5 C.F.R. Subpart K—Temporary Continuation of Coverage
Title 5 - Administrative Personnel
Source: 54 FR 52339, Dec. 21, 1989, unless otherwise noted.
This subpart identifies the individuals who may temporarily continue coverage after the coverage would otherwise terminate under this part and sets forth the circumstances of their enrollment. In this subpart— Gross misconduct means a flagrant and extreme transgression of law or established rule of action for which an employee is separated and concerning which a judicial or administrative finding of gross misconduct has been made. Qualifying event means any of the following events that qualify an individual for temporary continuation of coverage under subpart K of this part: (1) A separation from Government service. (2) A divorce or annulment. (3) A change in circumstances that causes an individual to become ineligible to be considered an unmarried dependent child under this part. (a) Except as provided by paragraph (b) of this section, individuals described by this section are eligible to elect temporary continuation of coverage under this subpart. Eligible individuals are as follows: (1) Former employees whose coverage ends because of a separation from Federal service under any circumstances except an involuntary separation for gross misconduct. (2) Individuals whose coverage as children under the family enrollment of an employee, former employee, or annuitant ends because they cease meeting the requirements for being considered unmarried dependent children. For the purpose of this section, children who are enrolled under this part as survivors of deceased employees or annuitants are considered to be children under a family enrollment of an employee or annuitant at the time of the qualifying event. (3) Former spouses of employees, of former employees having continued family coverage under this subpart, or of annuitants, if the former spouse would be eligible for continued coverage under subpart H of this part except for failure to meet the requirement of §890.803(a) (1) or (3) of this part or the documentation requirements of §890.806(a) of this part, including former spouses who lose eligibility under subpart H within 36 months after termination of the marriage because they ceased meeting the requirement of §890.803(a) (1) or (3) of this part. (b) An individual who is otherwise eligible for benefits under this part (excluding the temporary extension of coverage and conversion privilege set forth in subpart D of this part) is not entitled to continued coverage under this subpart. (a) In the case of a former employee who is eligible to elect temporary continuation of coverage under §890.1103(a)(1), the employing office must notify the former employee concerning his or her rights under this subpart no later than 30 days after the end of the temporary extension of coverage provided under §890.401. (b)(1) In the case of a child who is eligible to elect temporary continuation of coverage under §890.1103(a)(2), the enrollee may, within 60 days after the qualifying event, provide written notice to the employing office of the child's change in status and requesting information about temporary continuation of coverage. The written notice must include the child's name and address and the date of the terminating event. (2) If the notice described in paragraph (b)(1) is received by the employing office within 60 days after the date on which the child ceased meeting the requirements for being considered an unmarried dependent child, the employing office must notify the child of his or her rights under this subpart within 14 days after receiving the notice. (3) This paragraph does not preclude the employing office from notifying the child of his or her rights based on oral or written notification by the child, another family member, or any other source that the child no longer meets the requirements for being considered an unmarried dependent child. (c)(1) In the case of a former spouse who is eligible to elect temporary continuation of coverage under §890.1103(a)(3), the employee or the former spouse may, within 60 days after the termination of the marriage or the loss of coverage under subpart H of this part, notify the employing office of the terminating event and request information about temporary continuation of coverage. The notice must include the name and address of the former spouse and the date of the terminating event. (2) The employing office must notify the former spouse of his or her rights under this subpart within 14 days after receiving the notice described in paragraph (c)(1) of this section. (d) If the employing office cannot give the notice required by this section to the employee, child, or former spouse directly, it must send the notice by first class mail. A notice that is mailed is deemed to be received 5 days after the date of the notice. [54 FR 52339, Dec. 21, 1989, as amended at 57 FR 21192, May 19, 1992] (a) The election of temporary continuation of coverage may be in the form of a Standard Form 2809, letter, or written statement to the employing office. (b) Former employees. A former employee's election under this subpart must be submitted to the employing office within 60 days after the later of— (1) The date of separation; or (2) The