Annuitants

Eligibility for Health Benefits After Retirement

Requirements

Employees are eligible to continue health benefits coverage, upon retirement, if they meet all of the following requirements:

• he/she is entitled to retire on an immediate annuity under a retirement system for civilian employees (including retirements under FERS Minimum Retirement Age + 10); and
• he/she has been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date the annuity starts, or for the full period(s) of service since his/her first opportunity to enroll (if less than 5 years).

When an employee elects not to enroll or cancel his/her enrollment, the employee must certify by his/her signature on the Health Benefits Election form (SF 2809) that he/she understands the effect this has on eligibility to carry coverage into retirement.

MRA + 10

Minimum Retirement Age + 10

If a separating employee is covered under FERS and qualifies for an immediate annuity under the Minimum Retirement Age (MRA) + 10 provision, the employee can continue the enrollment when his/her annuity starts, as long as the employee meets the requirements for continuing coverage.

If an individual postpones receipt of an annuity, the enrollment will terminate when the individual separates from employment. The individual will be eligible for temporary continuation of coverage (TCC) or to convert to an individual contract. The employee may choose to resume FEHB coverage on the date selected for the annuity to begin.

Service

For purposes of continuing FEHB coverage into retirement, "service" means time in a position in which an individual was eligible to be enrolled. The individual is not required to have been an enrollee continuously, but the individual must have been continuously covered by an FEHB enrollment. Continuous coverage includes:

• Time covered as a family member under another person's FEHB enrollment.
• Time covered under the Uniformed Services Health Benefits Program (also known as TRICARE or CHAMPUS) or CHAMPVA as long as the individual was covered under an FEHB enrollment at the time of retirement. (The individual must enroll in FEHB within 60 days after losing coverage under the Uniformed Services Health Benefits Program or CHAMPVA for that time to be considered as part of continuous FEHB coverage.)

Coverage under Medicare does not count in determining continuous coverage.

Service as a Non-appropriated Fund employee does not count in determining continuous coverage since it is not Federal service and not subject to FEHB coverage.

Break in Service

Breaks in service are not counted as interruptions when the 5 years of service requirement is determined, as long as the individual reenrolls within 60 days after his/her return to Federal service.

Example 1

Joan elected FEHB coverage on February 11, 2007, and had a break in service from January 1, 2011 through January 1, 2013. Upon her return to service, she again elected to enroll. She retires on December 31, 2014. She is eligible to continue her health benefits coverage into retirement, since she has been continuously enrolled for the 5 years of service prior to retirement.

Example 2

Eduardo elected not to enroll in the FEHB Program upon his employment. He left Federal service in 2011. He was rehired in 2011, and elected to enroll. When he retired in 2014, he was not eligible to continue health benefits into retirement since he was not covered for the five years of service before his retirement. His 2011 rehire date does not count as his first opportunity to be insured because of his prior employment in which he elected not to enroll.

Late Election

An individual is considered to have been continuously enrolled when allowed to make a late election after the employing office determined that the individual wasn't able to timely enroll for reasons beyond the individual's control.

Example

Anne's employing office notified her on March 20, 2011 that she could make a late election to enroll in the FEHB Program. She promptly enrolled, and on January 1, 2016, she retired. She is able to continue her health benefits coverage into retirement, since March 20, 2011, is considered to be her first opportunity to enroll.

Service with an International Organization

If an enrollee transfers to an International Organization and elects to continue FEHB coverage, the service with the International Organization is included in determining whether the 5 years of service requirement is met. If the enrollee doesn't elect to continue FEHB coverage or drops enrollment before returning to Federal service, the time with the International Organization without FEHB coverage is not included in determining whether the 5-year requirement was met.

Eligibility as a Temporary Employee

An individual's decision not to enroll as a temporary employee eligible for coverage under 5 U.S.C. 8906a doesn't affect the individual's future eligibility to continue coverage as a retiree. Only service for which the Government contributes toward the cost of health benefits counts in determining whether the individual has met the 5 years of service (or first opportunity) requirements to continue coverage as a retiree. Since the Government doesn't share in the cost of a temporary employee's enrollment, eligibility to enroll under 5 U.S.C. 8906a is not considered the first opportunity for purposes of continuing health benefits coverage into retirement.

Eligibility under Temporary Continuation of Coverage

Enrollment or eligibility for enrollment as a former employee under the TCC provisions is not considered in determining whether an individual meets the 5 years of service requirement for continued coverage as a retiree, since he/she is not a Federal employee at that time. However, the time an employee eligible to enroll in FEHB was covered as a family member under the TCC enrollment of another person does count toward the 5 years of service requirement.

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Eligibility for Health Benefits After Retirement

Who Makes the Determination?

At retirement, the employing office will tentatively determine if an individual is eligible to continue enrollment. OPM's Office of Retirement Programs (or another qualified retirement system) will review the retirement and health benefits documents and make a final determination of eligibility to continue the FEHB enrollment into retirement.

Waiver of 5-Year Enrollment Requirement

Public Law 99-251 gave OPM the authority to waive the 5 years of service requirement when, in its sole discretion, it determines that it would be against equity and good conscience not to allow a person to be enrolled in the FEHB Program as an annuitant. An employee's failure to satisfy the 5-year requirement must be due to exceptional circumstances. Employees requesting a waiver must provide OPM with evidence that:

• the employee intended to have FEHB coverage as a retiree;
• the circumstances that prevented the employee from meeting the 5-year requirement were essentially outside of the employee's control; and
• the employee acted reasonably to protect the right to continue FEHB coverage into retirement. (This includes reading and acting on information provided and requesting information if none is given automatically.)

How OPM Applies Its Waiver Authority

OPM's approval of a waiver request depends on the extent to which the individual could have controlled the events leading to the loss of coverage at retirement. When OPM reviews a waiver request, it considers:

• whether the individual had a compelling reason to believe he/she was covered as a family member of another person enrolled in FEHB during the time in question;
• evidence that an individual's employing office would not allow him/her to enroll;
• the extent to which an individual could have controlled the events that led up to the loss of the right to continued FEHB coverage;
• whether the individual had acted to gain FEHB coverage at the earliest opportunity after learning of the loss of benefits or possible loss of future rights; and
• whether the individual had substantial FEHB coverage during his/her career even though there was a break in continuity during the last 5 years of service.

