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Termination, Conversion and Temporary Continuation of Coverage

FEHB Program Handbook Table of Contents

Termination, Conversion and Temporary Continuation of Coverage

Cancellation

Electing to Cancel

If the enrollee participates in premium conversion, he/she may cancel his/her enrollment:

during the annual Open Season; or
within 60 days after the enrollee has a qualifying life event. His/her cancellation must be consistent with and correspond to the QLE.

Example

LaTonya gets married, and since her husband's company provides health insurance for a spouse, she wants to cancel her FEHB enrollment. She can make this enrollment change outside of Open Season since it is consistent with and corresponds to her qualifying life event (marriage).

The enrollee’s cancellation is effective on the last day of the pay period in which his/her employing office receives his/her Health Benefits Election Form (SF 2809) or other enrollment request. When the enrollee cancels enrollment, he/she is not eligible for the 31-day extension of coverage and he/she cannot convert your coverage to an individual policy.

If the enrollee's temporary continuation of coverage (TCC) or Spouse Equity enrollment ends because he/she didn't pay the premiums, it is considered to be a voluntary cancellation.

When the enrollee cancels his/her enrollment, his/her family members' coverage terminates at midnight of the day that the enrollee's cancellation is effective, with no 31-day extension of coverage.

Enrollee Responsibilities

When the enrollee cancels his/her enrollment, his/her signature certifies that he/she is aware:

of the effect the election not to enroll could have on his/her eligibility to continue health benefits coverage after retirement; and
that he/she may not enroll again until an event occurs (such as marriage or Open Season) that permits enrollment.

The enrollee’s employing office will process his/her termination by following the applicable instructions in "Employing Office Review of SF 2809." It will use the old carrier copy to notify the enrollee’s carrier of the cancellation and discard the new carrier copy.

Annuitants

When the enrollee cancels his/her enrollment as an annuitant, he/she may never reenroll unless:

he/she becomes reemployed in a position that conveys coverage, or
he/she has suspended his/her FEHB enrollment to enroll in a Medicare Advantage plan, Medicaid, or TRICARE and that coverage ends.

Termination

Enrollees

The employee’s enrollment will terminate, subject to a 31-day extension of coverage, on the earliest of the following dates:

the last day of the pay period in which the employee separates from service (unless he/she transfers, retires, or begins receiving Workers' Compensation benefits);
the last day of the pay period in which the employee separates after he/she meets the requirements for an immediate annuity under the FERS MRA+10 provision and he/she postpones receipt of his/her annuity (see chapter 42A of the CSRS/FERS Handbook for Personnel and Payroll Offices);
the last day of the pay period in which the employee changes to a position that is excluded from coverage;
the last day of the pay period in which the employee dies, unless he/she has a family member eligible to continue enrollment as a survivor annuitant;
the last day of the pay period that includes the 365th day of continuous leave without pay status or the last day of leave under the Family and Medical Leave Act, whichever is later;
the last day of the last pay period in pay status, if he/she hasn't had 4 consecutive months of pay status after he/she has exhausted the 365 days continuation of coverage in leave without pay status;
the day he/she is separated, furloughed, or placed on leave of absence to serve in the uniformed services for duty over 30 days, if he/she elects in writing to have his/her employing office terminate his/her enrollment;
the date that is 24 months after the date of his/her separation, furlough, or leave of absence to serve in the uniformed services for active duty over 30 days, or the date of his/her entitlement to continued coverage ends, whichever is earlier;
the day on which his/her TCC expires; or
the last day of the pay period for which withholding was made when he/she is a temporary employee enrolled under 5 U.S.C. 8906a whose pay is insufficient to pay the withholdings and he/she did not or could not choose a plan for which his/her pay would cover the premiums.

The employee's enrollment may also terminate when he/she enters leave without pay status.

Family Members

The enrollee’s family member's coverage terminates, subject to a 31-day extension of coverage, at midnight on the earlier of the following dates:

the day that the enrollee decreases his/her enrollment or his/her enrollment terminates (unless he/she dies and he/she has a survivor eligible to continue his/her enrollment); or
the day that he/she is no longer an eligible family member.

The enrollee cannot continue coverage for his/her spouse under his/her Self and Family enrollment upon their divorce. He/she may be eligible for his/her own enrollment under either the Spouse Equity or temporary continuation of coverage provisions.

When the enrollee cancels his/her enrollment, his/her family members' coverage terminates at midnight of the day that the enrollee’s cancellation is effective, with no 31-day extension of coverage.

Processing Terminations

Employing Office Responsibilities

When enrollment terminates, the enrollee’s employing office must prepare a Notice of Change in Health Benefits Enrollment form (SF 2810), showing the reason for his/her termination in the remarks section. The employing office must prepare, process, and distribute the SF 2810 as quickly as possible so his/her carrier knows that he/she is no longer covered under the health benefits plan.

By Termination of Membership in Employee Organization

When the employee organization plan the employee is enrolled in instructs his/her employing office to terminate his/her enrollment because he/she is no longer a member, the enrollee’s employing office will do so on the Notice of Change in Health Benefits Enrollment (SF 2810). It will note in the Remarks section: "His/Her enrollment was terminated by the plan because he/she is no longer a member of the sponsoring employee organization. He/she may enroll in another plan from 31 days before to 60 days after the date in Part A, item 8, above." (This date is the last day of the pay period in which his/her employing office received the plan's notice of termination.) His/her new enrollment will be processed as an enrollment change.

For Other Reasons

When his/her enrollment terminates for any reason other than cancellation or termination of his/her membership in an employee organization, his/her employing office must:

complete parts A, B, and H of the Notice of Change in Health Benefits Enrollment (SF 2810);
state the reason for the termination in the Remarks section (e.g., "Employee resigned"); and
send the carrier and payroll office copies to the payroll office for transmission to the carrier and for posting to the payroll records, respectively.

31-Day Extension of Coverage and Conversion

An enrollee or family member whose enrollment is terminated other than by cancellation or discontinuance of the plan is entitled to a 31-day extension of coverage for self only, self plus one, or self and family without contributions by the enrollee or the Government. During this period he or she is entitled to exercise the right of conversion. OPM requires carriers to either offer the individual a guaranteed-issue conversion policy or to provide assistance to the individual in enrolling in a guaranteed-issue policy on or off the healthcare Marketplace or Exchange.