date the former employee received the notice from the employing office. (c) Children. A child's election under this subpart must be submitted to the employing office within 60 days after the later of— (1) The date of the qualifying event; or (2) If the employee notified the employing office within the 60-day time period specified under §890.1104(b)(1) of this part, the date the child received the notice from the employing office. If the employee did not notify the employing office within the specified time period, the child's opportunity to elect continued coverage ends 60 days after the qualifying event. (d) Former spouses. (1) A former spouse's election must be received by the employing office within 60 days after the later of— (i) The date of the qualifying event; or (ii) The date coverage under subpart H of this part was lost because of remarriage or loss of qualifying court order, if the loss of coverage under subpart H occurred before the expiration of the 36-month period specified in §890.1107(c); or (iii) If the employee, annuitant, or former spouse notified the employing office of the termination of the marriage within the time period specified in §890.1104(c)(1), the date the former spouse received the notice from the employing office described in §890.1104(c)(2). If the employee, annuitant, or former spouse did not notify the employing office within the specified time period, the former spouse's opportunity to elect continued coverage ends 60 days after the qualifying event. (2) The effective date of former spouse coverage is the later of— (i) The date determined under paragraph (g) of this section; or (ii) The date of the divorce or annulment. (e) If an individual who is eligible for temporary continuation of coverage under this section is unable to file an election on his or her own behalf because of a mental or physical disability, an election may be filed by a court-appointed guardian. (f) Belated elections. Except as provided in paragraphs (c)(2) and (d)(1)(iii) of this section, when an employing office determines that an eligible individual was unable, for cause beyond his or her control, to elect temporary continuation of coverage within the time limits prescribed by this section, that office must accept the election within 60 days after it advises the individual of that determination. (g) Effective date of coverage. Except as provided in paragraph (d)(2)(ii) of this section, the effective date of temporary continuation of coverage is the day after other coverage under this part expires, including the 31-day temporary extension of coverage under §890.401. If an individual elects temporary continuation of coverage after the 31-day temporary extension of coverage expires, but before the expiration of the applicable election period specified in this section, coverage is restored retroactively, with appropriate contributions and claims, to the same extent and effect as though no break in coverage occurred. [54 FR 52339, Dec. 21, 1989, as amended at 62 FR 38442, July 18, 1997] (a) Type of enrollment. An individual who enrolls under this subpart may elect coverage for self alone or self and family. (1) For an enrollee who is eligible for continued coverage under §890.1103(a) (1) or (2), a covered family member is an individual whose relationship to the enrollee meets the requirements of 5 U.S.C. 8901(5) and who meets any applicable requirements of 5 CFR 890.302 of this part. (2) For a former spouse who is eligible for continued coverage under §890.1103(3) of this part, a covered family member is an individual who meets the requirements of §890.804 of this part. (b) Plans and options. An individual who elects to continue coverage under this subpart may enroll in a plan or option different from the plan or option covering the individual at the time of the qualifying event. (a) In the case of a former employee who is eligible for continued coverage under §890.1103(a)(1), the temporary continuation of coverage ends on the date that is 18 months after the date of separation, unless it is terminated earlier under the provisions of §890.1110. (b)(1) Except as provided in paragraph (b)(2) of this section, in the case of individuals who are eligible for continued coverage under §890.1103(a)(2) of this part, the temporary continuation of coverage ends on the date that is 36 months after the date the individual first ceases to meet the requirements for being considered an unmarried dependent child, unless it is terminated earlier under the provisions of §890.1110. (2) The temporary continuation of coverage ends on the date that is 36 months after the date of the separation from service on which the former employee's continuation of coverage is based, unless it is terminated earlier under the provisions of §890.1110, in the case of individuals who— (i) Are eligible for continued coverage under §890.1103(a)(2); and (ii) As of the day before ceasing to meet the requirements for being considered unmarried dependent children, were covered family members of a former employee receiving continued coverage under this subpart; and (iii) Cease meeting the requirements for being considered unmarried dependent children before the end of the 18-month period specified in paragraph (a) of this section. (c)(1) Except