OPM would approve the following examples of waiver requests.

Examples

Sean drops coverage in the FEHB Program for a period of time, but reenrolls later. He is later forced to retire because of a disability before meeting the 5-year participation requirement. (Employees who retire voluntarily although they have a medical condition that would make them eligible for disability retirement are considered as disability retirees for the purpose of granting waivers.)

Lilly does not meet the 5 year participation requirement, but had been covered under FEHB for a substantial number of years during her career, including 3 years immediately before retirement. She is forced to retire because of an involuntary separation.

Jill had a break in coverage during the 5 years of service immediately before retirement because her Federally employed spouse changed from a Self and Family enrollment to a Self Only enrollment without telling her. She enrolled at the first opportunity after learning of the loss of coverage.

When OPM Does Not Grant a Waiver

OPM generally doesn't grant a waiver if it is within the individual's control to complete the eligibility requirements for continued coverage. For example, in the case of a voluntary early retirement, an individual could have chosen instead to remain in Federal service to complete the eligibility requirements. In this case, the individual generally can't qualify for a waiver unless some circumstance other than an early retirement made it impossible to complete the participation requirement (but see "Current Waiver Policy" for exceptions).

OPM generally wouldn't approve the following examples of waiver requests.

Examples

Keesha loses non-Federal coverage, enrolls for FEHB at the earliest opportunity thereafter, and then retires voluntarily before meeting the participation requirement.

Jim does not meet the 5-year participation requirement. Although his employing office didn't specifically inform him that FEHB coverage wouldn't continue after retirement, it did prepare a Notice of Change in Health Benefit Enrollment (SF 2810) terminating his enrollment at retirement.

Sara doesn't meet the 5-year participation requirement and retires under an early optional retirement authority.

Robert claims to be unaware of the 5-year participation requirement.

Where to Send a Waiver Request

If a retiring employee wants to ask OPM to waive the participation requirement, the employee should call the Office of Personnel Management, Retirement Programs at (202) 606-1535 to request a waiver.

Waivers for Same-Sex Spouses of FEHB Enrollees who Passed Away On or Before June 26, 2013

Following the Supreme Court's June 26, 2013 decision in United States v. Windsor, same-sex spouses became eligible family members who may receive coverage under an FEHB enrollment. Because existing same-sex marriages were not recognized by the Federal government before the Windsor decision, all legal same-sex marriages that predated the Windsor decision were treated as new marriages. FEHB enrollees, which included Federal employees and annuitants, had 60 days from June 26, 2013 until August 26, 2013, to submit a request to change FEHB enrollment from Self Only to Self and Family, to provide FEHB coverage to a same-sex spouse. However, Federal employees and annuitants who died on or before the date of the Windsor decision, June 26, 2013, did not have an option to elect FEHB coverage for a same-sex spouse.

In the ordinary course for a surviving spouse to be enrolled in FEHB after the death of the Federal employee or annuitant, the deceased Federal employee or annuitant must have been enrolled in Self and Family FEHB coverage that covered the surviving spouse at the time of death and the surviving spouse must be entitled to a monthly annuity as the survivor of a deceased Federal employee or annuitant. This means, absent a waiver of the FEHB eligibility requirements codified at 5 U.S.C. § 8905(b)(2), individuals who are now receiving a survivor annuity as the surviving same-sex spouse of a deceased employee or annuitant who died on or before June 26, 2013, are not eligible for FEHB enrollment.

Accordingly, OPM has updated the FEHB Eligibility Waiver Policy to outline the criteria OPM will consider when reviewing waiver requests from individuals who are receiving a monthly survivor annuity benefit as the surviving same-sex spouse of a Federal employee or annuitant who died on or before June 26, 2013.

Section 8905(b) of title 5, U.S. Code allows OPM to waive certain FEHB eligibility requirements for an individual if OPM "determines that, due to exceptional circumstances, it would be against equity and good conscience not to allow such individual to be enrolled as an annuitant in a health benefits plan under [chapter 89]." The implementing regulation, promulgated at 5 CFR 890.108, requires the annuitant to provide OPM with evidence of the following in order to be granted a waiver for FEHB enrollment:

1. The individual intended to have FEHB coverage as an annuitant (retiree);
2. The circumstances that prevented the individual from meeting the requirements of 5 U.S.C. § 8905(b) were beyond the individual's control; and
3. The individual acted reasonably to protect his or her right to continue coverage into retirement.

OPM does not want to penalize an individual who is receiving a survivor annuity as a same-sex spouse and who was not covered by a FEHB Self and Family or Self Plus One plan before his/her spouse's death because prior to June 26, 2013, the provisions of the Defense of Marriage Act (DOMA) prevented OPM from recognizing the same-sex marriage. Therefore, it would be against equity and good conscience not to grant a waiver request submitted by such individual.

Based on the waiver authority in 5 U.S.C. § 8905(b), OPM will grant waivers for individuals who submit a written request for waiver and provide the following documentation:

• Proof of a legally valid same-sex marriage performed prior to June 26, 2013, to the deceased annuitant;
• Proof that the deceased annuitant died prior to June 26, 2013; and
• Proof that the deceased annuitant was enrolled in FEHB at death.

Individuals must submit requests for waiver of the FEHB enrollment eligibility requirements under 5 U.S.C. § 8905(b) to OPM in writing.

Call the Office of Personnel Management, Retirement Programs at (202) 606-1535 to request a waiver. These waiver requests should be mailed to:

Office of Personnel Management
Retirement Programs
Attn: Retirement Eligibility Services — HB Waiver Request
1900 E Street, NW; Room 2416 
Washington, DC 20415

In addition, the individual who is seeking a waiver of the FEHB eligibility requirements must have already been adjudicated eligible for a survivor annuity before he or she may seek a waiver under 5 U.S.C § 8905(b).

After a survivor annuitant is granted a waiver pursuant to section 8905(b) and the procedures described above, the FEHB enrollment will be effective the first day of the first pay period that begins after the date on which that OPM granted the waiver. The survivor annuitant may not be enrolled in FEHB retroactively, unless there is clear administrative error.

