5 C.F.R. Subpart A—Administration and General Provisions
Title 5 - Administrative Personnel
(a) In this part, the terms annuitant, carrier, employee, employee organization, former spouse, health benefits plan, member of family, and service, have the meanings set forth in section 8901 of title 5, United States Code, and supplement the following definitions: Appropriate request means a properly completed health benefits registration form or an alternative method acceptable to both the employing office and OPM. Alternative methods must be capable of transmitting to the health benefits plans the information they require before accepting an enrollment, change of enrollment, or cancellation. Electronic signatures, including the use of Personal Identification Numbers (PIN), have the same validity as a written signature. Basic employee death benefit has the meaning set out at §843.102. Survivors receiving this benefit are deemed to be “annuitants” for purposes of this chapter. Cancel means to submit to the employing office an appropriate request electing not to be enrolled by an enrollee who is eligible to continue enrollment. Change the enrollment means to submit to the employing office an appropriate request electing a change of enrollment to a different plan or option, or to a different type of coverage (self only or self and family). Claim means a request for (i) payment of a health-related bill; or (ii) provision of a health-related service or supply. Compensation means compensation under subchapter I of chapter 81 of title 5, United States Code, which is payable because of a job-related injury or disease. Compensationer means an employee or former employee who is entitled to compensation and whom the Department of Labor determines is unable to return to duty. A compensationer is also an annuitant for purposes of chapter 89 of title 5, United States Code. Covered individual means an enrollee or a covered family member. Covered family member means a member of the family of an enrollee with a self and family enrollment who meets the requirements of §§890.302, 890.804, or 890.1106(a), as appropriate to the type of enrollee. Election not to enroll means to submit to the employing office an appropriate request electing not to be enrolled by an employee who is eligible to enroll. Eligible means eligible under the law and this part to be enrolled. Employing office means the office of an agency to which jurisdiction and responsibility for health benefits actions for an employee, an annuitant, a former spouse eligible for continued coverage under subpart H of this part, or an individual eligible for temporary continuation of coverage under subpart K of this part, have been delegated. (1) For an enrolled annuitant (including survivor annuitant, former spouse annuitant, and surviving spouses receiving a basic employee death benefit under 5 U.S.C. 8442(b)(1)(A)) who is not also an eligible employee, employing office is the office which has the authority to approve payment of annuity, basic employee death benefit, or workers' compensation for the annuitant concerned. (2) For a former spouse of an annuitant whose marriage dissolved after the employee's retirement and who has entitlement to receive future annuity payments under sections 8341(h), 8345(j), 8445, or 8467 of title 5, United States Code, employing office is the office that has the authority to approve payment of annuity for the annuitant or former spouse concerned. (3) For a former spouse of a current employee, and a former spouse of an annuitant or separated employee having title to a deferred annuity or to an immediate annuity under 5 U.S.C. 8412(g), whose marriage dissolved during the employee's Federal service, employing office is the agency that employed the employee or annuitant at the time the marriage was dissolved. (4) For a surviving spouse in receipt of a basic employee death benefit under 5 U.S.C. 8442(b)(1)(A) who is not also an eligible employee, the employing office is the retirement system which has authority to approve the basic employee death benefit. (5) For a former spouse of an employee or former employee of the Central Intelligence Agency (CIA) whose marriage was dissolved before May 7, 1985, and who meets the requirements under §890.803(a)(3)(iv), the employing office is the CIA. (6) For a former spouse of an employee or former employee of the Foreign Service whose marriage was dissolved before May 7, 1985, and who meets the requirements under §890.803(a)(3)(v) of this part, the employing office is the Department of State. (7) [Reserved] (8) For a former spouse of an employee who separated from service after qualifying for an immediate annuity under 5 U.S.C. 8412(g), whose marriage dissolves after the employee separated from service but before the date the separated employee's annuity commences, and who is entitled to continued coverage under subpart H of this part, employing office is the office that has the authority to approve payment of annuity for the annuitant or former spouse concerned. Enroll means to submit to the employing office an appropriate request electing to be enrolled in a health benefits plan. Enrolled means an appropriate request has been