as provided in paragraph (c)(2) of this section, in the case of former spouses who are eligible for continued coverage under §890.1103(a)(3), the temporary continuation of coverage ends on the date that is 36 months after the former spouse ceased meeting the requirements for coverage as a family member, unless it is terminated earlier under the provisions of §890.1110. (2) The temporary continuation of coverage ends on the date that is 36 months after the date of the separation from service on which the former employee's continuation of coverage is based, unless it is terminated earlier under the provisions of §890.1110, in the case of a former spouse— (i) Who is eligible for continued coverage under §890.1103(a)(3); and (ii) Whose marriage to the former employee terminates after the former employee's separation but before the expiration of the 18-month period specified in paragraph (a) of this section. (a) Effective date—generally. Except as otherwise provided, a change of enrollment takes effect on the first day of the first pay period that begins after the date the employing office receives an appropriate request to change the enrollment. (b) Belated change of enrollment. When an employing office determines that an enrollee was unable, for cause beyond his or her control, to change the enrollment within the time limits prescribed by this section, the enrollee may do so within 60 days after the employing office advises the enrollee of its determination. (c) Change of enrollment by proxy. Subject to the discretion of the employing office, an enrollee's representative, having written authorization to do so, may change the enrollment for the enrollee. (d) Change to self only. (1) An enrollee may change the enrollment from self and family to self only at any time. (2) A change of enrollment to self only takes effect on the first day of the first pay period that begins after the date the employing office receives an appropriate request to change the enrollment, except that at the request of the enrollee and upon a showing satisfactory to the employing office that there was no family member eligible for coverage under the family enrollment, the employing office may make the change effective on the first day of the pay period following the one in which there was no family member. (e) Open season. (1) During an open season as provided by §890.301(f), an enrollee (except for a former spouse who is eligible for continued coverage under §890.1103(a)(3)) may change the enrollment from self only to self and family, from one plan or option to another, or make any combination of these changes. A former spouse who is eligible for continued coverage under §890.1103(a)(3) may change from one plan or option to another, but may not change from self only to self and family unless the individual to be covered under the family enrollment qualifies as a family member under §890.1106(a)(2). (2) An open season change of enrollment takes effect on the first day of the first pay period that begins in January of the next following year. (3) When a belated open season change of enrollment is accepted by the employing office under paragraph (b) of this section, it takes effect as required by paragraph (e)(2) of this section. (f) Change in family status. (1) Except for a former spouse, an enrollee may change the enrollment from self only to self and family, from one plan or option to another, or make any combination of these changes when the enrollee's family status changes, including a change in marital status or any other change in family status. The enrollee must change the enrollment within the period beginning 31 days before the date of the change in family status, and ending 60 days after the date of the change in family status. (2) A former spouse who is covered under this section may change the enrollment from self only to self and family, from one plan or option to another, or make any combination of these changes within the period beginning 31 days before and ending 60 days after the birth or acquisition of a child who qualifies as a covered family member under §890.1106(a)(2). (3) A change of enrollment made in conjunction with the birth of a child, or the addition of a child as a new family member in some other manner, takes effect on the first day of the pay period in which the child is born or becomes an eligible family member. (g) Reenrollment of individuals who lose other coverage under this part. An individual whose continued coverage under this section terminates because of the provisions of §890.1110(a)(3) (termination due to other coverage under another provision of this part) may reenroll if the coverage that terminated the enrollment under this part ends, but not later than the expiration of the period described in §890.1107. Coverage does not extend beyond the expiration of the period described in §890.1107. The effective date of the reenrollment is the day following the termination of the coverage described in §890.1110(a)(3). (h) Loss of coverage under this part or under another group insurance plan. An enrollee may change the enrollment from self only to self and family, from one plan or option to another, or make any combination of these changes when the enrollee loses coverage under this