Previous Waiver Policies

Waiver Policy for Retirements on and after March 30, 1994

Public Law 103-226, the Federal Workforce Restructuring Act of 1994 (FWRA), authorized certain Federal agencies to offer voluntary separation incentive payments (VSIPs) or buyouts to their employees who retired during the period from March 30, 1994, to March 31, 1995. Congress instructed OPM to consider the widespread use of early voluntary retirement authorizations and VSIPs as exceptional circumstances that warrant the use of its waiver authority.

OPM granted a waiver to any Executive agency employee who received a VSIP during this time period (or if the employing office retained the employee due to its need, not later than March 31, 1997). During the same period, OPM also granted waivers to any employee authorized a buyout by similar legislation (such as the Department of Defense program) for the period beginning March 30, 1994 and ending at the termination of the buyout period applicable to the agency. To be eligible for a pre-approved waiver, the employee must have been enrolled in FEHB as of March 30, 1994.

During the same period, OPM also granted a waiver if the employee:

• Took an early optional retirement as a result of an agency's early-out authority, or
• Took a discontinued service retirement based on an involuntary separation due to reduction in force, directed reassignment, reclassification to a lower grade, or abolishment of position.

Waiver Policy for Retirements On and After October 1, 1996

OPM revised the waiver policy on October 1, 1996 to cover VSIPs authorized by Public Law 104-208. Under the revised policy, OPM granted a pre-approved waiver to any Executive agency employee who separated for retirement on or after October 1, 1996, who was covered under the FEHB Program on and after October 1, 1996, and who:

• received a voluntary incentive payment under P.L. 104-208; or
• during the statutory buyout period (October 1, 1996, through December 30, 1997), took early optional retirement as a result of early out authority in the agency; or
• during the statutory buyout period (October 1, 1996, through December 30, 1997), took a discontinued service retirement based on an involuntary separation due to reduction in force, directed reassignment, reclassification to a lower grade, or abolishment of position.

To the extent that these statutes allowed a postponement of the individual's departure, if the employee separated after the statutory buyout period and received a buyout, the employee was eligible for a waiver under this policy. If separated after the statutory buyout period and didn't receive a buyout, the employee wasn't eligible for a waiver under this policy.

Current Waiver Policy

While Public Laws 103-226 and 104-208 authorized Government-wide VSIPs, more recently, Congress has been authorizing buyouts for individual agencies. Each agency's VSIP legislation specifies different beginning and ending dates.

OPM's current waiver policy provides pre-approved waivers for any employee who has been covered under the FEHB Program continuously since October 1, 1996, or the beginning date of an agency's latest statutory buyout authority, whichever is later.

To be eligible for a pre-approved waiver, the employee must:

• retire during an agency's statutory buyout period; and
• receive a buyout under the agency's statutory buyout authority; or
• took an early optional retirement as a result of early-out authority in the agency; or
• took a discontinued service retirement based on an involuntary separation due to reduction in force, directed reassignment, reclassification to a lower grade, or abolishment of position.

If an employee meets these requirements, he/she does not need to write a letter requesting a waiver. Instead, the agency must attach a memorandum to his/her retirement application stating that he/she meets the requirements for a pre-approved waiver by OPM as set forth in Benefits Administration Letter (BAL) 00-220 . The memorandum should provide the number of the Public Law granting the agency's VSIP authority and the beginning and the ending dates of the agency's statutory buyout period.

If You Do Not Qualify for a Pre-approved Waiver

Some employees who retire during a buyout period will not be eligible for a pre-approved waiver. This includes employees who retire on a regular optional retirement but do not qualify for a VSIP.

If an employee does not qualify for a pre-approved waiver, he/she may ask OPM to waive the participation requirements. OPM will consider each case on its own merits, based on the criteria that are applied to all other retiring employees. The employee must explain why he/she believes OPM should consider them for a waiver (e.g. why he/she was unable to meet the 5-year participation requirement or why meeting it would be harmful to the employee). Employees must call the Office of Personnel Management, Retirement Programs at (202) 606-1535 to request a waiver.

When an Agency has Separate Buyout Authority

Some agencies, such as the Departments of Defense and Agriculture, have separate buyout authority. If an employee retired before October 1, 1996 from an agency that has separate buyout authority, the employing office should follow the waiver policy for retirements on or after March 30, 1994. If separated for retirement on or after October 1, 1996, the employing office should follow the waiver policy for retirements on and after October 1, 1996.

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Qualifying Retirement Systems

Type of System

For FEHB purposes, employees must retire under a civilian retirement system for Federal or District of Columbia Government employees.

Qualifying Systems

Qualifying civilian retirement systems include, but are not limited to, the following:

• Civil Service Retirement System (CSRS)
• Federal Employees Retirement System (FERS)
• Board of Governors of the Federal Reserve System
• CIA Retirement System
• District of Columbia Courts Judges Retirement System
• Federal Judiciary Retirement System [28 U.S.C. 371(a)]
• Financial Institutions Retirement Fund System
• Foreign Service Pension System
• Foreign Service Retirement System
• Judiciary of the Territories Retirement System (28 U.S.C. 373)
• Lighthouse Retirement System
• Military Court of Appeals Judges Retirement System
• National Oceanic and Atmospheric Administration System
• Nonappropriated Fund Retirement System
• Officers of the Public Health Service System
• Policemen and Firemen of the District of Columbia Retirement System
• Public School Teachers of the District of Columbia System
• Teachers Insurance Annuity Association and Collegiate Retirement Equities Fund Retirement System
• U.S. Court of Veterans Appeals Judges Retirement System
• U.S. Tax Courts Judges Retirement System

For FEHB purposes, the Social Security system is not a qualifying civilian retirement system.

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Benefits and Cost

Annuitants are entitled to the same benefits and Government contribution as non-Postal active employees enrolled in the same plan. The enrollee's share of the premium cost also continues to be the same as for a non-Postal employee and is deducted from the retiree's annuity payments.

