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Three types of enrollment are available:
A Self Only enrollment provides benefits only for you as the enrollee. You may enroll for Self Only even though you have a family, but they will not be eligible for FEHB coverage (even upon your death or disability).
A Self Plus One enrollment provides benefits for you and one eligible family member you designate to be covered. You may enroll in Self Plus One even though you have more than one eligible family member, but family members who are not covered will not be eligible for FEHB coverage (even upon your death or disability).
A Self and Family enrollment provides benefits for you and your eligible family members. All of your eligible family members are automatically covered, even if you didn't list them on your Health Benefits Election Form (SF 2809) or other appropriate request. You cannot exclude any eligible family member and you cannot provide coverage for anyone who is not an eligible family member.
You may enroll for Self and Family coverage before you have any eligible family members. Then, a new eligible family member (such as a newborn child or a new spouse) will be automatically covered by your family enrollment from the date he/she becomes a family member. When a new family member is added to your existing Self and Family enrollment, you do not have to complete a new SF 2809 or other appropriate request, but your carrier may ask you for information about your new family member. You will send the requested information directly to the carrier. Exception: if you want to add a foster child to your coverage, you must provide eligibility information to your employing office.
If both you and your spouse are eligible to enroll, one of you may enroll for Self and Family to cover your entire family. If you have no eligible children to cover, one of you may enroll for Self Plus One or each of you may enroll for Self Only in the same or different plans. Generally, you will pay lower premiums for two Self Only enrollments.
An enrollment code identifies the plan, the option (high or standard), and the type of enrollment (Self Only, Self Plus One or Self and Family) you have chosen. The first two places in the three-digit code identify the plan, and the third place identifies the option and type of enrollment. Enrollment codes are found on the front cover of each plan's brochure.
Unless otherwise specified, enrollments or changes in enrollment become effective on the first day of the first pay period that begins after your employing office receives your enrollment request and that follows a pay period during any part of which you were in pay status.
If I Participate in Premium Conversion, Can I Still Change My Enrollment?
Yes, you can still make changes to your enrollment as detailed in this section with three exceptions. You must have a qualifying life event to change from Self and Family to Self Only or to cancel your FEHB coverage outside of Open Season.
You may enroll or change enrollment during Open Season or within a specific timeframe of experiencing a Qualifying Life Event. For most of the enrollment opportunities, you will have up to 60 days after the date of the event. Note that if you take the full 60 days, you will be without FEHB coverage until the effective date of your enrollment. This gap or delay in your coverage may be of concern if you are enrolling because of a loss of other group health insurance coverage. However, as long as you enroll within the required enrollment timeframe, it will not count against you for purposes of meeting the requirements for continuing your FEHB into retirement.
If you are a new employee, you may enroll in any available plan, option, and type of enrollment within 60 days after your date of appointment, unless your position is excluded from coverage. If you were employed in a position that was excluded from coverage and then appointed to a position that conveys coverage, you may enroll within 60 days after the change.
If you are a Nonappropriated Fund (NAF) employee who moves to Federal employment, you are eligible for coverage just as any other new employee, even if you have continued coverage under the NAF retirement system.
If you participate in premium conversion, you may decrease your enrollment (from Self Plus One or Self and Family to Self Only; or from Self and Family to Self Plus One):
Joel gets divorced, and since he doesn't have any children, he wants to change to a Self Only enrollment. He can make this enrollment change outside of Open Season since it is consistent with and corresponds to his qualifying life event (divorce).
If you do not participate in premium conversion, you may decrease your enrollment at any time.
Note: Different rules apply for some U.S. Postal Service employees. Check with your employing office if you want to change to a differnet enrollment type.
A decrease in enrollment becomes effective on the first day of the first pay period that begins after the employing office receives your enrollment request.
Any change in family status that results in an increase or decrease in the number of eligible family members is a qualifying life event. For example, your spouse's death, your divorce, or a child's reaching age 26, may leave you as the only person covered by a Self Plus One or a Self and Family enrollment. If you are the only person left in a Self and Family enrollment, you should change to a Self Only enrollment promptly so that you are not unnecessarily paying additional premiums rates. Likewise, if a change in your family status leaves only you and one eligible fmaily member then you may change to a Self Plus One enrollment.