accepted by the employing office and the enrollment in a health benefits plan approved by OPM under this part has not been terminated or cancelled. Enrollee means the individual in whose name the enrollment is carried. The term includes employees, annuitants, former employees, former spouses, or children who are enrolled after completing an appropriate request under the provisions of §§890.301, 890.306, 890.601, 890.803, or 890.1103 or have continued an enrollment as an annuitant or survivor annuitant under 5 U.S.C. 8905(b) or §890.303. Foster child means a child who: (1) Lives with an employee, former employee, or annuitant or with a child enrolled under §890.1103(a)(2) in a regular parent-child relationship and (2) Is expected to be raised to adulthood by the enrollee. Immediate annuity means an annuity which begins to accrue not later than 1 month after the date enrollment under a health benefits plan would cease for an employee or member of family if he were not entitled to continue enrollment as an annuitant. Notwithstanding the foregoing, an annuity which commences on the birth of the posthumous child of an employee or annuitant is an immediate annuity. For an individual who separates from service upon meeting the requirements for an annuity under §842.204(a)(1) of this chapter, immediate annuity includes an annuity for which the commencing date is postponed under §842.204(c). Letter of credit is defined in 48 CFR 1602.170–10. Option means a level of benefits. It does not include distinctions as to whether the members of the family are covered. OWCP means the Office of Workers' Compensation Programs, U.S. Department of Labor, which administers subchapter I of chapter 81 of title 5, United States Code. Pay period means the biweekly pay period established pursuant to section 5504 of title 5, United States Code, for the employees to whom that section applies and the regular pay period for employees not covered by that section. Pay period, as it relates to a former spouse or annuitant who is not actively receiving an annuity, including surviving spouses receiving a basic employee death benefit, and enrollees temporarily continuing coverage under subpart K of this part, means any regular pay period for employees of the agency to which jurisdiction and responsibility for health benefits actions for the enrollee have been delegated as provided under the definition of “employing office” in this section. Pay period for annuitants in active receipt of annuity means the period for which a single installment of annuity is customarily paid. Reconsideration means the final level of administrative review of an employing office's initial decision to determine if the employing office correctly applied the law and regulations. Underdeduction means a failure to withhold the required amount of health benefits contributions from an individual's pay, annuity, or compensation. This definition includes both nondeductions (when none of the required amounts was withheld) and partial deductions (when only part of the required amount was withheld). Though FEHB contributions are required to cover a period of nonpay status, the nonpayment of contributions during such period does not result in an underdeduction. (b) Whenever, in this part, a period of time is stated as a number of days or a number of days from an event, the period is computed in calendar days, excluding the day of the event. Whenever, in this part, a period of time is defined by beginning and ending dates, the period includes the beginning and ending dates. [33 FR 12510, Sept. 4, 1968] Editorial Note: For (a) Each employee, other than those excluded by paragraph (c) of this section, is eligible to be enrolled in a health benefits plan at the time and under the conditions prescribed in this part. (b) An employee who serves in cooperation with non-Federal agencies and is paid in whole or in part from non-Federal funds may register to be enrolled within the period prescribed by OPM for the group of which the employee is a member following approval by OPM of arrangements providing that (1) the required withholdings and contributions will be made from Federally-controlled funds and timely deposited into the Employees Health Benefits Fund, or (2) the cooperating non-Federal agency will, by written agreement with the Federal agency, make the required withholdings and contributions from non-Federal funds and transmit them for timely deposit into the Employees Health Benefits Fund. (c) The following employees are not eligible: (1) An employee (other than an acting postmaster, a Presidential appointee appointed to fill an unexpired term, and an appointee whose appointment meets the definition of provisional appointment set out in §§316.401 and 316.403 of this chapter) who is serving under an appointment limited to 1 year or less and who has not completed 1 year of current continuous employment, excluding any break in service of 5 days or less. (2) An employee who is expected to work less than 6 months in each year, except for an employee who is employed under an OPM approved career-related work-study program under Schedule B of at least 1 year's duration and who is expected to be in a pay status for