If the annuity is not large enough to cover the annuitant's share of the premiums for his/her current plan, the annuitant may either change to a lower-cost plan or option (one in which the share of the premium is low enough to be withheld from the retiree's annuity) or the retiree can choose to pay the premiums directly to the retirement system. Even if the employing office thinks that the annuity will not cover the retiree's share of the premiums, it will transfer the existing enrollment to the retiree's retirement system. The retirement system will notify affected annuitants of their options and take whatever actions are necessary to honor the annuitant's request.

Direct Premium Payments

If an annuitant decides to pay his/her share of premiums directly to his/her retirement system, the retirement system will establish a payment schedule for the annuitant. The annuitant must continue to make premium payments directly for the length of the enrollment even if his/her annuity increases enough to cover premium costs.

Nonpayment of Premiums

If an annuitant makes direct payments and the retirement system doesn't receive the premium payment by the due date, the retirement system must notify the annuitant in writing that payment must be made within 15 days (45 days if the annuitant is living overseas) for coverage to continue. If the payment is not made, the retirement system will terminate the enrollment 60 days (90 days for annuitants living overseas) after the date of the notice. Coverage will be terminated retroactive to the end of the last pay period in which the annuitant made the payment. An annuitant terminated for nonpayment may not reenroll, unless the nonpayment was for reasons beyond his/her control.

If an annuitant wasn't able to make timely payment for reasons beyond his/her control, he/she may write to the retirement system to ask that coverage be reinstated. The request must be filed within 30 days from the date enrollment was terminated and provide proof that the nonpayment was beyond the annuitant's control. The retirement system will determine if an annuitant is eligible for reinstatement of coverage. If it decides to allow reinstatement, it will be restored retroactive to the termination date. If the request is denied, annuitants may request that the retirement system reconsider its initial decision.

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Procedures for Retiring Employees

Retiring Individuals that Want to Continue Health Benefits Coverage

If an annuitant meets all the requirements, he/she does not need to do anything to have the same health benefits enrollment continue after retirement.

Cancel, Suspend, or Change Health Benefits Coverage

If an annuitant doesn't want to continue his/her health benefits enrollment upon retirement, the annuitant must cancel it by completing the Health Benefits Election form (SF 2809) or other appropriate request (e.g., agency electronic enrollment system or a letter). This must be the annuitant's action. The employing office must not initiate the termination of the enrollment unless the individual isn't eligible to continue the enrollment after retirement.

When the individual cancels his/her FEHB enrollment as an annuitant, he/she will never be able to reenroll. However, an annuitant or survivor annuitant may suspend enrollment in FEHB coverage for the purpose of enrolling in a Medicare-sponsored plan under sections 1833, 1876, or 1851 of the Social Security Act, or to enroll in the Medicaid program or a similar State-sponsored program of medical assistance for the needy, or to use Peace Corps or CHAMPVA or TRICARE (including coverage provided by the Uniformed Services Family Health Plan) or TRICARE-for-Life instead of FEHB coverage. To suspend FEHB coverage, documentation of eligibility for coverage under the non-FEHB program must be submitted to the retirement system. If the documentation is received within the period beginning 31 days before and ending 31 days after the effective date of the enrollment in the Medicare-sponsored plan, or the Medicaid or similar program, or within 31 days before or after the day designated by the annuitant or survivor annuitant as the day he/she wants to suspend FEHB coverage to use Peace Corps or CHAMPVA or TRICARE (including the Uniformed Services Family Health Plan) or TRICARE-for-Life instead of FEHB coverage, then suspension will be effective at the end of the day before the effective date of the enrollment or the end of the day before the day designated. Otherwise, the suspension is effective the first day of the first pay period that begins after the date the retirement system receives the documentation. Annuitants and survivors who have suspended their enrollment may be able to reenroll in an FEHB plan during a future Open Season for any reason, other than an involuntary loss of coverage. If an annuitant or survivor is involuntarily disenrolled from the other coverage, he/she can reenroll in the FEHB Program immediately. If a retiring employee submits a request to cancel, suspend, or change his/her enrollment, but the cancellation or change can't become effective until after the starting date of the annuity, the employing office will note on part H of the request the date it received the form, and will send all copies of the request to the retiring employee's retirement system with all other health benefits and retirement records.

The retirement system will make the cancellation effective on the last day of the pay period in which the employing office received his/her request. If the individual requested an enrollment change, it will be made effective as indicated in "Opportunities to Enroll or Change Enrollment." Even though he/she has requested a cancellation or change, the retirement system needs information on the enrollment in effect on the day of his/her retirement, since this enrollment may remain in effect during a part of his/her retirement.

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Employing Office Procedures

General

Upon an individual's retirement, the employing office will tentatively determine whether the retiring employee is eligible to continue the current health benefits enrollment. The retirement system will make the final determination after it reviews all of the individual's retirement and health benefits documents. The employing office must take the appropriate action described below.

If the Retiring Employee Appears Eligible to Continue the Enrollment

Nondisability Retirement

The employing office will document the health benefits status on the retirement application (Section A, item 6 of the Agency Checklist). It will attach a separate memorandum to note any circumstances that would be helpful for the retirement system to know when it determines an individual's eligibility for continued coverage (such as information about any previous coverage as a family member before the individual's own enrollment).

It will note the appropriate plan's enrollment code in the Remarks space on the Individual Retirement Record (SF 2806 for the Civil Service Retirement System and SF 3100 for the Federal Employees Retirement System). For other retirement systems, it should follow the same procedures.

It will send the following to the retirement system along with the Individual Retirement Record, the retirement application, and any other retirement papers:

• all Notice of Change in Health Benefits Enrollment forms (SF 2810), and
• all Health Benefits Election forms (SF 2809) or other enrollment requests, with any attached medical certificates or other documentation, filed in the Official Personnel Folder (including any on which the retiring individual elected not to enroll or to cancel, or that are marked VOID).

Disability Retirement

The employing office will note the individual's current plan enrollment code in the Remarks section of the preliminary Individual Retirement Record. It will not send any health benefits forms from the Official Personnel Folder to the retirement system with the preliminary Individual Retirement Record, even if the individual is enrolled and eligible to continue the enrollment.