A qualifying life event (QLE) is a term defined by OPM to describe events deemed acceptable by the IRS that may allow premium conversion participants to change their participation election for premium conversion outside of an Open Season.
The qualifying life events that may allow you to change your premium conversion election are:
Please see the complete Table of Permissible Changes reflecting qualifying life events.
You may enroll during the Open Season if you are an eligible employee. If you are enrolled, you may change plans, options, type of enrollment, or premium conversion status.
If you are a non-enrolled annuitant, you are not permitted to enroll during an open season unless you had suspended your FEHB enrollment to join an Medicare managed care plan or because of your eligibility under Medicaid or a similar State-sponsored program of medical assistance for the needy.
The effective dates of the annual Open Season enrollments and changes in enrollment are as follows:
You may enroll, decrease enrollment, increase enrollment, change from one plan or option to another, or make any combination of these changes during the period beginning 31 days before and ending 60 days after a change in your family status. You can change your enrollment only once during this time period (unless there is another event during this time that would permit an enrollment change). You can also change your premium conversion status as long as the change in enrollment is on account of and consistent with a qualifying life event.
If you increase enrollment because of the birth or addition of a child, the effective date of your enrollment change is the first day of the pay period in which the child becomes a family member.
If you and your spouse each are enrolled for Self Only and you want a Self Plus One or a Self and Family enrollment because of a change in family status, one of you may change to either if the other cancels his/her Self Only enrollment.
If you want to provide immediate coverage for your new spouse, you may submit an enrollment request during the pay period before the anticipated date of your marriage. If the effective date of the change is before your marriage, your new spouse does not become eligible for coverage until the actual day of your marriage.
If you enroll or change your enrollment before the date of your marriage and intend to change your name, you must note on your request: "Now: [Current Name] will be: [Married Name]." The reason for the change and the date of the marriage must be given in your request.
If you enrolled or changed your enrollment before your anticipated marriage date and you do not get married, your employing office must void the request. If you changed plans, your employing office must be sure to notify both the old and the new carrier that your change was voided.
Even if you are legally separated, your spouse is still considered a family member and eligible for coverage under your Self Plus One or Self and Family enrollment. To continue to provide health benefits coverage for your child(ren), you must continue your Self and Family enrollment. Upon a final divorce decree, your spouse is no longer an eligible family member and is not covered under your enrollment.
When two Federal employees divorce, one person usually continues a Self Plus One or a Self and Family enrollment to provide coverage for the child(ren), while the other enrolls for Self Only. When the enrollment covering the child(ren) is canceled or changed to Self Only, the other parent may change to a Self Plus One or a Self and Family enrollment to provide immediate coverage for your child(ren).
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If you are a former spouse who has coverage under the spouse equity or temporary continuation of coverage (TCC) provisions of FEHB law, you may increase enrollment or change from one plan or option to another, or both, within 60 days after the birth or acquisition of an eligible child. To be eligible, the child must be that of both you and the employee or annuitant on whose service your coverage is based.
Generally, you may enroll or increase enrollment, decrease enrollment, chnage from one plan or option to another, or make any combination of these changes within 60 days after a change in your employment status. You can also change your premium conversion status if the enrollment change is on account of and consistent with a qualifying life event. Various changes in employment status and the allowable enrollment changes that you may make are described below.
If your enrollment terminated:
you may enroll for Self Only, Self Plus One or Self and Family in any available plan or option when you return to pay status. If you were not enrolled at the time leave without pay status began, you may enroll upon return to pay status only if a qualifying event occurred while you were on leave without pay.
If you move from one employing office to another (other than by retirement) with a break in service of more than 3 days, you may enroll the same as a new employee. If you are a Nonappropriated Fund (NAF) employee who returns to Federal employment, you are eligible for coverage, even when you have continued coverage under the NAF retirement system.
If you are restored to a civilian position after serving in the uniformed services under conditions that entitle you to benefits under 5 CFR part 353, or similar authority, you may enroll in any option of any available plan after returning to civilian duty. If your enrollment was terminated on entry into military service, you will have the same enrollment reinstated effective on the day of restoration to duty in a civilian position. In addition, you may change your enrollment based on your return to civilian duty.