at least one-third of the total period of time from the date of the first appointment to the completion of the work-study program. (3) An intermittent employee—a non-full-time employee without a prearranged regular tour of duty. (4) A beneficiary or patient employee in a Government hospital or home. (5) An employee paid on a contract or fee basis, except an employee who is a citizen of the United States who is appointed by a contract between the employee and the Federal employing authority which requires his personal service and is paid on the basis of units of time. (6) An employee paid on a piecework basis, except one whose work schedule provides for full-time service or part-time service with a regular tour of duty. (7) An individual first employed by the government of the District of Columbia on or after October 1, 1987. However, this exclusion does not apply to: (i) Employees of St. Elizabeths Hospital who accept offers of employment with the District of Columbia government without a break in service, as provided in section 6 of Pub. L. 98–621 (98 Stat. 3379); (ii) The Corrections Trustee and the Pretrial Services, Defense Services, Parole, Adult Probation and Offender Supervision Trustee and employees of these Trustees who accept employment with the District of Columbia government within 3 days after separating from the Federal Government; and (iii) Effective October 1, 1997, judges and nonjudicial employees of the District of Columbia Courts, as provided by Pub. L. 105–33 (111 Stat. 251). (8) An individual first employed by the government of the District of Columbia on or after October 1, 1987. However, this exclusion does not apply to: (i) Employees of St. Elizabeths Hospital who accept offers of employment with the District of Columbia government without a break in service, as provided in section 6 of Pub. L. 98–621 (98 Stat. 3379); (ii) The Corrections Trustee and the Pretrial Services, Parole, Adult Probation and Offender Supervision Trustee and employees of these Trustees who accept employment with the District of Columbia government within 3 days after separating from the Federal Government; (iii) Effective October 1, 1997, judges and nonjudicial employees of the District of Columbia Courts, as provided by Pub. L. 105–33 (111 Stat. 251); and (iv) Effective April 1, 1999, employees of the Public Defender Service of the District of Columbia, as provided by Pub. L. 105–274 (112 Stat. 2419). (d) Paragraph (c) of this section does not deny coverage to: (1) An employee appointed to perform “part-time career employment,” as defined in section 3401(2) of title 5, United States Code, and 5 CFR part 340, subpart B; or (2) An employee serving under an interim appointment established under §772.102 of this chapter. (e) The Office of Personnel Management makes the final determination of the applicability of this section to specific employees or groups of employees. (f) An employee of the District of Columbia Financial Responsibility and Management Assistance Authority (the Authority) who makes an election under the Technical Corrections to Financial Responsibility and Management Assistance Act (section 153 of Pub. L. 104–134, 110 Stat. 1321) to be considered a Federal employee for health benefits and other benefit purposes is subject to this part. If the employee is eligible to make an election to enroll under §890.301, such election must be made within 60 days after the later of either the date the employment with the Authority begins or the date the Authority receives his or her election to be considered a Federal employee. Employees of the Authority who are former Federal employees are subject to the provisions of §890.303(a), except that a former Federal employee employed by the Authority before October 26, 1996, and within 3 days following the termination of the Federal employment may make an election to enroll under §890.301(c). Annuitants who have continued their coverage under this part as annuitants are not eligible to enroll under this paragraph. An election to enroll under this part is effective under the provisions of §890.306(a) unless the employee requests the Authority to make the enrollment effective on the first day of the first pay period following the date the employee entered on duty in a pay status with the Authority. (g) Notwithstanding any other provision in this part, the hiring of a Federal employee, whether in pay status or nonpay status, for a temporary, intermittent position with the decennial census has no effect on the withholding or Government contribution for his/her coverage or the determination of when 365 days in nonpay status ends. [33 FR 12510, Sept. 4, 1968, as amended at 33 FR 20002, Dec. 31, 1968; 35 FR 753, Jan. 20, 1970; 44 FR 57382, Oct. 5, 1979; 46 FR 25595, May 8, 1981; 52 FR 38220, Oct. 15, 1987; 54 FR 7755, Feb. 23, 1989; 56 FR 10143, Mar. 11, 1991; 57 FR 3715, Jan. 31, 1992; 61 FR 58460, Nov. 15, 1996; 62 FR 50997, Sept. 30, 1997; 63 FR 9402, Feb. 25, 1998; 63 FR 28891, May 27, 1998; 64 FR 15289, Mar. 31, 1999] Editorial Note: At 64 FR 15289, Mar. 31, 1999, paragraph (c)(8) of §890.102 was revised; however paragraph (c)(8) did not exist in the 1999 edition of this volume. (a) The