If a disability retirement application is denied, the employing office doesn't need to take any further action unless the individual is separated from employment.

If the disability retirement application is approved, the employing office will then follow the same procedures as for a non-disability retirement.

If an Individual Appears Ineligible to Continue the Enrollment

If the individual doesn't meet all the requirements for continuing the enrollment into retirement, the employing office will document the retirement application (Section A, item 6 of the Agency Checklist) and note in the Remarks column of the Individual Retirement Record (both the preliminary and final Record in disability retirement cases): "Not eligible to continue health benefits" and state the reason (e.g., "not enrolled since first opportunity" or "not enrolled 5 years"). The employing office will terminate the individual's enrollment on the Notice of Change in Health Benefits Enrollment (SF 2810) and transmit all of the health benefits documents to the retirement system, where a final decision on the individual's eligibility to continue the FEHB enrollment will be made.

If an individual is unable to continue the regular FEHB enrollment into retirement, the individual may be eligible to temporarily continue health benefits coverage through TCC provision of the FEHB law. Employing offices must provide enrollees with information on TCC.

If an Individual is Not Enrolled

If an individual is not enrolled in the FEHB Program, the employing office will document the retirement application (Section A, item 6 of the Agency Checklist) and note in the Remarks column of the Individual Retirement Record (both the preliminary and final Record in disability retirement cases): "Not enrolled for health benefits." It will retain all health benefits forms in the individual's Official Personnel Folder. It doesn't need to take any other action on the health benefits, unless the enrollment terminated after 365 days in leave without pay status.

If The Enrollment Terminates after 365 Days in Leave without Pay Status

If an individual's enrollment terminates because of 365 days in leave without pay status, it will be reinstated if his/her retirement application is approved with an annuity starting date before the end of the 365 days of leave without pay status. The employing office should follow the procedures described in “If the Retiring Employee Appears Eligible to Continue the Enrollment” if the individual otherwise would be eligible to continue the enrollment. The employing office will send the Notice of Change in Health Benefits Enrollment (SF 2810) that terminated the enrollment to the retirement system along with his/her other documents.

If an enrollment terminates after 365 days in leave without pay status and the individual has a pending disability retirement application, the individual should convert to an individual contract. If the disability retirement application is approved later, the retirement system will reinstate the enrollment, retroactive to the starting date of the annuity (as long as the individual meets the requirements to continue the enrollment).

If an Individual Separates and Later Retires

When an individual is eligible for an immediate annuity, but doesn't apply for retirement, the employing office will terminate the enrollment on the Notice of Change in Health Benefits Enrollment (SF 2810) upon the individual's separation. Also, the enrollment will terminate when the individual is separated while the application for retirement (such as for disability) is pending in a retirement system.

An individual should enroll under the TCC provisions even though the individual plans to apply for retirement later or has a disability retirement application pending in a retirement system. If the individual's retirement application is approved later, the retirement system will reinstate the enrollment, retroactive to the starting date of the annuity (as long as the individual meets the requirements to continue the enrollment). The employing office will refund the premiums paid for the TCC coverage when the individual provides documentation showing the retroactive coverage as a retiree.

FERS MRA + 10 Benefits

If the individual is a separating FERS employee eligible for an immediate annuity under the minimum retirement age and 10 years of service (MRA + 10) provision, the individual may receive the benefits immediately or he/she may postpone receiving the annuity to lessen the age reduction applicable to persons under age 62.

If the individual is eligible for an MRA+10 annuity and is not applying for retirement at the time of separation, the employing office will terminate the enrollment on the Notice of Change in Health Benefits Enrollment form (SF 2810). The employing office will notify the individual of the right to enroll under TCC or convert to an individual contract. If the individual meets the requirements for continuing health benefits as a retiree, the individual may reenroll when the individual decides to allow the annuity to begin.

If the individual is applying for retirement and appears eligible to continue the enrollment, the employing office will follow the procedures in "Non-disability Retirement."

If the individual applies for an immediate annuity under the MRA + 10 provisions and later decide to postpone the annuity starting date, OPM will notify his/her employing office that it must offer him/her the opportunity to elect TCC coverage.

When an Individual Applies for MRA + 10 Annuity

If the individual is requesting that the annuity begin under the MRA + 10 provision, the individual may enroll in any plan for which the individual is eligible within 60 days after OPM notifies the individual of his/her eligibility. If the individual dies before the end of this 60 day period, the survivor(s) entitled to an annuity may enroll within 60 days after OPM's notification to the survivor of his/her eligibility.

The enrollment is effective the first day of the month after the month that OPM receives the request, or on the starting date of the annuity, whichever is later. The survivor's enrollment is effective on the first day of the month after the month that OPM receives his/her request for enrollment.

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Opportunities for Annuitants to Enroll or Change Enrollment

Effective Date

Unless otherwise specified, enrollment changes take effect on the first day of the month that follows the retirement system's receipt of his/her enrollment change request.

Late Elections

If an individual was unable, for reasons beyond his/her control, to make an enrollment election or change within the required time limits, the retirement system may allow the individual to make a late election. Elections must be made within 60 days after the individual was notified of the retirement system's determination.

Election by Proxy

A retirement system may permit an individual's representative to make an enrollment election or change with the individual's written authorization.

Decrease Enrollment

Annuitants may decrease their enrollment (from Self Plus One or Self and Family to Self Only; or from Self and Family to Self Plus One) at any time under the same conditions as an active employee with one exception. An annuitant who, as an employee, was subject to a court or administrative order requiring coverage for his/her child(ren) at the time of retirement cannot:

• cancel or suspend his or her enrollment,
• change to Self Only;
• or change to a comprehensive medical plan that does not serve the area where his or her children live.

This remains true after retirement as long as the court or administrative order is still in effect and the annuitant has at least one child identified in the order who is still eligible under the FEHB Program, unless the annuitant provides documentation to the retirement system that he or she has other coverage for the child or children.

Open Season

Enrolled annuitants may change plans, options, or type of enrollment during Open Season.