Requests to Lengthen of the 31-day Extension of Coverage

The effective date of a conversion policy is retroactive to the end-date of the 31 day extension of coverage. However, if an individual timely purchases guaranteed-issue insurance coverage on or off the Exchange, as opposed to a conversion policy offered by an FEHB Program carrier, the effective date of the conversion coverage may be more than 31 days after the termination of his or her FEHB coverage. In the event this 31-day temporary extension period provides insufficient opportunity for the enrollee to exercise his or her right to convert to a guaranteed-issue non-group contract with an effective date commencing before or immediately upon the end of the 31-day temporary extension of coverage period, the Carrier may provide an additional extension of coverage not to exceed a total of 60 days as appropriate to avoid an interruption in coverage.

Carriers will collect requests for an additional extension period from terminating individuals. The enrollee or covered family member must explain to the Carrier in writing the circumstances for seeking an additional extension. The carrier must grant an extension if the terminating individual shows proof of guaranteed-issue conversion coverage with an effective date after the initial 31 day extension of coverage period. If that proof is not available, carriers may also grant extensions if an individual shows other good cause. Once the Carrier grants the extension, the Carrier will notify the plan’s OPM contract specialist of the extension granted within 30 days of the individual’s termination. The carrier will then contact the plan’s OPM contract specialist to obtain prior approval of any extension request that is proposed for denial within 15 days of the Carriers proposed denial determination.

Conversion Procedures

The employing agency must notify the enrollee of the termination of the enrollment and of the right to convert to a guaranteed-issue non-group contract within 15 days after the date the enrollment terminates. The individual whose enrollment terminates must request conversion information from the losing Carrier within 15 days of the date of the agency notice of termination of the enrollment and of the right to convert. The losing Carrier must provide information to the individual that will assist the individual in enrolling in a guaranteed-issue non-group contract for which the individual is eligible within 15 days of the date of the individual’s coverage termination from the losing Carrier.

When an agency does not provide the notification within 15 days of the date the enrollment terminates, or the individual fails for other reasons beyond his or her control to request conversion, he or she may request assistance with conversion to a guaranteed-issue non-group contract by writing directly to the Carrier. This request must be filed within 6 months after the individual became eligible to convert his or her group coverage and must be accompanied by verification of termination of the enrollment; e.g., an SF 50, showing the individual's separation from service. In addition, the individual must show that he or she was not notified of the termination of the enrollment and of the right to convert, and was not otherwise aware of it, or that he or she was unable, for cause beyond the control of the individual to convert. The Carrier will determine if the individual is eligible to convert. If determined eligible, the individual may convert within 31 days of the determination. If the Carrier determines the individual is ineligible to convert, the individual may request a review of the Carrier's determination from OPM.

When an individual converts his or her coverage any time after the group coverage has ended, the guaranteed-issue non-group plan coverage is effective on the date governed by the rules applicable to the guaranteed-issue non-group plan. An individual who fails to exercise his or her rights to convert to a guaranteed-issue non-group plan during the extension period is deemed to have declined the right to convert unless the Carrier, or, upon review, OPM will determine if the failure to enroll was not the fault of the individual.

Benefits under a Conversion Contract

Many conversion contracts provide fewer benefits at a higher cost than what is offered under the FEHB Program. Also, there is no Government contribution to the cost of the individual conversion contract. If the enrollee anticipates that a family member will lose coverage in the near future, the benefits and cost of a plan's conversion contract may be an important consideration in his/her choice of a health plan. If he/she or a family member is considering converting to an individual policy, he/she should contact the carrier of his/her plan for information about the benefits and cost of its conversion contract.

Late Conversion

When his/her employing office doesn't give him/her the required conversion notice within 15 days, or he/she isn’t able to request conversion on time for reasons beyond his/her control, he/she can request a late conversion by writing directly to the carrier of his/her plan.

He/she must send his/her request within six months after the date the enrollment terminated. The request must:

include some documentation that the enrollment has terminated (for example, an SF 50 showing separation from service); and either;
include proof that he/she was not notified of the enrollment termination and the right to convert (for example, a letter from his/her employing office confirming that it did not provide timely notice of the conversion option), and were not otherwise aware of it; or
include proof that he/she wasn’t able to convert because of reasons beyond his/her control.

If six months or more have passed since the date he/she became eligible to convert, the carrier of his/her plan is not required to accept a request for conversion.

If the carrier accepts the request for a late conversion, he/she must enroll and pay his/her first premium within 31 days of the carrier's notice. If he/she does not do so within this time period, he/she is considered to have waived his/her conversion rights, unless the carrier determines that he/she did not convert for reasons beyond his/her control. If the carrier determines that the failure to convert was within his/her control, he/she may request that OPM review the carrier’s decision. To request an OPM review, write to the U.S. Office of Personnel Management, Healthcare and Insurance, P.O. Box 436, Washington, D.C. 20044.

Effective Date of Conversion Contract

The enrollee or his/her family member's conversion contract becomes effective at the end of the 31-day extension of coverage, even when the enrollee or his/her family member is an inpatient in a hospital on the 31st day of extended coverage.

Reinstatement of Enrollment after Conversion

If an employee converted to a non-group contract after his/her enrollment terminated, and his/her enrollment is later reinstated retroactive to the effective date of the termination (e.g., he/she was removed and later ordered restored to duty with full restitution of back pay; or he/she retires with an annuity starting date made prior to the enrollment termination because of 365 days in leave without pay status), he/she may get a refund of all the premiums paid on the conversion contract. He/she must apply in writing to the carrier of the plan for the refund. If he/she received benefits when the conversion contract was in effect, he/she is entitled to an adjustment of the difference between the benefits paid by the carrier under the conversion contract and the benefits payable under the FEHB enrollment.

Termination of Erroneous Enrollment

If the enrollee's position is excluded from FEHB coverage but he/she was erroneously allowed to enroll, his/her employing office must terminate or void the coverage as soon as the error is discovered. The employing office must explain to him/her why he/she is not eligible for coverage and the effect of the termination.

If Withholdings were Made

If he/she was erroneously enrolled and premium withholdings and contributions were made, the employing office must terminate coverage and discontinue withholdings and contributions at the end of that pay period. No adjustments are made for contributions and withholdings that already have been made. The enrollee and his/her covered family members are entitled to full plan benefits during the time they were erroneously enrolled. He/she is entitled to convert to a non-group contract the same as any other employee whose enrollment is terminated.