employing office may make prospective corrections of administrative errors as to enrollment at any time. The employing office may make retroactive corrections of administrative errors that occur after December 31, 1994. (b) OPM may order correction of an administrative error upon a showing satisfactory to OPM that it would be against equity and good conscience not to do so. (c) The employing office may make retroactive correction of enrollee enrollment code errors if the enrollee reports the error by the end of the pay period following the one in which he or she received the first written documentation (i.e. pay statement or enrollment change confirmation) indicating the error. (d) OPM may order the termination of an enrollment in any comprehensive medical plan described in section 8903(4) of title 5, United States Code, and permit the individual to enroll in another health benefits plan for purposes of this part, upon a showing satisfactory to OPM that the furnishing of adequate medical care is jeopardized by a seriously impaired relationship between a patient and the comprehensive medical plan's affiliated health care providers. (e) Retroactive corrections are subject to withholdings and contributions under the provisions of §890.502. [45 FR 23637, Apr. 8, 1980, as amended at 53 FR 2, Jan. 4, 1988; 54 FR 52336, Dec. 21, 1989; 55 FR 22891, June 5, 1990; 59 FR 66437, Dec. 27, 1994; 62 FR 38435, July 18, 1997] (a) Who may file. Except as provided under §890.1112, an individual may request an agency or retirement system to reconsider an initial decision of its employing office denying coverage or change of enrollment. (b) Initial employing office decision. An employing office's decision is considered an initial decision as used in paragraph (a) of this section when rendered by the employing office in writing and stating the right to an independent level of review (reconsideration) by the agency or retirement system. However, an initial decision rendered at the highest level of review available within OPM is not subject to reconsideration. (c) Reconsideration. (1) A request for reconsideration must be made in writing, must include the claimant's name, address, date of birth, Social Security number, name of carrier, reason(s) for the request, and, if applicable, retirement claim number. (2) The reconsideration review must be an independent review designated at or above the level at which the initial decision was rendered. (d) Time limit. A request for reconsideration of an initial decision must be filed within 30 calendar days from the date of the written decision stating the right to a reconsideration. The time limit on filing may be extended when the individual shows that he or she was not notified of the time limit and was not otherwise aware of it, or that he or she was prevented by circumstances beyond his or her control from making the request within the time limit. An agency or retirement system decision in response to a request for reconsideration of an employing office's decision is a final decision as described in paragraph (e) of this section. (e) Final decision. After reconsideration, the agency or retirement system must issue a final decision, which must be in writing and must fully set forth the findings and conclusions. [59 FR 66437, Dec. 27, 1994] (a) General. (1) Each health benefits carrier resolves claims filed under the plan. All health benefits claims must be submitted initially to the carrier of the covered individual's health benefits plan. If the carrier denies a claim (or a portion of a claim), the covered individual may ask the carrier to reconsider its denial. If the carrier affirms its denial or fails to respond as required by paragraph (c) of this section, the covered individual may ask OPM to review the claim. A covered individual must exhaust both the carrier and OPM review processes specified in this section before seeking judicial review of the denied claim. (2) This section applies to covered individuals and to other individuals or entities who are acting on the behalf of a covered individual and who have the covered individual's specific written consent to pursue payment of the disputed claim. (b) Time limits for reconsidering a claim. (1) The covered individual has 6 months from the date of the notice to the covered individual that a claim (or a portion of a claim) was denied by the carrier in which to submit a written request for reconsideration to the carrier. The time limit for requesting reconsideration may be extended when the covered individual shows that he or she was prevented by circumstances beyond his or her control from making the request within the time limit. (2) The carrier has 30 days after the date of receipt of a timely-filed request for reconsideration to: (i) Affirm the denial in writing to the covered individual; (ii) Pay the bill or provide the service; or (iii) Request from the covered individual or provider additional information needed to make a decision on the claim. The carrier must simultaneously notify the covered individual of the information requested if it requests additional information from a provider. The carrier has 30 days after the date the information is