When you are eligible to enroll as a temporary employee under 5 U.S.C. 8906a and you change to an appointment that makes you eligible for FEHB coverage with a Government contribution, you may change plans, options, and types of enrollment.
Your change in health benefits status is effective either:
If there is a break in service of more than 3 days, your old enrollment terminates at the end of the pay period in which your temporary appointment ends. You have a new opportunity to enroll based on the new appointment.
If you are separating from service and you or your spouse are pregnant, you may enroll or change your enrollment during your final pay period. You must provide medical documentation of the pregnancy to your employing office.
The effective date of the change is the first day of the pay period in which your employing office receives your appropriate request.
Although you can usually enroll for Self Plus One or Self and Family under temporary continuation of coverage (TCC) provisions, it does not become effective until the day after the 31-day extension of coverage. An enrollment election prior to separation will ensure that the baby's health care costs will be covered if he/she is born during the 31-day extension of coverage. If you are not eligible for TCC, a change to a Self Plus One or a Self and Family enrollment, as appropriate, during your final pay period will allow you to convert to an individual policy for the whole family.
You may enroll or change enrollment when you transfer from a duty post within the United States to a duty post outside the United States or the reverse. You have 31 days before the date you are expected to leave your former duty post and 60 days after your arrival at the new duty post to enroll or change enrollment.
If you are at an overseas duty post at the time of your retirement, you may change your enrollment within 60 days after your retirement.
When you change to part-time career employment (16 to 32 hours a week under 5 U.S.C. 3401(2)) with a break in service of 3 days or less, you may enroll or change your enrollment within 60 days from the change in your employment status. Similarly, when you change from part-time employment under 5 U.S.C. 3401(2) to full-time employment, you may enroll or change enrollment. This does not apply to part-time appointments of other than 16 to 32 hours per week (or 32 to 64 hours biweekly in the case of a flexible or compressed work schedule) nor to any noncareer appointment.
If you are an employee eligible for FEHB coverage, you may enroll, increase or decrease enrollment , change from one plan or option to another, or make any combination of these changes when you or an eligible family member lose coverage under FEHB or any other group health benefits plan (including coverage under another Federally-sponsored health benefits program or under Medicaid). Except as otherwise provided below, you must enroll or change your enrollment within the period beginning 31 days before and ending 60 days after the date you lost coverage. You can also change your premium conversion status if the enrollment change is on account of and consistent with a qualifying life event.
If you are eligible for FEHB coverage in your own right and you become a survivor annuitant, you have the option to continue the current enrollment with withholdings made from your survivor annuity. If you elect to enroll as an employee, and you later separate or your employment status changes so that your enrollment terminates, you may continue the enrollment as a survivor annuitant.
If you are entitled to health benefits coverage as a former spouse, but you are instead enrolled as an employee or family member, you may enroll or resume enrollment under spouse equity when your coverage as an employee or family member ends (as long as you still meet the spouse equity requirements).
If you were enrolled under temporary continuation of coverage (TCC) provisions and you acquired regular FEHB coverage (either as an employee or family member), you may reenroll in TCC if the regular coverage ends before the original TCC enrollment would have expired. You may reenroll in the same plan and option as your original TCC enrollment. If you are not eligible to enroll in the plan you had when your TCC enrollment ended, you may enroll in the same option of any available plan. The second TCC enrollment cannot extend beyond the date the original TCC enrollment would otherwise have stopped.
If you are enrolled in a plan sponsored by a union or employee organization and you stop being a member of that organization, your plan can ask your employing office to terminate your enrollment, subject to a 31-day extension of coverage.
Your plan will send a notice to your employing office and a copy to you. Your employing office will terminate your enrollment on a Notice of Change in Health Benefits Enrollment (SF 2810), effective at the end of the pay period in which it receives the notice. You may then enroll for Self Only or Self and Family in any available plan or option. If you reenroll within 60 days after termination, you are considered to have been continuously enrolled (for purposes of continuing enrollment after retirement) even though there actually may have been a break between the effective date of termination of your enrollment in the employee organization plan and the effective date of your new enrollment.