If Withholdings were not Made

If no premium withholdings and contributions were made before the erroneous enrollment is discovered, the employing office must void the enrollment. In addition, the employing office will note in the Remarks section of the payroll office copy of the Health Benefits Election Form (SF 2809) (which is sent to the carrier): "Erroneous enrollment--enrollee responsible for any benefits provided." The enrollee will be responsible for any claims paid during the erroneous enrollment. The carrier will contact the enrollee to recover any payment it made.

Temporary Continuation of Coverage

If the enrollee loses FEHB coverage because he/she separates from Federal service, he/she may enroll under the Temporary Continuation of Coverage (TCC) provision of the FEHB law to continue his/her coverage for up to 18 months from the date of separation. Exception: he/she is not eligible for TCC if the separation is due to gross misconduct.

Family members who lose coverage because they are no longer eligible family members may enroll under TCC to continue FEHB coverage for up to 36 months.

Law

Title II of Public Law 100-654, effective January 1, 1990, established the temporary continuation of coverage provision for the FEHB Program.

Eligibility

An employee, a child, and a former spouse are eligible for temporary continuation of coverage based on specific qualifying events.

Employee

He/she is eligible for TCC when he/she:

separates from service, voluntarily or involuntarily, unless the separation is due to gross misconduct; and
he/she would not otherwise be eligible to continue FEHB coverage (beyond the 31-day extension of coverage).

The enrollee is eligible for TCC when he/she separates for retirement and is not eligible to continue FEHB coverage as an annuitant.

Child

The enrollee’s child is eligible for TCC when he/she:

has been covered as a child under Self Plus One or Self and Family enrollment through an employee, former employee, or annuitant;
stops meeting the requirements of an eligible child; and
would not otherwise be eligible to continue FEHB coverage (beyond the 31-day extension of coverage).

This includes a child who:

Loses coverage because he/she reaches age 26;
No longer meets coverage requirements as a foster child;
Was covered as a disabled child age 26 and older, and recovers from his/her disability or becomes self-supporting;
Loses FEHB coverage upon the death of an employee or annuitant because he/she does not qualify for a survivor annuity; and
Loses FEHB coverage because his/her survivor annuity as a dependent of the deceased stops (for any reason, including because he/she is no longer a full-time student).

Former Spouse

The enrollee's former spouse is eligible for TCC when he/she has been covered as a family member at some time during the 18 months before the marriage ended, but does not meet the remaining requirements for coverage under the Spouse Equity provisions of the FEHB law because he/she:

remarried before reaching age 55; or
is not entitled to a portion of his/her annuity benefits or a survivor benefit based on his/her service.

Persons not Eligible

An individual is not eligible for TCC when he/she:

transfers to a position that is excluded from FEHB coverage by law;
loses coverage after 12 months in a leave without pay status;
is a compensationer and loses coverage because the compensation terminates;
is a family member who loses coverage when the enrollee changes to a Self Only enrollment, cancels coverage, or separates from service and the family member does not elect TCC;
is a spouse who loses coverage because of the death of an employee or annuitant, and does not need TCC because he/she can continue regular coverage as a survivor annuitant;
is a surviving spouse whose annuity terminates;
is a child who enters military service (because he/she is still considered an eligible child); or
is involuntarily separated for gross misconduct.

Length of Temporary Continuation of Coverage

Former Employee

A former employee’s TCC eligibility time period continues up to 18 months from the date he/she separated from service.

Example

Laura separates from service on February 3, 2011. She is no longer an employee on February 4. Her period of TCC coverage expires on August 3, 2012.

Child

An enrollee's child's TCC eligibility time period continues for up to 36 months from the date of his/her change in status as an eligible family member. If the change in status as a family member takes place while he/she is covered as a family member under the enrollee’s TCC enrollment as a former employee, the child is eligible to enroll under TCC in his/her own right, but the TCC enrollment cannot continue beyond 36 months after the date of the enrollee’s separation from service.

Example 1

Robert's child turns 26 on April 22, 2012. She is considered to have turned 26 at midnight on April 21 and on April 22 is no longer a family member. She enrolls under TCC; her TCC eligibility ends at the end of the day on April 21, 2015.

Example 2

Laura separates from service on February 3, 2012. She enrolls under TCC for a Self and Family enrollment. Her child turns 26 on April 22, 2012 and enrolls under TCC. Her child's TCC eligibility ends on February 3, 2015.

Former Spouse

An enrollee’s former spouse's TCC eligibility time period continues for up to 36 months from the date of the divorce or annulment that takes place before the employee separated from service. If the divorce or annulment takes place while he/she is covered as a family member under the enrollee’s TCC enrollment as a former employee, the former spouse is eligible to enroll under TCC in his/her own right, but the TCC enrollment cannot continue beyond 36 months after the date of the employee’s separation from service.

Example 1

Paul (the employee) and Betsy’s divorce becomes final on December 10, 2012. She is considered to no longer be a family member on December 11. She enrolls under TCC; her TCC eligibility ends on December 10, 2015.

Example 2

Maria separates from service on September 1, 2012 and enrolls under TCC for a self and family enrollment. On December 10, 2013, her divorce from Eugene becomes final. Eugene enrolls under TCC; his TCC eligibility ends on September 1, 2015.

Length of Coverage Based on Qualifying Event

An enrollee’s TCC eligibility time period is based on the qualifying event that made him/her eligible for TCC.

Separating Employee

If an enrollee is a separating employee, he/she loses regular FEHB coverage at the end of the pay period in which he/she separates. Then he/she has a 31-day extension of coverage, at no cost to him/her, before his/her TCC coverage begins. The 18-month time period begins immediately after separation, although the first 31 days fall under the 31-day extension of coverage provision. The TCC coverage is effective on the day after the 31-day extension of coverage ends.

If the enrollee changes plans or options upon election of TCC, enrollment in the previous plan or option will continue through the 31-day extension of coverage. Enrollment in the new plan or option will become effective the day after the 31-day extension of coverage and will continue for up to 17 months.

After TCC coverage ends (except if the enrollee canceled his/her enrollment or the plan was discontinued), the enrollee is eligible for another 31-day extension of coverage at no cost to him/her, and the enrollee is eligible to convert to a non-group contract offered by his/her health benefits plan.