received to affirm the denial in writing to the covered individual or pay the bill or provide the service. The carrier must make its decision based on the evidence it has if the covered individual or provider does not respond within 60 days after the date of the carrier's notice requesting additional information. The carrier must then send written notice to the covered individual of its decision on the claim. The covered individual may request OPM review as provided in paragraph (b)(3) of this section if the carrier fails to act within the time limit set forth in this paragraph (b)(2)(iii). (3) The covered individual may write to OPM and request that OPM review the carrier's decision if the carrier either affirms its denial of a claim or fails to respond to a covered individual's written request for reconsideration within the time limit set forth in paragraph (b)(2) of this section. The covered individual must submit the request for OPM review within the time limit specified in paragraph (e)(1) of this section. (4) The carrier may extend the time limit for a covered individual's submission of additional information to the carrier when the covered individual shows he or she was not notified of the time limit or was prevented by circumstances beyond his or her control from submitting the additional information. (c) Information required to process requests for reconsideration. (1) The covered individual must put the request to the carrier to reconsider a claim in writing and give the reasons, in terms of applicable brochure provisions, that the denied claim should have been approved. (2) If the carrier needs additional information from the covered individual to make a decision, it must: (i) Specifically identify the information needed; (ii) State the reason the information is required to make a decision on the claim; (iii) Specify the time limit (60 days after the date of the carrier's request) for submitting the information; and (iv) State the consequences of failure to respond within the time limit specified, as set out in paragraph (b)(2) of this section. (d) Carrier determinations. The carrier must provide written notice to the covered individual of its determination. If the carrier affirms the initial denial, the notice must inform the covered individual of: (1) The specific and detailed reasons for the denial; (2) The covered individual's right to request a review by OPM; and (3) The requirement that requests for OPM review must be received within 90 days after the date of the carrier's denial notice and include a copy of the denial notice as well as documents to support the covered individual's position. (e) OPM review. (1) If the covered individual seeks further review of the denied claim, the covered individual must make a request to OPM to review the carrier's decision. Such a request to OPM must be made: (i) Within 90 days after the date of the carrier's notice to the covered individual that the denial was affirmed; (ii) If the carrier fails to respond to the covered individual as provided in paragraph (b)(2) of this section, within 120 days after the date of the covered individual's timely request for reconsideration by the carrier; or (iii) Within 120 days after the date the carrier requests additional information from the covered individual, or the date the covered individual is notified that the carrier is requesting additional information from a provider. OPM may extend the time limit for a covered individual's request for OPM review when the covered individual shows he or she was not notified of the time limit or was prevented by circumstances beyond his or her control from submitting the request for OPM review within the time limit. (2) In reviewing a claim denied by the carrier, OPM may: (i) Request that the covered individual submit additional information; (ii) Obtain an advisory opinion from an independent physician; (iii) Obtain any other information as may in its judgment be required to make a determination; or (iv) Make its decision based solely on the information the covered individual provided with his or her request for review. (3) When OPM requests information from the carrier, the carrier must release the information within 30 days after the date of OPM's written request unless a different time limit is specified by OPM in its request. (4) Within 90 days after receipt of the request for review, OPM will either: (i) Give a written notice of its decision to the covered individual and the carrier; or (ii) Notify the individual of the status of the review. If OPM does not receive requested evidence within 15 days after expiration of the applicable time limit in paragraph (e)(3) of this section, OPM may make its decision based solely on information available to it at that time and give a written notice of its decision to the covered individual and to the carrier. (5) OPM, upon its own motion, may reopen its review if it receives evidence that was unavailable at the time of its original decision. [61 FR 15178, Apr. 5, 1996] 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 health benefits contracts, OPM delegates this function to the Armed Services Board of Contract Appeals. [40 FR 50023, Oct. 28, 1975; 40 