evaluations or diagnostic procedures, and, in the case of psychiatric disease, the findings of mental status examinations and the results of psychological tests;
  • assessment of the current clinical status and plans for future treatment;
  • assessment of degree to which the medical condition has become static or stabilized and an explanation of the medical basis for the conclusion;
  • the probable future course and duration of the disability, including an estimate of the expected date of full or partial recovery;
  • the special supervisory, physical assistance, or custodial care requirements of your child;
  • any treatments, rehabilitation programs, educational training or occupational accommodation that would result in your child becoming self-supporting; and
  • the doctor's name, signature, office address and telephone number.

When to Submit Certificate

You may submit the medical certificate to your employing office when you first enroll to cover your child under your Self and Family enrollment. To maintain continued coverage for your child after he or she turns age 26, submit the medical certificate within 60 days of your child reaching age 26.

If your employing office determines that your child is incapable of self-support, your employing office must notify the carrier of your plan by letter. The letter must identify you by name and social security number, and state the name and date of birth of your disabled child as well as the duration of the approval. It will send the letter to the carrier with a regular transmittal report. It will not send the medical evidence used in its determination to the carrier, but will attach it to your most recent Health Benefit Election form (SF 2809) or other enrollment request in your Official Personnel Folder.

If you have a new enrollment, your employing office will note its determination of incapacity of self-support in the Remarks section of your SF 2809.

Use of Physicians

In making its medical determinations, your employing office must use a physician's services if available, unless your child's condition is one for which it can automatically extend continued coverage. In doubtful cases, or if no physician is available, your employing office may request assistance from: Office of Personnel Management, Healthcare and Insurance, P.O. Box 436, Washington, D.C. 20044.

Duration and Approval of Incapacity for Self-Support

Depending on your child's medical certificate, your employing office may approve coverage due to disability for a limited period of time (1 year, for example), or without time limitation (permanent).

Renewal of Medical Certificate

If your employing office approves your child's medical certificate for a limited period of time, it must remind you, at least 60 days before the date the certificate expires, to submit either a new certificate or a statement that the certificate will not be renewed. If it is renewed, your employing office must notify the carrier of your plan of the new expiration date by letter.

Failure to Renew Certificate

If you don't renew a medical certificate for a disabled child age 26 or over, your child's status as a family member automatically ends and he/she is no longer covered. Your employing office must notify you and the carrier of your plan that your child is no longer covered.

Late Certificates

If you submit a medical certificate for a child after a previous certificate has expired, or after your child reaches age 26, your employing office must determine whether the disability existed before age 26. If your employing office determines that it did, and you continuously had a Self and Family enrollment, your child is considered to have been a covered family member continuously since age 26.

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