Example

Tyra separates from service on January 15, 2012. She enrolls under TCC and changes her enrollment to a different health benefits plan. Her enrollment with her previous plan continues for the first 31 days after separation. Her TCC coverage with the new plan begins on February 16, 2012. Her TCC eligibility time period ends on July 15, 2013. Her 31-day extension of coverage ends on August 16, 2013.

Child or Former Spouse

A child or former spouse of a Federal employee or annuitant also has a 31-day extension of regular FEHB coverage (at no cost) before his/her TCC coverage begins, beginning the day after the event that caused the loss of coverage. The 36-month TCC eligibility time period begins immediately after the event, although the first 31 days fall under the 31-day extension of coverage provision. TCC coverage is effective on the day after the 31-day extension of coverage ends, and continues for up to 35 more months.

If the child or former spouse changes plans or options upon election of TCC, his/her enrollment in the previous plan or option will continue through the 31-day extension of coverage. Enrollment in the new plan or option will become effective the day after the 31-day extension of coverage and will continue for up to 35 more months.

After the TCC coverage ends (except if the child or former spouse canceled his/her enrollment or his/her plan was discontinued), he/she is eligible for another 31-day extension of coverage at no cost, and he/she is eligible to convert to a non-group contract offered by his/her health benefits plan.

Example

Caroline turns age 26 on October 1, 2012 and loses coverage under her father's self and family enrollment. She elects TCC coverage and decides to enroll in the same plan that she was enrolled in under her father's coverage. Her 31-day extension of coverage ends on October 31, 2012 and her TCC eligibility time period ends on September 30, 2015. Her second 31-day extension of coverage ends on October 31, 2015.

Employing Office Responsibilities

The employing office that is responsible for the TCC enrollment on the date of the event qualifying the individual for TCC remains responsible for the enrollment for the length of the TCC enrollment. Many employing offices contract with the National Finance Center to administer TCC enrollments and to act as the employing office.

Providing Information for Employees

The employing office is responsible for providing all employees who are enrolled or eligible to enroll in FEHB with information about their right to TCC. This information is included in plan brochures and the booklet Temporary Continuation of Coverage under the Federal Employees Health Benefits Program (RI 79-27).

However, the employing office is not obligated to notify the enrollee or his/her family member when he/she is no longer eligible for coverage under the enrollment or provide notification of his/her eligibility for TCC.

Administering the Enrollment Process

Each employing office must establish procedures for notifying former employees about their eligibility to enroll, including what documents are needed to determine eligibility, and accepting enrollment elections from former employees, children, and former spouses.

Verifying Eligibility to Enroll

The employing office must verify the eligibility of a child or former spouse to enroll. If there is conflicting information on a child's date of birth or the date of a divorce, the employing office must determine the correct date.

Collecting Premiums

The employing office of the employee or annuitant at the time of the qualifying event is responsible for collecting premiums. The employing office sends the premiums it collects to OPM.

Maintaining the Health Benefits File

The employing office must maintain a health benefits file for each TCC enrollee separate from the personnel records of the employee or former employee.

Denying TCC Due to Involuntary Separation for Gross Misconduct

The employing office must make determinations of gross misconduct and follow the required administrative procedures.

Maintaining Enrollment

The employing office must provide services to TCC enrollees similar to those provided to enrolled employees. For example, it must provide Open Season information and process enrollment changes and cancellations.

Notification Requirements for Separating Employees

When an employee separates from service and is eligible for TCC, the employing office must notify him/her no later than 61 days after his/her separation of his/her opportunity to elect TCC.

This notice should include the employee’s right to convert to a non-group contract offered by his/her plan. This notice must explain his/her right to enroll in TCC and how he/she can get the registration form and additional information. His/her employing office should attach the pamphlet, Temporary Continuation of Coverage under the Federal Employees Health Benefits Program (RI 79-27) to the notice. If he/she wants to elect TCC, he/she must respond within the specified time limit.

Sample TCC Notice for Separating Employees

Dear (name):

Your coverage in the Federal Employees Health Benefits (FEHB) Program ends on the last day of the pay period in which you separate from Federal service, subject to a 31-day extension of coverage (at no cost to you) with opportunity for conversion to a non-group contract with your insurance carrier.

You also have the right to temporarily continue your FEHB coverage for up to 18 months after your separation instead of converting to a non-group contract at this time. You may select any plan in the FEHB Program in which to continue your coverage if you are eligible to enroll in the plan. To continue your coverage, you must pay the full amount of the premium (both the employee and Government shares) plus a 2 percent administrative charge. If you choose to continue your coverage, you have the free coverage described above for the first 31 days. Your Temporary Continuation of Coverage (TCC) enrollment and premium charges begin on the day after the 31-day period of free coverage ends. If you continue TCC to the end of the 18-month period, you will have another 31-day extension of coverage with opportunity for conversion to a non-group contract.

If you are interested in continuing your FEHB coverage, you can get additional information and an election form by calling (Name of person to contact) at (telephone number) or you can pick up the material at the following address: (enter address).

If you want to continue your coverage, your election form must be received at the address shown below within 60 days after the date of separation or 65 days after the date of this notice, whichever is later. Bring or mail your election form to: (enter address)

We also want to inform you that the Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. If you would like to learn more about the ACA including the health insurance marketplace, please visit www.healthcare.gov.

Sincerely,

(Name of appropriate official)

If your employing office gives this notice directly to you, it should add the following note and make two copies of the notice:

I acknowledge receipt of this notice.

Employee's signature Date

Notification Requirements for Children

If the employee’s child becomes eligible for TCC after a loss of FEHB coverage, it is the employee’s responsibility as the enrollee to notify his/her employing office of the change in the child's status. The enrollee must provide the child's name, address, and date of the event that caused his/her loss of FEHB coverage within 60 days from the loss of coverage. The employing office then has 14 days to notify the child of his/her TCC rights.

The child or another person may notify the enrollee’s employing office of the child's loss of coverage, but the time limit for electing TCC will be shorter than if the enrollee provided the notification.

The notice from the employing office to the child must include:

an explanation of your child's right to TCC;
Health Benefits Election Form (SF 2809);
how the child can get additional information; and
if there is doubt about the date of the qualifying event, a request for the appropriate information or documentation.

Sample TCC Notice for Ineligible Family Members - Children

Dear (child's name):

Your coverage in the Federal Employees Health Benefits (FEHB) Program as a family member of (enrollee's name) ended when you (enter reason), subject to a 31-day extension of coverage (at no cost) with opportunity for conversion to a non-group contract with your insurance carrier.