You may change to another plan when you are enrolled in a plan that is discontinued in whole or in part. You may enroll in the new plan for either Self Only, Self Plus One or Self and Family coverage. If your plan is discontinued at the end of a contract year, you must change your enrollment during Open Season unless OPM establishes a different time. If the whole plan is discontinued and you do not change to another plan, you are considered to have canceled your enrollment. If one option of a two-option plan is discontinued and you do not change to another plan, you are considered to have enrolled in the remaining option of the plan.
Normally, a plan that terminates its participation in the FEHB Program will terminate as of December 31 of a given year. The plan will continue to provide benefits until the new coverage takes effect. When a plan is discontinued at any time other than at the end of a contract year, OPM will announce a special enrollment period and give instructions about the proration of premiums and the effective date of enrollment changes.
When your or your spouse's loss of non-Federal coverage is due to a move outside of the commuting area, you must enroll or change enrollment within the period beginning 31 days before the date you leave employment in the old commuting area and ending 180 days after you enter on duty at the place of employment in the new commuting area.
Your spouse may elect to temporarily continue the employer-provided group insurance under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). You may choose to enroll either at the time your spouse or child loses coverage through the non-Federal employer or whenever the COBRA coverage terminates for any reason.
If you are enrolled in an HMO and you move or become employed outside the HMO's service area (or, if you are already living or working outside this area, you move or become employed further away), you may change your enrollment. Also, you may change your enrollment if an enrolled family member moves outside the service area (or moves further away). You must notify your employing office of the move.
The effective date of the change is the first day of the pay period that begins after your employing office receives your appropriate request.
You may change your enrollment to any option of any available plan 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.
If you are temporary employee eligible under 5 U.S.C. 8906a and your salary is not sufficient to pay your plan's premiums, your employing office must notify you of the plans available at a cost that does not exceed your available salary. You may enroll in another plan where the cost is no greater than your available salary within 60 days after receiving notification from your employing office.
Coverage under your new plan is effective immediately upon termination of your old plan's coverage.
If you changed your enrollment from one plan or option to another and you or a covered family member are an inpatient in a hospital or other institution on the last day of your enrollment under the prior plan or option, the benefits of the prior plan or option will continue for the confined person for the length of the inpatient stay, up to 91 days from the last day of enrollment in the prior plan or option. This provision does not apply when a plan is discontinued or when OPM orders an enrollment change.
Your new plan or option does not pay benefits for you while you are receiving continued inpatient benefits from your old plan or option. The new plan or option will begin coverage on the earlier of:
Coverage for other family members (who are not confined in a hospital or other institution) under the new plan begins on the normal effective date of coverage.
Dual enrollment is when you or an eligible family member under your Self Plus One or Self and Family enrollment are covered under more than one FEHB enrollment. Generally, dual enrollment is prohibited except when you or a family member would otherwise lose coverage.
For example, both your children and your spouse's children are all covered under one Self and Family enrollment. If both you and your spouse have Self and Family enrollments, you must cancel one of the enrollments to eliminate the dual enrollment.
Your carrier must contact the employing offices involved when it discovers an unauthorized dual enrollment case. One of the enrollments must be voided or canceled from the date that dual enrollment began. The health benefits premiums you paid during the unallowable enrollment will be refunded, and your employing office must make a corresponding adjustment in the Government's contribution. The carrier of the enrollment that is voided or canceled may require that you refund any benefits it paid under the unallowable enrollment, although these benefits may be payable under the allowable enrollment.
If you and your spouse are unable to agree on which enrollment to continue, the enrollment of the spouse with a court order to provide coverage for the children will be continued. Otherwise, the second (later) enrollment must be voided or canceled.
Dual enrollment must be authorized by your employing office(s) and will only be allowed when you or an eligible family member would otherwise lose coverage. Some examples of allowable dual enrollment include when:
No enrollee or family member may receive benefits under more than one FEHB enrollment. You must inform the carriers involved which family members will be covered and receive benefits under which enrollment. If you or a family member receive benefits under more than one plan, it is considered fraud and you are subject to disciplinary action.
Each year OPM provides an Open Season from the Monday of the second full workweek in November through the Monday of the second full workweek in December.