A non-enrolled annuitant is not permitted to enroll during an Open Season unless he/she canceled his/her FEHB enrollment:

• to join, and have subsequently voluntarily disenrolled from, a Medicare managed care plan; or
• because he/she furnished proof of eligibility for Medicaid (or a similar State-sponsored program of medical assistance for the needy) and wishes to reenroll in FEHB for reasons other than involuntary loss of that other coverage.

An enrollment change or reenrollment (including a belated enrollment change) is effective on the first day of the first pay period that begins in January of the next year (January 1 for most annuitants).

Change in Family Status

Annuitants may change plans, options, or type of enrollment when they have a change in family status under the same conditions as an active employee (but an annuitant can't enroll if he/she isn't already enrolled). There are different rules for an enrolled survivor annuitant.

When Coverage under Medicare Managed Care Plan or Medicaid Ends

If an individual was enrolled (or eligible to enroll) in the FEHB Program as an annuitant and:

• he/she suspended the FEHB enrollment to enroll in a Medicare managed care plan or because he/she furnished proof of eligibility for Medicaid (or a similar State-sponsored program of medical assistance for the needy); and
• the enrollment in the Medicare managed care plan or Medicaid ends involuntarily,

the annuitant can immediately reenroll in any available plan at any time from 31 days before to 60 days after the coverage in the Medicare managed care plan or Medicaid ends. The reenrollment is effective on the date following the involuntary loss of coverage as shown in documentation from the Medicare managed care plan or Medicaid. An involuntary loss of coverage includes when the Medicare managed care plan ceases to be offered, the annuitant moves from the area served by the Medicare managed care plan, or the annuitant loses eligibility for Medicaid.

If the annuitant voluntarily disenrolls from the Medicare managed care plan or Medicaid, he/she may reenroll in the FEHB Program during the following Open Season.

Upon Restoration of Disability Annuity

If an individual was receiving a disability annuity and:

• the disability annuity was terminated because the individual was found restored to earnings capacity or recovered from the disability;
• the individual was enrolled in an FEHB plan immediately before the disability annuity was terminated; and
• the disability annuity is later restored,

the individual may reenroll in a health benefits plan within 60 days from OPM's notice to the individual of his/her eligibility to reenroll. The reenrollment is effective on the first day of the month after OPM receives the enrollment request.

Loss of Coverage under FEHB or Another Group Insurance Plan

If the annuitant is eligible to enroll, but is covered as a family member under another FEHB enrollment, the annuitant may enroll in his/her own name if he/she loses coverage under the other enrollment.

If the individual is an enrolled annuitant, the individual may change plans, options, or from Self Only to Self Plus One or Self and Family when the annuitant loses coverage under another group health benefits plan or when an eligible family member loses coverage under the FEHB or another group health benefits plan.

Some examples of loss of coverage are:

• the individual or the individual's family member loses FEHB coverage because the covering enrollment was terminated, canceled, or changed to Self Only or Self Plus One;
• the individual or the individual's family member loses coverage under another federally-sponsored program;
• the individual's membership ends in the employee organization that sponsors the individual's health benefits plan;
• the individual is enrolled in a plan that is terminating participation in the FEHB Program;
• the individual or his/her family member loses coverage under Medicaid or a similar program; and
• the individual or his/her family member loses coverage under a non-Federal health plan.

When a Plan is Terminating Participation in the FEHB Program

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 in whole or in part at any time other than at the end of a contract year, OPM will issue special instructions about the proration of premiums and the effective date of subsequent enrollment changes.

The enrollee may enroll in the new plan for either Self Only, Self Plus One, or Self and Family coverage. If the plan is discontinued at the end of a contract year, the enrollee must change his/her enrollment during Open Season unless OPM establishes a different time. If the enrollee doesn't change to another plan, he/she will be automatically enrolled in the lowest cost nationwide option of a participating FEHB plan. An enrollee may change to another plan option when he/she is enrolled in a plan that is discontinuing one of its plan options. A plan that discontinues one of its options will do so effective December 31 of a given year. The plan will send notification to all members enrolled in the discontinued option advising them of this change prior to Open Season.

• If the plan option is being discontinued at the end of a contract year, the enrollee must change his/her enrollment during Open Season. Enrollees may enroll in a new plan for either Self Only, Self Plus One or Self and Family coverage. If the enrollee does not change to a new plan, he/she will be automatically enrolled in the remaining plan option. If one or more options of a plan are discontinued, an employee who does not change the enrollment will be enrolled in the remaining option of the plan, or in the case of a plan with two or more options remaining, the lowest cost remaining option that is not a High Deductible Health Plan (HDHP).

Move from an HMO's Service Area

If an individual is enrolled in an HMO, and the enrollee or an enrolled family member move or become employed outside the HMO's service area, or, if already outside of this area, move or become employed further from this area, the enrollee may change the enrollment under the same conditions as an active employee.

Retirement from Overseas Duty Post

An individual may change plans, options, and type of enrollment within 60 days of retirement from a post of duty outside the United States. The eligible survivors may also make these changes if the individual was stationed outside the United States at the time of the enrollee's death.

Return from Military Service

Enrollees may change plans, options, and type of enrollment within 60 days after separation from at least 31 days of duty in a uniformed service.

Becoming Eligible for Medicare

Enrollees may change their enrollment to any option of any available plan at any time beginning on the 30th day before becoming eligible for Medicare. Enrollees may make an enrollment change under this event only once.

Annuity Insufficient to Pay Withholdings

If an individual's annuity is not sufficient to pay the plan's premiums, the retirement system must notify the enrollee of the plans available at a cost that doesn't exceed the annuity. An enrollee may either pay his/her premiums directly to the retirement system or may enroll in another plan where the cost is no greater than the annuity. Coverage under the new plan is effective immediately upon termination of the old plan's coverage.

If the enrollee doesn't take either of these actions and he/she is enrolled in the high option of a plan, the enrollee is considered to have enrolled in the standard option of the same plan (unless the annuity is insufficient to pay the standard option premiums).

If the enrollee doesn't take either of these actions and the enrollment is terminated, the enrollee may apply to his/her retirement system for reinstatement of an enrollment in any available plan or option.