You also have the right to temporarily continue your FEHB coverage for up to 36 months after the date of (enter reason) instead of converting to a non-group contract at this time. You may select any plan in the FEHB Program in which to continue your coverage if you are eligible to enroll in the plan. If you choose family coverage, your spouse and your children will also be covered. To continue your coverage under the temporary continuation of coverage (TCC) provision, you must pay the full amount of the premium (both the employee and Government shares) plus a 2 percent administrative charge. If you choose to continue your coverage, during the first 31 days you have the free coverage described above. Your TCC enrollment and premium charges begin on the day after the 31-day period of free coverage ends. If you continue the coverage to the end of the 36-month period, you will have another 31-day extension of coverage with opportunity for conversion to a non-group contract.

An election form is enclosed and detailed information about your opportunity to continue coverage is available on the OPM website. You may get additional information by calling (name of contact) at (telephone number).

If you want to continue your coverage, your election form must be received at the address shown below within 60 days after the date of your (enter reason) or 65 days after the date of this notice, whichever is later. Bring or mail your election form to: (enter address).

Sincerely,

(Name of appropriate official)

If your employing office gives the notice directly to your child, it should add the following note and make two copies of the notice:

I acknowledge receipt of this notice.

Child's signature Date

If someone other than the enrollee notified the employing office of the child's loss of coverage, the sample notice's fourth paragraph should be replaced by the following paragraph:

If you want to continue your coverage, your election form must be received at the address shown below within 60 days after the date of your (enter reason). Bring or mail your election form to: (enter address).

Notification Requirements for Former Spouses

If the employee’s former spouse is eligible for TCC, either the employee or his/her former spouse must notify the employee’s employing office within 60 days after the date of his/her divorce or annulment. The employing office then has 14 days to notify the employee’s former spouse of his/her rights. The notice to the former spouse must include the same information as the notice to a child. In addition, the notice must request a certified copy of the divorce decree or other document showing the date of the divorce or annulment. If he/she wants to elect TCC, he/she must respond within the specified time limit.

Another person may notify the employee’s employing office of his/her former spouse's loss of coverage; but the time limit for electing TCC will be shorter than if the employee or his/her former spouse provided the notification.

Sample TCC Notice for Ineligible Family Members - Former Spouses

Dear (former spouse's name):

Your coverage as a family member in the Federal Employees Health Benefits (FEHB) Program ended when you were divorced or your marriage was annulled, subject to a 31-day extension of coverage (at no cost) with opportunity for conversion to a non-group contract with your insurance carrier.

You also have the right to temporarily continue your FEHB coverage for up to 36 months after your divorce or annulment instead of converting to a non-group contract at this time. You may select any plan in the FEHB Program in which to continue your coverage if you are eligible to enroll in the plan. If you choose a family enrollment, it will cover yourself and the children of both you and the Federal employee under whose enrollment you have been covered. If your former spouse still carries a family enrollment, you can enroll for self only. To continue your coverage under the Temporary Continuation of Coverage provision (TCC), you must pay the full amount of the premium (both the employee and Government shares) plus a 2 percent administrative charge. If you choose to continue your coverage, during the first 31 days you have the free coverage described above. The TCC enrollment and premium charges begin on the day after the 31-day period of free coverage ends. If you continue the coverage to the end of the 36-month period, you will have another 31-day extension of coverage with opportunity for conversion to a non-group contract.

Enclosed is an election form and detailed information about your opportunity to continue your coverage is available on the OPM website. You can get additional information by calling (name of contact) at (telephone number).

If you want to continue your coverage, your election form must be received at the address shown below within 60 days after the date of your divorce or annulment or 65 days after the date of this notice, whichever is later. Bring or mail your election form and a certified copy of the divorce decree or another document showing your divorce date to: (enter address).

Sincerely,

(Name of appropriate official)

If your employing office gives the notice directly to your former spouse, it should add the following note and make two copies of the notice:

I acknowledge receipt of this notice:

Former spouse's signature Date

If someone other than the employee or his/her former spouse notified the employing office of his/her loss of coverage, the sample notice's fourth paragraph should be replaced by the following paragraph:

If you want to continue your coverage, your election form must be received at the address shown below within 60 days after the date of your divorce or annulment. Bring or mail your election form to: (enter address).

Receipt of Notice

The employee’s employing office must either give the notice directly to the person eligible for TCC or send it by first class mail. (A notice that is mailed is considered to be received 5 days after the date on the notice.) If the employee, his/her child, or his/her former spouse is given the notice directly by the employing office, it will require that he/she acknowledge receipt by signing a copy of the notice. The signed copy must be placed on the right side of his/her Official Personnel Folder (OPF) or the equivalent. If the notice is sent by mail, a dated copy of the notice must be filed in his/her OPF.

Time Limits for Electing Temporary Continuation of Coverage

If an individual is a separating employee, he/she must submit a TCC election to his/her employing office within 60 days after the date of his/her separation or 65 days after the date of his/her employing office's notice, whichever is later.

An eligible child must submit his or her TCC election to the employee’s employing office within either:

60 days after the date of the qualifying event, if the enrollee did not notify his/her employing office within the required 60-day notification period (even if someone else provided notification); or,
65 days after the date of the employing office's notice, if the enrollee notified the employing office within the required 60-day notification period.

A former spouse must submit his or her TCC election to the employee’s employing office by the later of:

60 days after the date of the divorce or annulment, if the employee or his/her former spouse did not notify the employing office within the required 60-day notification period (even if someone else provided notification); or
65 days after the date of the employing office's notice, if the employee or his/her former spouse notified the employing office within the required 60-day notification period; or
60 days after the date he/she lost coverage under Spouse Equity provisions (because of remarriage before age 55 or loss of the qualifying court order), if the loss of coverage is within the 36-month period of TCC eligibility for a former spouse.

If the employee or his/her former spouse does not notify the employing office within the 60-day period, the former spouse's opportunity to elect TCC ends 60 days after the divorce or annulment.

Guardian may file

A court-appointed guardian may file a TCC election on behalf of an eligible person that is unable to file because of a mental or physical disability.

Late Election

The employing office may allow a late TCC election if it determines that the employee or his/her family member was unable to elect it on a timely basis for reasons beyond his/her control. It must accept the TCC election within 31 days after it provides notification of its decision to allow a late enrollment. Coverage is made retroactive to the date it would have been effective if elected on a timely basis, and retroactive premiums are due.

