5 C.F.R. Subpart D—Coverage
Title 5 - Administrative Personnel
(a) To apply for coverage, you must complete the application in a form appropriate for your eligibility status as prescribed by the Carrier and approved by OPM. (b) If you are the qualified relative of a workforce member, you may apply for coverage even if the workforce member does not apply for coverage. (a) The first open season for enrollment under this section began July 1, 2002, as described in a (b) There are no regularly scheduled open seasons for long term care insurance. OPM will announce any subsequent open seasons via a (c) In situations where new eligibility groups are added to the Program, and OPM determines that it is appropriate to have an open season, OPM will provide notice and set the requirements for a special open season limited to those eligible individuals. [68 FR 5534, Feb. 4, 2003, as amended at 70 FR 30607, May 27, 2005] If you are eligible for coverage, you may submit an application at any time outside of an open season. You will be subject to full underwriting requirements. The only exceptions to the full underwriting requirements outside of an open season are described in §875.206 and §875.405. [68 FR 5534, Feb. 4, 2003, as amended at 70 FR 30607, May 27, 2005] (a) The effective dates of coverage under open season enrollments will be announced in a (b)(1) If you enroll at any time outside of an open season, your coverage effective date is the 1st day of the month after the date your application is approved. (2) If you are an active workforce member and you are applying for coverage under abbreviated underwriting, you also must be actively at work at least 1 day during the calendar week immediately before the week which contains your coverage effective date for your coverage to become effective. You must inform the Carrier if you do not meet this requirement. In the event you do not meet this requirement, the Carrier will issue you a revised effective date, which will be the 1st day of the next month. You also must meet the actively at work requirement for any revised effective date for coverage to become effective, or you will be issued another revised effective date in the same manner. [68 FR 5534, Feb. 4, 2003, as amended at 70 FR 30607, May 27, 2005] (a)(1) If you are a Federal civilian or Postal employee or member of the uniformed services and you have married, your spouse is eligible to submit an application for coverage under this section within 60 days from the date of your marriage, and will be subject to the underwriting requirements in force for the spouses of civilian employees and members of the uniformed services during the most recent open season. You, however, are not eligible for abbreviated underwriting because of your marriage. You may apply for coverage along with your spouse, but full underwriting will be required for you. (2) After 60 days, your spouse may still apply for coverage but will be subject to full underwriting. Your new qualified relatives (such as parents-in-law) may apply for coverage with full underwriting at any time following the marriage. (b) The new spouse and other qualified relatives of an annuitant or retired member of the uniformed services may apply for coverage with full underwriting at any time following the marriage. (a) You may make the following changes to your coverage: (1) You may apply to increase your coverage at any time. Full underwriting is required, except when an open season allows abbreviated underwriting. (2) If you increase your coverage by adding to your daily benefit amount, the premiums for the additional coverage will be based on your age, prevailing premium rates, and coverage rules in effect at the time you purchase the additional coverage. (3) For other types of coverage increases, your entire premium will be based on your age, prevailing premium rates, and coverage rules in effect at the time you purchase the increased coverage. Any increase in coverage will take effect on the 1st day of the month following the date the Carrier approves your request for an increase. (b) You may decrease your coverage at any time, although any decrease will be subject to coverage rules at the time of the decrease. Decreased coverage takes effect on the 1st day of the month after the Carrier receives your request. You will not receive any refund of premiums paid for coverage you held before the decrease; however, your subsequent premiums will be reduced based on your new, lower level of coverage. The Carrier will refund or credit any portion of premium paid in advance for the period following the date on which you decrease your coverage. (c) You may cancel your coverage at any time. (1) If you cancel during the free look period, your premiums will be refunded to you. (2) If you cancel your coverage at any time other than during the free look period, cancellation will take effect on your requested cancellation date or at the end of the period covered by your last premium payment, whichever occurs first. You will not receive any refund of premiums paid, other than any premiums paid in advance for the period following the effective date of your cancellation of coverage, and you will not have to pay any more premiums unless you owed retroactive premiums. The Carrier determines the insurability of all applicants. The Carrier's decision may not be appealed to OPM. (a) Incontestability means coverage