5 C.F.R. Subpart A—Administration and General Provisions
Title 5 - Administrative Personnel
This part is written as if the reader were an applicant or enrollee. Accordingly, the terms “you,” “your,” etc., refer, as appropriate, to the applicant or enrollee. In this part, the terms annuitant, employee, member of the uniformed services, retired member of the uniformed services, and qualified relative have the meanings set forth in section 9001 of title 5, United States Code, and supplement the following definitions: Abbreviated underwriting is a type of underwriting that asks fewer questions about your health status than with full underwriting to enable the Carrier to determine whether your application for coverage will be approved. The Carrier may also require review of your medical records, a phone interview, or an in-home interview. Actively at work means: (1) That as an active workforce member other than a member of the uniformed services you meet all of the following conditions: (i) You are reporting for work at an approved work location and you work at least one-half of your regularly scheduled hours for that day; and (ii) You are able to perform all the usual and customary duties of your employment on your regular work schedule. (2) For a member of the uniformed services, that you are on active duty and are physically able to perform the duties of your position. Carrier means a qualified carrier as defined in section 9001 of title 5, United States Code, with which OPM has contracted to provide long term care insurance coverage under this section. A Carrier may designate 1 or more administrators to perform some of its obligations. Eligible individual means an annuitant, active workforce member, member of the uniformed services, retired member of the uniformed services or qualified relative, as defined in section 9001 of title 5, United States Code. Enrollee means an eligible individual whose application for coverage the Carrier has approved and whose coverage is in effect. FLTCIP means the Federal Long Term Care Insurance Program. Free look means that within 30 days after you receive the Benefit Booklet, you may cancel your coverage if you are not satisfied with it and receive a refund of any premium you paid. It will be as if the coverage was never issued. Full underwriting is the more comprehensive type of underwriting under the FLTCIP, which requires that you answer many questions about your health status to enable the Carrier to determine whether your application for coverage will be approved. The Carrier may also require review of your medical records, a phone interview, or an in-home interview. Stepparent means any person, other than your mother or father, who is currently married to one of your parents, or, if one of your parents is dead, a person who was married to that parent at the time of that parent's death. Underwriting requirements means the information about your current health status and history and other information that you must provide to the Carrier with your application for coverage to enable the Carrier to determine your insurability. Workforce member means a Federal civilian or Postal employee, member of the uniformed services, Federal annuitant, retired member of the uniformed services, or member of any other eligible group, as defined in section 9001 of title 5, United States Code. An active workforce member is one who is currently employed or is on active duty. [68 FR 5534, Feb. 4, 2003, as amended at 70 FR 30606, May 27, 2005] You must submit your benefit claims to the FLTCIP Carrier or its designee. Yes, if you file a claim for benefits, the Carrier needs to have a valid authorization from you to release your medical records. (a) If you dispute the Carrier's denial of your eligibility for benefits or your claim for payment of benefits, you must first send a written request for reconsideration to the Carrier no later than 60 days from the date of its decision. (b) The Carrier must provide you with written notice of its review decision no later than 60 days after the date it receives your reconsideration request. (c) If the Carrier upholds its denial (or does not respond within 60 days), you have the right to appeal its reconsideration decision directly to the Carrier. You must make this appeal in writing within 60 days from the date of the Carrier's notice upholding its decision. You will be notified of the decision on your appeal in writing no later than 60 days from receipt of your appeal request. (d) If a denial of your eligibility for benefits or a denial of your claim is upheld upon appeal due to the evaluation of your medical condition/functional capacity, the Carrier will inform you that you may request that an independent third party, mutually agreed to by OPM and the Carrier, review the decision. You must make this request in writing within 60 days from the date of the notice informing you of the appeal decision. The independent third party must notify you in writing of its decision no later than 60 days from the Carrier's or its designee's receipt of your request for appeal to the third party. This is the final administrative remedy available to you. The decision of the independent third party is final and binding on the Carrier. (e) You may seek judicial review of the final administrative denial of a claim. Such action may not be brought prior to exhaustion of the administrative process provided in this section. To pursue such judicial review, you must bring legal action against the Carrier in an appropriate United States district court within 2 years from the date of the final decision. You may not sue OPM, the independent reviewer, or any other entity. If you prevail in court, your recovery is limited to the amount of benefits payable under your benefit booklet and schedule of benefits. [68 FR 5534, Feb. 4, 2003, as amended at 70 FR 30607, May 27, 2005] OPM may order correction of administrative errors after reviewing evidence and finding that it would be against equity and good conscience not to do so. Federal agencies and uniformed services establishments are responsible for: (a) Providing access to information about the FLTCIP to eligible individuals; (b) Responding to questions from the Carrier, including questions on the employment status of an applicant or enrollee; (c) Providing reports as OPM requires; (d) Complying with Benefits Administration Letters and other OPM issuances/instructions; and (e) Deducting premiums as authorized by a workforce member and as requested by the Carrier, when possible. Consistent with the authority and discretion given to OPM by the FLTCIP law, OPM's responsibilities include those functions typically associated with, and preemptive of, State insurance regulatory authorities such as: (a) Reviewing and approving the content and format of materials associated with the FLTCIP pursuant to section 9008(d) of title 5, United States Code; (b) Reviewing and approving rates, forms, and marketing materials; and (c) Determining the qualifications of enrollment personnel and the Program administrator(s). If the Carrier approves your application for coverage, OPM and/or the Carrier will make available to you a benefit booklet and schedule of benefits with complete coverage information, which will serve as your proof of insurance. You will also get a copy of your approved application for coverage. For the purpose of making findings of fact and to the extent that conclusions of law may be required under any proceeding conducted in accordance with the provisions of the disputes clause included in the FLTCIP master contract, OPM delegates this function to the Armed Services Board of Contract Appeals.
Title 5: Administrative Personnel
PART 875—FEDERAL LONG TERM CARE INSURANCE PROGRAM
Subpart A—Administration and General Provisions
§ 875.101 Definitions.
§ 875.102 Where do I send benefit claims?
§ 875.103 Do I need to authorize release of my medical records when I file a claim?
§ 875.104 What are the steps required to resolve a dispute involving benefit eligibility or payment of a claim?
§ 875.105 May OPM correct errors?
§ 875.106 What responsibilities do agencies have under this Program?
§ 875.107 What are OPM's responsibilities as regulator under this Program?
§ 875.108 If the Carrier approves my application, will I get a certificate of insurance?
§ 875.109 Is there a delegation of authority for resolving contract disputes between OPM and the Carrier?