The employee’s employing office cannot accept a late election when it did not receive the required notification of his/her family member's eligibility for TCC within the time limits set by law and regulation.

Election Options

When an employee elects TCC, he/she may choose Self Only, Self Plus One, or Self and Family coverage in any plan or option that he/she is eligible to join. He/she is not limited to the plan, option, or type of enrollment under which he/she had been covered.

Covered Family Members

If a former employee with TCC has a Self Plus One or Self and Family enrollment, the eligibility requirements for his/her family members are the same as for active employees.

When a child with TCC has a Self Plus One or Self and Family enrollment, covered family members are the child’s spouse and eligible children.

When a former spouse with TCC has a Self Plus One or Self and Family enrollment, covered family members are limited to the children of both the employee and the former spouse. If the former spouse remarries, the new husband or wife is not covered. Stepchildren who were covered under the employee’s enrollment are not covered under the former spouse's TCC enrollment. The stepchild then becomes eligible to enroll under TCC because he/she is no longer a covered family member.

After the initial enrollment, a TCC enrollee may change enrollment during an open season or when another event occurs that would allow a change in enrollment.

Election Procedures

To make a TCC election, an individual should submit a Health Benefits Election Form (SF 2809) to the employing office that is servicing his/her account. If he/she submits a signed election request in a format other than the SF 2809, the employing office must complete a SF 2809 on his/her behalf based on the submitted written request. The enrollee’s name, date of birth, and social security number must be entered in part A of the form.

If he/she is a separated employee, the employing office must enter the following information under Remarks: "Eligibility expires: (enter date 18 months after separation date)."

If he/she is a child or former spouse, the employee’s servicing employing office must enter the following information under Remarks: name, date of birth, and social security number of the employee or annuitant; the expiration date of eligibility for enrollment; and the relationship to the employee.

Example:

Employee: Archibald M. Higgenbottom, SSN 123 45 6789, DOB 12/12/55. Eligibility ends: 4/20/97. Former spouse.

Effective Date of Coverage

The effective date of a TCC enrollment is the day after the 31-day extension of coverage ends. Coverage is retroactive to that date if TCC was elected after the 31-day extension of coverage ends.

Exception: When a former spouse loses coverage in the 18 month period before the divorce or annulment because the employee changed to a Self Only enrollment, the 31-day extension of coverage takes place after he/she loses coverage, not after the divorce or annulment. In this case, the former spouse's TCC enrollment is effective the day after the date of the divorce or annulment. Since there is a gap in FEHB coverage between the end of the 31-day extension of coverage and the beginning of the TCC enrollment, the employee’s former spouse may want to convert his/her coverage to a non-group contract until the TCC enrollment can begin.

If an employee elects a different plan or option when he/she enrolls under TCC, and the enrollee or a covered family member is an inpatient in a hospital on the 31st day of the extension of coverage, coverage under the old plan or option will continue for the hospitalized person for the length of the confinement, up to 60 days. The other family members' coverage will switch to the new plan or option after the 31-day extension of coverage ends.

Premium Payments

There is no Government contribution towards the premiums charged for a TCC enrollment. A TCC enrollee must pay the full premium (both the employee and Government shares) plus a 2 percent administrative charge. Premium charges, and TCC coverage, begin on the day after the free 31-day extension of coverage ends. If an enrollee elects TCC after the 31-day extension of coverage, he/she will be billed for premiums retroactive to the effective date of coverage.

Exception: certain Department of Defense employees who have TCC based on a separation due to reduction in force as described in 5 U.S.C.8905a(d)(4) continue to receive a Government contribution towards premiums.

Each payment is due after the pay period in which he/she is covered according to the schedule established by the servicing employing office. The servicing employing office submits the premium payments it collects along with its regular health benefits payments to OPM.

Unlike most enrollments, the beginning and ending dates of TCC enrollments are not always the same as the beginning and ending date of a pay period. In this case, the servicing employing office must prorate the premium charge. It must determine a daily premium rate by multiplying the monthly premium rate (including the administrative charge) by 12 and dividing the result by 365.

Nonpayment of Premiums

If an enrollee’s servicing employing office does not receive his/her premium payment by the due date, it must notify him/her in writing that he/she must make payment within 15 days (45 days if he/she lives overseas) for coverage to continue. If the enrollee doesn't make any payments within 60 days (90 days if he/she lives overseas) after the date of the notice, the enrollment is terminated, effective with the end of the last pay period that he/she paid his/her premiums.

If coverage is terminated because the enrollee didn't pay his/her premiums, he/she is not entitled to the 31-day extension of coverage and cannot convert to a non-group contract. He/she may not reenroll or be reinstated unless he/she was unable to make payment within the specified time frames for reasons beyond his/her control.

Sample Notice for Delinquent Premiums

The employing office may use the following sample notice for enrollees who do not make payments on time:

Dear (name):

We have not received your payment for health benefits coverage in the amount of $ that was due on (date), and represents payment for coverage for the month of (month, year). If we do not receive the payment with 15 days after the date you receive this letter, your health benefits will be terminated, effective (last day of coverage for which premiums were paid).

Termination of health insurance because of nonpayment of premiums is considered to be a voluntary cancellation by the enrollee. If your enrollment is canceled, you may not enroll again nor be reinstated (except as explained in the following paragraph). In addition, you will not be entitled to convert your coverage to a non-group contract with your insurance carrier or to have the 31-day temporary extension of coverage.

If your coverage is canceled, it may be reinstated only if you were prevented by circumstances beyond your control from making the payment within the time frame specified above. You may request reinstatement by writing to the following address: (enter employing office address).

Sincerely,

(Name of appropriate agency official)

Effective Date of Enrollment Change

Generally, an enrollment change that an enrollee makes while he/she is covered under TCC is effective on the first day of the first pay period that begins after the date his/her servicing employing office receives his/her Health Benefits Election Form (SF 2809).

When the servicing employing office determines that the enrollee was unable, for reasons beyond his/her control, to change his/her enrollment within the specified time limits, he/she may do so within 60 days after his/her employing office notifies him/her of its determination.

At the servicing employing office's discretion, a person with the enrollee’s authorization to take health benefits actions may enroll or change his/her enrollment on his/her behalf.