issued based on an erroneous application may remain in effect. Such coverage will not remain in effect, and your claim may be denied, under any of the following conditions: (1) If your coverage has been in force for less than 6 months, the Carrier may void your coverage or deny a claim upon a showing that information on your signed application that was material to your approval for coverage is different than what is shown in your medical records. (2) If your coverage has been in force for at least 6 months but less than 2 years, the Carrier may void your coverage or deny a claim upon a showing that information on your signed application that was material to your approval for coverage is different than what is shown in your medical records, and pertains to the condition for which benefits are sought. (3) After your coverage has been in effect for 2 years, the Carrier may void your coverage only upon a showing that you knowingly and intentionally made a false or misleading statement or omitted information in your signed application for coverage regarding your health status. (b) Your coverage can be contested at any time when the Carrier finds that you were not an eligible individual at the time you applied and were approved for coverage. (c) If the Carrier voids coverage after it has paid benefits, it cannot recover the benefits already paid. (d) Incontestability does not apply when you have not paid your premiums on a timely basis. You must provide the Carrier with an authorization to release medical information when requested. The Carrier may deny a claim for benefits or void your coverage if the Carrier does not receive an authorization to release medical information within 3 weeks after its request (4 weeks for those outside the United States). If you are a Federal civilian or Postal employee or member of the uniformed services, your coverage will automatically continue when you leave active service, as long as the Carrier continues to receive the required premium when due. However, once you leave active service, you are no longer eligible for any abbreviated underwriting provided during any future open season. If you are already enrolled as a qualified relative, you may continue your FLTCIP coverage if you subsequently lose qualified relative status (such as upon divorce), as long as the Carrier receives the required premium when due. Your coverage will terminate on the earliest of the following dates: (a) The date you specify to the Carrier that you wish your coverage to end; (b) The date of your death; (c) The end of the period covered by your last premium payment if you do not pay the required premiums when due, after a grace period of 30 days; or (d) The date you have exhausted your maximum lifetime benefit. (However, in this event, care coordination services will continue.) (a) Under certain circumstances, your coverage can be reinstated. The Carrier will reinstate your coverage if it receives proof satisfactory to it, within 6 months from the termination date, that you suffered from a cognitive impairment or loss of functional capacity, before the grace period ended, that caused you to miss making premium payments. In that event, you will not be required to submit to underwriting. Your coverage will be reinstated retroactively to the termination date but you must pay back premiums for that period. The premium will be the same as it was prior to termination. (b) If your coverage has terminated because you did not pay premiums or because you requested cancellation, the Carrier may reinstate your coverage within 12 months from the termination date at your request. You will be required to reapply based on full underwriting, and the Carrier will determine whether you are still insurable. If you are insurable, your coverage will be reinstated retroactively to the termination date and you must pay back premiums for that period. The premium will be the same as it was prior to termination. Yes, benefits will be coordinated with other plans, following the coordination of benefits (COB) guidelines set by the National Association of Insurance Commissioners. The total benefits from all plans that pay a long term care benefit to you should not exceed the actual costs you incur. The other plans that are considered for COB purposes include government programs, group medical benefits, and other employer-sponsored long term care insurance plans. Medicaid, individual insurance policies, and association group insurance policies are not taken into consideration under this provision.
Title 5: Administrative Personnel
PART 875—FEDERAL LONG TERM CARE INSURANCE PROGRAM
Subpart D—Coverage
§ 875.401 How do I apply for coverage?
§ 875.402 When will open seasons be held?
§ 875.403 May I apply for coverage outside of an open season?
§ 875.404 What is the effective date of coverage?
§ 875.405 If I marry, may my new spouse apply for coverage?
§ 875.406 May I change my coverage?
§ 875.407 Who makes insurability decisions?
§ 875.408 What is the significance of incontestability?
§ 875.409 Must I provide an authorization to release medical information?
§ 875.410 May I continue my coverage when I leave Federal or military service?
§ 875.411 May I continue my coverage when I am no longer a qualified relative?
§ 875.412 When will my coverage terminate?
§ 875.413 Is it possible to have coverage reinstated?
§ 875.414 Will benefits be coordinated with other coverage?