The Director of OPM may modify the dates of Open Season or announce additional open seasons.
Your Open Season election generally will take effect the following January.
OPM notifies agencies of each regular Open Season by a Benefits Administration Letter (BAL). We give specific instructions on the coordination of Open Season, and let the agencies know of any changes in materials to be issued or procedures to be followed during that period.
If your employing office's health benefits official needs additional Open Season information or assistance, he/she may contact the headquarters benefits officer. The headquarters benefits officer may contact OPM with questions.
Your agency may allow or require you to make open season changes through "Employee Express," or another electronic method, instead of using a Health Benefits Election form (SF 2809). Check with your employing office to see if this method is available for your use.
While new enrollments and other permissible enrollment changes can be made as usual during the Open Season, these should not be identified as Open Season changes on the appropriate request because Open Season changes do not take effect until January. You should make sure that you specify the reason for your enrollment change on your enrollment request.
Your employing office must receive your Open Season election no later than the last day of Open Season to be considered timely filed.
Your employing office may accept and process a late election if it determines that you were unable to submit it timely for reasons beyond your control (e.g., your employing office did not distribute Open Season literature until after Open Season). Your failure to read the available material is not considered a reason beyond your control.
If your employing office decides to accept a late election, it enters "belated Open Season enrollment/change" in the Remarks section of your enrollment request. You or your employing office must explain why you could not make a timely election and attach the statement to the file copy of your enrollment request.
If your employing office decides that your late election was not beyond your control, it must explain to you in writing why it did not accept your late request and give you notice of your reconsideration rights.
If you change plans, any covered expenses you incur between January 1 and the effective date of coverage under your new plan count towards the prior year's deductible of your old plan.
You do not need to do anything if you want to continue your current enrollment (unless your plan is dropping out of the FEHB Program). If you do not change your enrollment, new benefit or rate changes will apply beginning January 1 of each year.
If you make an Open Season enrollment change, your agency or retirement system will automatically cancel your enrollment in your former health plan at the time your enrollment in your new health plan becomes effective. You do not need to contact your former health plan to cancel your enrollment. You will not be charged the premiums for both your former plan and your new plan.
OPM provides employing offices with instructions for processing Open Season enrollments and enrollment changes each year via a Benefits Administration Letter (BAL).
When you move from one employing office to another, your enrollment continues without interruption (see Employees Excluded from Coverage for the only exceptions to this) as long as you do not have a break in service of more than three calendar days. This is regardless of whether or not your move is designated as a transfer. You do not need to do anything to ensure your continued enrollment, but the gaining employing office must transfer your enrollment.
If you are enrolled in an HMO and transfer to a location outside of the HMO's service area, your enrollment continues. However, you will be covered only for emergency care, Point of Service (POS) benefits (if applicable), or care that you travel back to an HMO participating provider to receive. You may change to another plan before or after the move.
If you are enrolled in a plan sponsored by a union or employee organization and you transfer to another agency, you do not have the right to enroll in another plan because of your transfer. Your current enrollment will continue until:
Vincent is employed by the Department of State and is enrolled in the Foreign Service Benefit Plan (FSBP). He transfers to another agency where its employees are not eligible to join SAMBA. His enrollment in FSBP will continue, and the gaining agency must make withholdings and contributions for FSBP, until he changes his enrollment or FSBP takes steps to terminate his enrollment.
The effective date of the enrollment transfer for the gaining employing office is the first day you enter on its rolls.
If you are a Federal employee with D.C. Government service prior to October 1, 1987, and you move back to D.C. Government without a break in service, your enrollment must be transferred in by the D.C. Government on the Notice of Change in Health Benefits Enrollment form (SF 2810). Since your personnel files are not transferred, the D.C. Government must request copies of your health benefits forms when it requests other employment information from the losing Federal employing office.
If you move from the D.C. Government to a Federal agency, the gaining office must transfer your enrollment in on SF 2810 and ask the D.C. Government for the personnel folder copies of health benefits forms at the same time it asks for a transcript of personnel records.
The two personnel offices must verify your health insurance status so that withholdings can begin with the initial pay period even if documentation has not yet arrived from the losing office.