Opportunities for an Enrollee to Change TCC Enrollment

When an employee makes a change based on one of the following events, his/her servicing employing office will follow the same procedures as for employees enrolled under regular FEHB coverage.

Decrease Enrollment

An enrollee may decrease his/her enrollment from Self Plus One or Self and Family to Self Only at any time. Generally, the change is effective on the first day of the first pay period that begins after the date his/her servicing employing office receives his/her request to change his/her enrollment.

Open Season

During Open Season, an enrollee may increase enrollment, decrease enrollment, change from one plan or option to another, or make any combination of these changes. Exception: an enrolled former spouse may change from one plan or option to another, but cannot change from Self Only to Self Plus One or Self and Family unless he/she is covering a child of both the former spouse and the employee or annuitant on whose service coverage is based.

An Open Season enrollment change is effective on the first day of the pay period that begins in January of the next year. If the servicing employing office accepts a late Open Season change, the effective date is the same date it would have been if submitted timely, even if that means it is effective retroactively.

Change in Family Status

An enrolled former employee or child may increase or decrease enrollment, change from one plan or option to another, or make any combination of these changes, when he/she has a change in family status. The enrollee must make the enrollment change during the period beginning 31 days before and ending 60 days after the date of the change in family status.

An enrolled former spouse may increase or decrease enrollment, change from one plan or option to another, or make any combination of these changes within the period beginning 31 days before and ending 60 days after the birth or acquisition of a child of both the former spouse and the employee or annuitant on whose service coverage is based.

A change that the enrollee makes because of the birth or acquisition of a child is effective on the first day of the pay period in which his/her child is born or becomes an eligible family member.

Reenrollment Under TCC

If an enrollee’s TCC enrollment ended because he/she acquired regular FEHB coverage (as an employee or family member), he/she may reenroll in TCC if his/her newly acquired regular FEHB coverage ends before his/her 18- to 36-month eligibility period ends. However, the enrollee may be eligible for a new TCC enrollment period if his/her coverage does not extend beyond the original eligibility period. The effective date of reenrollment is the day following the date that regular FEHB coverage ended.

Loss of FEHB Coverage or Coverage under Another Group Insurance Plan

An enrollee may increase or decrease enrollment, change from one plan or option to another, or make any combination of these changes when he/she loses other FEHB coverage or his/her eligible family member loses FEHB coverage or coverage under another group health plan beginning 31 days before and ending 60 days after the loss of coverage.

Move from an HMO's Service Area

If an enrollee is enrolled in an HMO and moves or becomes employed outside the HMO's service area (or, if already living or working outside this area, moves or becomes employed further away), he/she may change his/her enrollment. The enrollee must notify his/her employing office of the change.

Newly Eligible for Medicare

An enrollee may change his/her enrollment from one plan or option to another at any time beginning on the 30th day before he/she becomes eligible for Medicare. An enrollment change under this event may be made only once in a lifetime.

Termination of TCC Enrollment or Coverage

An enrollee’s TCC enrollment will end either because his/her eligibility period ends or he/she cancels the enrollment (this includes cancellation when he/she doesn't pay his/her premiums). If the enrollment ends because the TCC eligibility period ends, he/she is entitled to the 31-day extension of coverage for conversion to a non-group contract.

Coverage for a family member ends when the enrollment ends or when he/she no longer is eligible for coverage as a family member. If the family member loses TCC coverage for any reason other than the enrollee’s cancellation (this includes cancellation when the enrollee doesn't pay his/her premiums), the family member is entitled to the 31-day extension of coverage for conversion to a non-group contract. If the enrollee is a former employee, his/her family member that loses coverage is also eligible for TCC in his/her own right.

Enrollment ends when premiums remain unpaid 60 days (90 days if the enrollee lives overseas) after the date of the employing office's notice of nonpayment.

If enrollment ends because the enrollee didn't pay his/her premiums, it is considered to be a voluntary cancellation effective with the last day of the pay period for which he/she made a payment. The servicing employing office must complete a Health Benefits Election Form (SF 2809) for the enrollee. In part G, which normally would have the enrollee’s signature, the employing office will enter "Canceled due to nonpayment of premiums." In part H, it will enter "N/A" in item 2, and in item 3 it will enter the effective date of the cancellation. In cases where the enrollee never made a payment, it enters the same effective date as on the original SF 2809 enrolling him/her. In the Remarks section it enters "This cancellation voids the prior SF 2809 enrolling this individual in his/her plan on the date in item 3." This voiding action has the same effect as a cancellation for nonpayment of premiums.

31-Day Extension of Coverage and Conversion to a Non-Group Contract

If an enrollee loses his/her TCC other than by cancellation (including cancellation by nonpayment of premiums) or discontinuance of the plan, his/her coverage is automatically extended for 31 days, at no cost. The enrollee is also entitled to convert to a non-group contract with his/her health benefits carrier, without providing evidence of insurability. An enrollee’s covered family member is eligible for the 31-day extension of coverage and has the right to convert even if he/she is eligible to elect TCC in his/her own right (e.g., he/she is a child of a former employee and loses TCC coverage because he/she is no longer considered a covered family member).

Denial of TCC because of Involuntary Separation for Gross Misconduct

Under the law, an enrollee is not eligible for TCC when he/she is involuntarily separated from Federal service because of gross misconduct.

The employing office must determine whether the offense for which the enrollee is being removed constitutes gross misconduct. The determination must be made on a case-by-case basis by employing office staff (employee relations, Office of General Counsel, etc.) with a knowledge of case law involving gross misconduct.

General Guidelines for Gross Misconduct Determination

Generally, an offense punishable as a felony is considered gross misconduct. Lesser offenses may also be gross misconduct, depending on the circumstances. Other elements that must be considered are:

There must be a connection between the offense and the employee’s job. Also, some individuals, such as judges, are held to a higher standard of conduct than others.
The employee must have the ability to understand the gravity of his/her conduct.
The employee’s offense must be affirmative and willful, not simply negligent.

An adverse action procedure (5 CFR Part 752) does not result in a specific finding of gross misconduct. There are some offenses for which the employee can be removed under adverse action procedures that are not considered gross misconduct or are even considered disciplinary in nature (e.g., refusal to transfer with his/her function).