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Reemployed Annuitants

If an Annuitant is not Enrolled when Reemployed

If an annuitant is not enrolled under the FEHB Program and becomes reemployed in a position that doesn't exclude him/her from coverage, he/she must make an election the same as any other new employee. An individual can continue enrollment after separation from reemployment if the individual meets all the requirements that any other retiring employee must meet. (The immediate annuity requirement is met if the individual receives a supplemental annuity when the individual separates from the reemployment.)

Exception: If the individual is reemployed under the authority of section 108 of the Federal Employees Pay Comparability Act (FEPCA) of 1990 to meet emergency hiring needs or because of severe recruiting difficulties, the individual is not considered an employee for retirement purposes. Although the individual may enroll in FEHB with his/her employing office if he or she doesn't have coverage as an annuitant, the individual doesn't earn eligibility toward continuing coverage as an annuitant during reemployment under FEPCA.

Annuity Terminated by Reemployment

If an individual is enrolled under the FEHB Program as an annuitant and is reemployed under conditions that terminate the annuity, the employing office must notify the individual's retirement system that he/she is reemployed and transfer in his or her enrollment. The employing office must then determine whether the individual is eligible to continue the enrollment during reemployment using the same criteria as for other employees that transfer from one payroll office to another, and must either allow the individual's enrollment to continue or terminate it, as appropriate.

When separated from service, the employing office will follow the procedures that apply to other employees being separated or retired. It will either terminate the enrollment or transfer the enrollment back to the appropriate retirement system.

Annuity Continued during Reemployment

If an individual is enrolled under the FEHB Program as an annuitant and then reemployed under conditions that do not terminate the annuity, the employing office needs to transfer the enrollment from the individual's retirement system to the current employing agency. FEHB premiums will be deducted from the employee's pay, not from his/her annuity. (This applies only if the enrollee wants to participate in premium conversion; see below.)

Reemployed Annuitants and Premium Conversion

Effective with the first pay period beginning on or after October 1, 2000, enrollees were covered automatically by premium conversion, if employed:

• in a position that conveys FEHB eligibility; and
• by an agency covered by premium conversion.

The employing office will contribute the employer share of the FEHB premium in the same manner as that for other employees.

Reemployed annuitants may waive participation in premium conversion within 60 calendar days from the date they become eligible for premium conversion. The waiver will be effective on the first day of the first pay period after the date the employing office receives it. In this case, the reemployed annuitant will keep his/her FEHB coverage as an annuitant and the premiums will be deducted on an after-tax basis.

A reemployed annuitant's participation in premium conversion ends on the last day of his/her last pay period as an employee. When he/she separates from active service, the FEHB enrollment must be transferred back from the employing agency to the individual's retirement system.

The individual's right to continue FEHB as an annuitant following the period of reemployment is unaffected.

Annuity Suspended during Reemployment

If the individual is a disability annuitant under age 60 who:

• has been found to be recovered or restored to earning capacity; and

becomes reemployed in a position that is not under his/her retirement system, the employing office must notify the individual's current retirement system that he/she is reemployed (so the annuity can be suspended). The new employing office must then transfer in the enrollment. When the individual separates from service, the retirement system must then transfer the enrollment back to the original retirement system.

Open Season Opportunities for Reemployed Annuitants

If a reemployed annuitant is not enrolled for health benefits, the individual may enroll during Open Season the same as any eligible employee. If an individual is already enrolled, during an Open Season the individual may change enrollment regardless of the type of appointment. The individual will submit the Open Season change to his/her employing office, if that office is administering the enrollment. If the retirement system administers the enrollment, individuals must follow the directions provided by the retirement system.

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Survivor Annuitants

Continued Enrollment for Family Members

If an individual dies while enrolled for Self Plus One or Self and Family, and all the requirements are met, the enrollment will continue for eligible family members who become survivor annuitants under a qualifying retirement system.

Benefits and Cost

If the enrollment continues, eligible survivors are entitled to the same benefits and Government contribution as active and retired employees enrolled in the same plan. The survivor annuitant's share of the premiums normally is deducted from his/her annuity payments.

Action by Survivor

Survivors don't need to take any action to continue their enrollment if they meet all the requirements.

If a survivor doesn't want to continue the enrollment, he/she must send to the retirement system a letter or a Health Benefits Election form (SF 2809) canceling the enrollment. The survivors must take this action because the employing office will not terminate the enrollment when the enrollee dies unless it appears that the enrollee has no survivors eligible to continue it.

Requirements for Continuing Enrollment

For surviving family members to continue the health benefits enrollment after the enrollee's death, all of the following requirements must be met:

• the deceased must have been enrolled for Self Plus One or Self and Family at the time of his/her death; and
• at least one family member must be entitled to an annuity as the survivor.

Any survivor who meets the definition of "family member" can continue his/her health benefits coverage under the deceased enrollment as long as any surviving family member is entitled to a survivor annuity. If the survivor annuitant is the only eligible family member, the retirement system will automatically change the enrollment to Self Only.

Under FERS, the surviving spouse who is entitled to a basic employee death benefit, or the surviving children whose benefits are offset by Social Security, may continue the deceased's health benefits enrollment by paying premiums directly to OPM.

If the survivor annuity is not large enough to cover the enrollee share of the premiums for his/her current plan, the survivors may either change to a lower-cost plan or option (one in which the enrollee share of the premium is low enough to be withheld from the annuity) or choose to pay the premiums directly to the retirement system. Even if the employing office thinks that the survivor annuity will not cover the enrollee share of the premiums, the retirement system will transfer in the enrollment. The retirement system will notify affected survivors of their options and take whatever actions they request.

When the surviving spouse will not receive any survivor benefits because a former spouse has a court-ordered entitlement to a survivor annuity, the surviving spouse can continue FEHB coverage if you had a Self Plus One or Self and Family enrollment. The retirement system will notify the surviving spouse of his/her options and take whatever actions are requested.

Employing Office Procedures

At the enrollee's death, the employing office will tentatively determine the survivors' eligibility for continued health benefits enrollment. The retirement system will make the final determination of eligibility after it reviews all of the retirement and health benefits records.