FR 55829, Dec. 2, 1975. Redesignated at 44 FR 37895, June 29, 1979 and 45 FR 23637, Apr. 8, 1980] (a) A suit to compel enrollment under §890.102 must be brought against the employing office that made the enrollment decision. (b) A suit to review the legality of OPM's regulations under this part must be brought against the Office of Personnel Management. (c) Federal Employees Health Benefits (FEHB) carriers resolve FEHB claims under authority of Federal statute (5 U.S.C. chapter 89). A covered individual may seek judicial review of OPM's final action on the denial of a health benefits claim. A legal action to review final action by OPM involving such denial of health benefits must be brought against OPM and not against the carrier or carrier's subcontractors. The recovery in such a suit shall be limited to a court order directing OPM to require the carrier to pay the amount of benefits in dispute. (d) An action under paragraph (c) of this section to recover on a claim for health benefits: (1) May not be brought prior to exhaustion of the administrative remedies provided in §890.105; (2) May not be brought later than December 31 of the 3rd year after the year in which the care or service was provided; and (3) Will be limited to the record that was before OPM when it rendered its decision affirming the carrier's denial of benefits. [61 FR 15179, Apr. 5, 1996] (a) OPM may waive the eligibility requirements under 5 U.S.C. 8905(b) for health benefits coverage as an annuitant in the case of an individual who fails to satisfy such requirements if OPM, in its sole discretion, determines that, because of 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 this part. (b) OPM may grant a waiver as described in paragraph (a) of this section to an annuitant in rare and unusual circumstances if the annuitant shows by the preponderance of the evidence that— (1) There is evidence demonstrating that the individual intended to be covered as an annuitant; (2) The circumstance(s) that prevented the completion of the requirements of 5 U.S.C. 8905(b) was (were) essentially outside the individual's control; and (3) The individual exercised due diligence in protecting the right to coverage as an annuitant. (c) OPM will not grant a waiver solely because— (1) An individual's retirement is based on disability or an involuntary separation; or (2) An individual was misadvised (or not advised) by his or her employing office regarding the requirements for continuation of health benefits coverage into retirement. [52 FR 3, Jan. 2, 1987] (a) Except as provided in paragraph (b) of this section, periods during which temporary employees are eligible under 5 U.S.C. 8906a to receive health benefits by enrolling and paying the full subscription charge, but are not eligible to participate in a retirement system, are not considered when determining eligibility for continued coverage during retirement. For the purpose of continuing coverage during retirement, an employee is considered to have enrolled at his or her first opportunity if the employee registered to be enrolled when he or she received a permanent appointment entitling him or her to participate in a retirement system and to receive the Government contribution toward the health benefits premium payments. (b) A temporary employee eligible under 5 U.S.C. 8906a may continue enrollment as a compensationer if he or she has been enrolled or covered as a family member under another enrollment under this part for: (1) The 5 years of service immediately preceding the commencement of his or her monthly compensation; or (2) During all periods of service since his or her first opportunity to enroll, if less than 5 years. For the purpose of this paragraph, an employee is considered to have enrolled at his or her first opportunity if the employee registered to be enrolled when he or she first became eligible under 5 U.S.C. 8906a. [58 FR 47824, Sept. 13, 1993] (a) Each employing office must report to each carrier or its surrogate on a quarterly basis the names of the individuals who are enrolled in the carrier's plan in a format and containing such information as required by OPM. (b) The carrier must compare the data provided with its own enrollment records. When the carrier finds in its total enrollment records individuals whose names do not appear in the report from the employing office of record, the carrier must request the employing office to provide the documentation necessary to resolve the discrepancy. [63 FR 59459, Nov. 4, 1998; 63 FR 64761, Nov. 23, 1998]
Title 5: Administrative Personnel
PART 890—FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
Subpart A—Administration and General Provisions
§ 890.101 Definitions; time computations.
§ 890.102 Coverage.
§ 890.103 Correction of errors.
§ 890.104 Initial decision and reconsideration on enrollment.
§ 890.105 Filing claims for payment or service.
§ 890.106 Delegation of authority for resolving certain contract disputes.
§ 890.107 Court review.
§ 890.108 Waiver of requirements for continued coverage during retirement.
§ 890.109 Exclusion of certain periods of eligibility when determining continued coverage during retirement.
§ 890.110 Enrollment reconciliation.