Removal Must Result from Gross Misconduct

In order to be denied TCC eligibility for gross misconduct, the removal (or resignation in lieu of removal) must be a direct result of his/her gross misconduct. If the enrollee resigns before his/her employing office initiates adverse action procedures, the separation is considered voluntary and he/she is entitled to TCC. If the enrollee resigns after receiving notice of the employing office's proposal to remove, but before he/she is removed, the separation is considered to be involuntary and he/she is not entitled to TCC. If the enrollee commits an offense that would be considered gross misconduct, but he/she is removed on another basis (e.g., unsatisfactory performance), the removal is not due to the gross misconduct and he/she is entitled to TCC.

Example

Simon was found to have embezzled money from his employing office's imprest fund. His employing office notifies him that it will begin an adverse action procedure to have him removed from service. Simon resigns the next day. He is not entitled to TCC since this is considered an involuntary separation.

Notification Requirements

When the enrollee’s employing office determines that his/her offense constitutes gross misconduct, it must notify the enrollee in writing that it intends to deny his/her TCC eligibility. The notice must:

give the reason for the denial;
give the enrollee at least 7 days to respond; and
be given to the enrollee no later than the date of separation.

This notification may be combined with other notifications required for adverse action procedures or other procedures for actions based on misconduct.

Response

The enrollee’s response may be oral or in writing. The enrollee is entitled to be represented by an attorney or other representative. The employing office must designate an official who has the authority to either make or recommend a final decision to hear the enrollee’s oral answer. If he/she responds to the notice of denial, the employing office must issue a final decision that fully describes its findings and conclusion.

The final decision is not subject to OPM reconsideration. If the enrollee wants to challenge the decision, he/she may file suit against the employing office in U.S. district court.

Coordination with the Office of Workers' Compensation Programs

The compensationer’s employing office is responsible for providing notification to eligible family members who lose family member status, for accepting their enrollments, and for collecting their premiums.

When an individual is a covered compensationer and he/she isn't entitled to continue his/her FEHB coverage as a compensationer upon his/her separation from service, the employing office must provide the compensationer with notification of his/her right to elect TCC, accept his/her enrollment, and collect his/her TCC premiums in the same way as for any other separating employee.

If the enrollment has been transferred to Office of Workers' Compensation Programs (OWCP), the compensationer’s employing office must contact OWCP to determine whether he/she is enrolled and, if the person seeking continued coverage is a family member, whether the enrollment is for Self Plus One or Self and Family. If the enrollee’s child is seeking continued coverage and his/her date of birth is not available, OWCP can supply that information.

For a compensationer who is no longer an employee, OWCP is responsible for providing notification to eligible family members who lose family member status, for accepting their enrollments, and for collecting their premiums.

Coordination with Spouse Equity Provisions

A former spouse of a Federal employee or annuitant and that does not qualify for FEHB coverage under Spouse Equity provisions may be eligible for TCC.

Coverage under the Spouse Equity provisions is often delayed because the retirement system must determine whether the former spouse has a qualifying court order. Coverage does not begin until the pay period after the employing office receives the determination that the court order is qualifying (although he/she may request retroactive enrollment). The former spouse may be eligible for TCC while he/she is waiting for coverage under the Spouse Equity provisions to begin (but not beyond 36 months after the divorce or annulment).

Coverage under the Spouse Equity provisions will end if the former spouse remarries before he/she reaches age 55. If he/she remarries during the 36 months following his/her divorce or annulment, he/she is eligible for TCC. The former spouse’s TCC will expire 36 months after the date of his/her divorce or annulment from the Federal employee.

Example

Nick and Nora's divorce becomes final on June 1, 2012. Nora applies for FEHB coverage under the Spouse Equity provisions and under TCC. She is covered under TCC until her Spouse Equity application is approved. Nora remarries on October 15, 2013, and since she is under age 55, her Spouse Equity coverage ends. She reenrolls under TCC provisions, and her coverage expires on June 1, 2015.

Health Benefits File

When an individual becomes enrolled under TCC, the servicing employing office will establish a health benefits file in the enrollee’s name. If the enrollee is a former employee, this file must be separate from his/her personnel records. If the enrollee is a former spouse or child, the name of the employee on whose service the TCC coverage is based must be noted on the front cover of the enrollee’s file.

The servicing employing office must keep the following documents in the health benefits file:

the Official Personnel Folder (OPF) copy of the Health Benefits Election forms (SF 2809) documenting the enrollment and any changes in enrollment;
the OPF copy of the Notice of Change in Health Benefits Enrollment (SF 2810) terminating the enrollment; and
copies of any correspondence or other documents related to the enrollment (e.g., employing office notice of the premium amount and payment schedule, any notice of overdue premiums, documentation of a child's mental or physical disability before age 26, a cancellation request).

The contents of the file are subject to the provisions of the Privacy Act [5 U.S.C. 552a(b)]. The health benefits file may be destroyed 2 years after the end of the calendar year in which the TCC eligibility period expires.

For a former spouse who elects TCC after losing coverage under the spouse equity provisions, the servicing employing office must forward his/her Spouse Equity health benefits file to the employee's (on whose service the TCC coverage is based) retirement system. It must prepare a new health benefits file for the former spouse’s TCC enrollment.

When an Individual with TCC Coverage becomes Employed by the Federal Government

When an individual has TCC and becomes employed by the Federal Government, the TCC coverage stops when he/she enrolls for regular FEHB coverage. Either the enrollee or his/her new employing office must send a copy of the Health Benefits Election Form (SF 2809) documenting the new enrollment to the employing office that maintains the TCC enrollment, with a cover letter instructing it to stop the TCC enrollment.

If the enrollee’s newly acquired regular FEHB coverage ends before the expiration of his/her TCC eligibility, he/she may resume the previous TCC enrollment. The enrollee will likely be eligible for a new TCC enrollment period based on his/her separation from service. In some cases, it may be more beneficial to continue the previous TCC enrollment. This would happen when the previous TCC enrollment was for 36 months and it extends beyond the 18-month eligibility period after the enrollee separates from service.

Example

Janice is covered as a family member under her mother's FEHB enrollment. She turns age 26 on May 15, 2012, and elects TCC coverage. Her eligibility period under TCC ends on May 14, 2015 (36 months). She later becomes employed by the Federal Government and elects to carry regular FEHB coverage, so her TCC coverage is terminated. She leaves Federal service on April 20, 2016, and is eligible to elect TCC as a separated employee. Her eligibility period would end on October 20, 2017 (18 months). She chooses instead to resume her original TCC coverage since this would give her a longer eligibility period.