If Survivors Appear Eligible to Continue the Enrollment

If the survivors appear eligible to continue the enrollment, the employing office will note the deceased's plan enrollment code in the Remarks section of the Individual Retirement Record. It will send the following to the retirement system along with the Individual Retirement Record, the retirement death claim (if any) and any other retirement papers:

• all Notice of Change in Health Benefits Enrollment forms (SF 2810);
• all Health Benefits Election forms (SF 2809) or other appropriate requests, with any attached medical certificates or other documentation, filed in the deceased Official Personnel Folder (including any elections not to enroll or to cancel, or that are marked VOID); and
• a memorandum giving any information regarding the health benefits that is not evident from the other documents.

If No Survivors are Eligible to Continue the Enrollment

If no survivors are eligible to continue the enrollment (e.g., the deceased had a Self Only enrollment), the employing office will note in the Remarks section of the Individual Retirement Record: "No survivor eligible to continue health benefits." It will terminate the enrollment on the Notice of Change in Health Benefits Enrollment (SF 2810), note in the Remarks section: "Enrollee died (date)," and leave all health benefits documents in the Official Personnel Folder.

The employing office will send the enrollee copy of the SF 2810 to the nearest living relative or to the representative of the enrollee's estate. However, if it appears that a survivor who has been covered as a family member may be eligible for conversion, it will send the SF 2810 to him/her.

If No Surviving Spouse Annuity is Payable because of a Former Spouse Benefit

When a surviving spouse will not receive any survivor benefits because the deceased's former spouse has a court-ordered entitlement to a survivor annuity, the surviving spouse can continue FEHB coverage if the deceased had a Self Plus One or Self and Family enrollment. The employing office should follow the procedures in "If Survivors Appear Eligible to Continue the Enrollment."

If the Deceased Was Not Enrolled

If the deceased wasn't enrolled for health benefits at death, the employing office will note in the Remarks section of the Individual Retirement Record: "Not enrolled for health benefits." It will leave all health benefits documents in the deceased's Official Personnel Folder and take no further action on health benefits.

When Eligible Both as an Employee and a Survivor Annuitant

If an employee is eligible for health benefits who is covered as a family member under a spouse's Self Plus One or Self and Family enrollment, and:

• the spouse dies; and
• the individual is eligible to continue the enrollment as a survivor annuitant,

the individual may cancel the enrollment as an annuitant and enroll as an employee because of a change in family status has occurred (death of spouse). Or, the individual may continue the enrollment as a survivor annuitant. However, if the individual wants to participate in premium conversion, the individual must be enrolled as an employee.

If the individual enrolls as an employee on this basis, and later separates under conditions not entitling the individual to continued enrollment, the employing office must terminate the enrollment. If the individual is still a survivor annuitant, the survivor may apply to the retirement system for reinstatement of the enrollment as a survivor annuitant, and for health benefits deductions to be made from the annuity.

If the retirement system receives an application within 60 days after the individual's separation from employment, it will reinstate the enrollment retroactive to the day after it was terminated by the employing office. If it receives an application more than 60 days after the separation, it will reinstate the enrollment effective on the first day of the month after the month that it received the application.

An enrolled employee with a Self Plus One or Self and Family enrollment can become a survivor annuitant upon his/her spouse's death (or, if both the employee and the spouse were enrolled in Self Only enrollments) and the employee later separates from service but cannot continue the enrollment as a retiree, the employee can enroll as a survivor annuitant. Eligible individuals can make a change from coverage as an employee to coverage as a survivor annuitant within 30 days of separation from service.

If the eligible individual decides to continue the survivor annuitant enrollment and later loses entitlement to a survivor annuity, the individual may enroll as an employee.

Deferred Annuity

Since individuals generally are not eligible for FEHB coverage when receiving a deferred annuity, a surviving spouse is not eligible for FEHB coverage as a survivor annuitant even if he/she had FEHB coverage as an employee. If he/she loses coverage as an employee, it can't be transferred to the survivor annuity.

If an individual is receiving a deferred annuity, his/her former spouse may be eligible for FEHB coverage under the Spouse Equity provisions.

Death Before Receipt of MRA+10 Annuity

If an individual dies before his/her postponed MRA+10 annuity begins, the surviving spouse is considered to be the surviving spouse of an annuitant. The surviving spouse is eligible for FEHB coverage under the same conditions as any other survivor annuitant and may enroll under FEHB when his/her survivor annuity begins.

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Opportunities for Survivor Annuitants to Change Enrollment

Enrolled survivor annuitants have the same opportunities to change enrollment as other annuitants, except when there is a change in family status because of the acquisition of a child.

Change in Family Status Due to Acquisition of an Eligible Child

A survivor annuitant's enrollment change based on the acquisition of a child can only be made when the child is an eligible family member of the deceased employee or annuitant. The enrollment can be changed from Self Only to Self Plus One or Self and Family, from one plan or option to another, or any combination of these changes from 31 days before to 60 days after the acquisition of the child, and will be effective on the first day of the pay period in which the child is born or becomes an eligible family member.

Restoration of Survivor Annuity

Spouse

If the surviving spouse's:

• survivor annuity or basic employee death benefit was terminated because he/she remarried;
• he/she was covered under an FEHB enrollment immediately before his/her annuity or death benefit terminated; and
• his/her survivor annuity or death benefit is later restored,

he/she may enroll in a health benefits plan within 60 days from OPM's notice of eligibility to enroll.

The restored survivor annuity enrollment is effective on the later of:

• the first day of the month after OPM receives his/her enrollment request; or
• the date the survivor annuity is restored.

The basic employee death benefit enrollment can only be restored when the surviving spouse's remarriage ends and he/she provides OPM with a certified copy of the employee's death notice or the court order terminating the remarriage. The restored enrollment is effective on the first day of the month after OPM receives his/her enrollment request and documentation of the end of the marriage.

Child

If a surviving child's:

• survivor annuity was terminated because he/she married or ceased being a student;
• he/she was covered under an FEHB enrollment immediately before his/her annuity terminated; and
• his/her survivor annuity is later restored, he/she may enroll in a health benefits plan within 60 days from OPM's notice of eligibility to enroll. The enrollment is effective on the later of:
• the first day of the month after OPM receives his/her enrollment request; or
• the date the survivor annuity is restored.

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