part or a qualified family member of the enrollee loses coverage under this part or under another group health benefits plan. Except as otherwise provided, an enrollee must change the enrollment within the period beginning 31 days before the date of loss of coverage and ending 60 days after the date of loss of coverage. Losses of coverage include, but are not limited to— (1) Loss of coverage under another FEHB enrollment due to the termination, cancellation, or change to self only, of the covering enrollment. (2) Loss of coverage under another federally-sponsored health benefits program. (3) Loss of coverage due to the termination of membership in an employee organization sponsoring or underwriting an FEHB plan. (4) Loss of coverage due to the discontinuance of an FEHB plan, in whole or in part. For an enrollee who loses coverage under this paragraph (h)(4)— (i) If the discontinuance is at the end of a contract year, the enrollee must change the enrollment during the open season, unless OPM establishes a different time. If the discontinuance is at a time other than the end of the contract year, OPM must establish a time and effective date for the enrollee to change the enrollment. (ii) If the whole plan is discontinued, an enrollee who does not change the enrollment within the time set is considered to have cancelled the plan in which enrolled. (iii) If a plan has two options, and one option of the plan is discontinued, an enrollee who does not change the enrollment is considered to be enrolled in the remaining option of the plan. (5) Loss of coverage under the Medicaid program or similar State-sponsored program of medical assistance for the needy. (6) Loss of coverage under a non-Federal health plan. (i) Move from comprehensive medical plan's area. An enrollee in a comprehensive medical plan who moves or becomes employed outside the geographic area from which the plan accepts enrollments, or, if already outside this area, moves or becomes employed further from this area, may change the enrollment upon notifying the employing office of the move or change of place of employment. Similarly, an enrollee whose covered family member moves outside the geographic area from which the plan accepts enrollments, or if already outside this area, moves further from this area, may change the enrollment upon notifying the employing office of the family member's move. The change of enrollment takes effect on the first day of the pay period that begins after the employing office receives an appropriate request. (j) On becoming eligible for Medicare. An enrollee may change the enrollment from one plan or option to another at any time beginning on the 30th day before becoming eligible for coverage under title XVIII of the Social Security Act (Medicare). A change of enrollment based on becoming eligible for Medicare may be made only once. [62 FR 38442, July 18, 1997] (a) Except as provided in paragraph (b) of this section, the enrollee must pay the full enrollment charge as determined under §890.503(a), including both the Government contributions and employee withholdings, plus the administrative charge described under §890.1113, for every pay period during which the enrollment continues, exclusive of the 31-day temporary extension of coverage for conversion provided under §890.401 of this part. (b) If the enrollee is not covered under this subpart for the full pay period, he or she pays the premium charge for only the days actually covered. The daily premium rate is an amount equal to the monthly rate (including the administrative charge) multiplied by 12 and divided by 365. (c) The enrollee must make the payment after the pay period during which he or she is covered in accordance with a schedule established by the employing office. If the employing office does not receive the payment by the date due, the employing office must notify the enrollee in writing that continuation of coverage depends upon payment being made within 15 days (45 days for enrollees residing overseas) after receipt of the notice. If no subsequent payments are made, the employing office terminates the enrollment 60 days (90 days for enrollees residing overseas) after the date of the notice. An enrollee whose coverage terminates because of nonpayment may not reenroll or reinstate coverage except as provided under paragraph (d) of this section. (d)(1) If the enrollee was prevented by circumstances beyond his or her control from making payment within the timeframe specified in paragraph (c) of this section, he or she may request reinstatement of coverage by writing to the employing office. The request must be filed within 30 calendar days from the date of termination and must be accompanied by verification that the enrollee was prevented by circumstances beyond his or her control from paying within the time limit. (2) The employing office determines whether the individual is eligible for reinstatement of coverage. If the determination is affirmative, coverage is reinstated retroactively to the date of termination. If the determination is negative, the individual may request a review of the decision from the employing agency as provided under §890.104. [54 FR 52339, Dec. 21, 1989, as amended at 59 FR 67607, Dec. 30, 1994; 61 FR 37810, July 22, 