If you do not have D.C. Government service prior to October 1, 1987, and you transfer to the D.C. Government, your enrollment is terminated because you are no longer an eligible employee. If you were first employed by the D.C. Government on or after October 1, 1987, and you transfer to a Federal agency, you may enroll in the FEHB Program if you are otherwise eligible.
If you leave a Federal agency and become employed by the U.S. Senate or House of Representatives without a break in service of more than three calendar days, your health benefits enrollment is transferred.
If you leave employment with the U.S. Senate or House of Representatives and become employed by a Federal agency without a break in service of more than three calendar days, your enrollment will terminate effective at the end of the month that you separate. Withholdings and contributions will be made for that entire month. The gaining employing office will ask you for a copy of the termination Notice of Change in Health Benefits Enrollment (SF 2810), verify your eligibility for continued enrollment, and ask the losing office for the employing office copies of your health benefits forms. The gaining office will reinstate your enrollment on the SF 2810 effective the first day of the following month, so you will not have to pay double premiums.
When you retire and are eligible to continue FEHB coverage into retirement, your enrollment is transferred in by the retirement system and automatically continued.
If you die in service while enrolled in Self Plus One; enrollment for the designated family member who was listed on your enrollment automatically continues when they meet the requirements for continuation.
If you die in service while enrolled in Self and Family, enrollment for your family members automatically continues when they meet the requirements for continuation.
Generally, your enrollment may continue for up to 365 days of leave without pay. You must pay the employee share of premiums for every pay period that your enrollment continues.
If you are suspended without pay, your enrollment may continue for up to 365 days in leave without pay status. If you are removed from service, your enrollment terminates at the end of the pay period in which you are removed. If your enrollment terminated and you are ordered restored to duty because the suspension or removal was unwarranted or unjustified, you may elect either to:
Your employing office must notify you of the health benefits coverage choices available.
If you elect to have your prior enrollment reinstated retroactively, premium withholdings and contributions must also be made retroactively as if the erroneous suspension or removal had not taken place. The amount of the retroactive withholdings due may be withheld from your backpay award. Your health benefits coverage is considered to have been continuously in effect and you and your covered family members are retroactively entitled to full plan benefits. If you had converted to an individual contract, you may get a refund of the premiums you paid for that coverage.
If you elect to enroll the same as a new employee instead of having your prior enrollment reinstated, your enrollment is effective the first day of the first pay period that begins after your employing office receives your appropriate request and that follows any part of a pay period of which you are in pay status. You are not retroactively entitled to plan benefits and no retroactive premium withholdings and contributions will be made.
The period of suspension or removal (during which the enrollment was not in effect) is not considered when determining your eligibility to continue coverage into retirement, as long as you enroll within 60 days after the date you are ordered restored to duty.
If you lose health benefits coverage because you separate from Federal service, whether voluntary or involuntary (except for removal due to gross misconduct), you may elect temporary continuation of coverage (TCC).
If you have an interim appointment under the Whistleblower Protection Act of 1989 [5 U.S.C. 7701(b)(2)(A)], you are entitled to the same coverage provisions as other employees with appointments that entitle them to coverage under the FEHB Program.
If your interim appointment is terminated and your prior separation still stands, you have the same rights under the FEHB Program as any other employee whose appointment terminates. These rights are based on the termination from the interim appointment - the prior separation has no bearing. If you were ineligible for temporary continuation of coverage (TCC) based on your prior separation, this has no effect on your eligibility for TCC based on the separation from your interim appointment.
If you are eligible for retirement and you receive an interim appointment, your annuity will be suspended. Your employing office must notify the retirement system to transfer your enrollment back to your employing office. If your interim appointment ends and your prior separation still stands, your enrollment will be transferred back to the retirement system.
If you are restored to duty and your interim appointment terminates, you may choose retroactive reinstatement of your health benefits coverage. If you continued health benefits coverage under TCC between your prior separation and your interim appointment, a retroactive reinstatement terminates your TCC enrollment retroactively. You are due a refund for the premiums you paid for the TCC enrollment. This amount may be applied to the premiums you owe for the retroactive reinstatement. If your backpay award and TCC enrollment refund will not cover the amount you owe for the retroactive reinstatement, you must pay the balance due directly to your employing office.