1996] (a) General. An enrollment under this subpart terminates at midnight of the earlier of the following dates: (1) The date the temporary continuation of coverage expires as set forth in §890.1107, subject to the temporary extension of coverage for conversion. (2) The last day of the pay period in which the enrollee dies. (3) The day before the effective date of coverage under another provision of this part. (4) The date provided under paragraphs (b) or (c) of this section. (b) Failure to pay premiums. Termination of enrollment for failure to pay premiums within the timeframe established under §890.1109 of this part is retroactive to the end of the last pay period for which payment was timely received. The enrollee and covered family members, if any, are not entitled to the temporary extension of coverage for conversion or to convert to an individual contract for health benefits. (c) Cancellation. An enrollee may cancel his or her enrollment as provided under §890.304(d) of this part. (d) Family member coverage. The coverage of a family member terminates under the conditions set forth in §890.304(c). Covered family members of former employees and former spouses are entitled to temporary continuation of coverage only as set forth under §890.1103. (a) Providing information to employees. Employing offices are responsible for providing employees who are eligible to enroll under this part with literature developed by OPM that sets forth their rights under this subpart. This literature must be distributed to employees prior to each open season occurring under §890.301. (b) Administration of the enrollment process. The employing office must establish procedures for notifying the former employee, child, or former spouse about his or her eligibility to enroll, including what documents are needed to determine eligibility, and for accepting enrollment registrations. (c) Collecting premiums. (1) Collection of the contributions is the responsibility of the employing office of the employee or annuitant at the time of the qualifying event. (2) The employing office must submit all premium payments collected from enrollees along with its regular health benefits payments to OPM in accordance with procedures established by that Office. (d) Health benefits file. The employing office must maintain a health benefits file for the enrollee as a file separate from the personnel records of the employee or former employee. This file may be destroyed 2 years after the end of the calendar year during which the 18- or 36-month period described in §890.1107 (a) or (b)(1) expires. [54 FR 52339, Dec. 21, 1989, as amended at 55 FR 22891, June 5, 1990] (a) Notice of denial. (1) When an employing office determines that the offense for which an employee is being removed constitutes gross misconduct for the purpose of this subpart, the employing office must notify the employee in writing of its intention to deny temporary continuation of coverage. The notice must set forth the reason for the denial and give the employee a reasonable amount of time to respond. The notice must be made no later than the date of separation. (2) If the employee is being removed under the authority of part 752 of this chapter (or other law, Executive Order, or regulation that prescribes procedures for removing employees because of misconduct), the notification requirement of paragraph (a)(1) of this section may be combined with the notification requirement of such authority. (b) Employee's response. (1) The employee must be allowed a reasonable time for response, but not less than 7 days. The employee may respond orally or in writing and is entitled to be represented by an attorney or other representative. (2) The agency must designate an official to hear the employee's oral answer who has the authority either to make or recommend a final decision on the denial. The right to answer orally does not include the right to a formal hearing with examination of witnesses. (c) Final decision. If the employee responds to the notice of denial, the employing office must issue a final decision in writing that fully sets forth its findings and conclusions. The agency's decision is not subject to reconsideration by OPM. (d) Resignation in lieu of involuntary separation. If an employee resigns after receiving the employing office's notification of intent to separate the employee involuntarily but before the scheduled separation date, his or her separation is considered involuntary for the purpose of this subpart. (a) OPM has determined that the administrative charge as provided under 5 U.S.C. 8905a(d)(1)(A)(ii) is 2 percent of the enrollment charge described in §890.503(a). (b) It is OPM's responsibility to establish procedures for receiving the administrative payment into the Employees Health Benefits Fund and for making this amount available to the employing office. [54 FR 52339, Dec. 21, 1989, as amended at 55 FR 22891, June 5, 1990]
Title 5: Administrative Personnel
PART 890—FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
Subpart K—Temporary Continuation of Coverage
§ 890.1101 Purpose.
§ 890.1102 Definitions.
§ 890.1103 Eligibility.
§ 890.1104 Notification by agency.
§ 890.1105 Initial election of temporary continuation of coverage; application time limitations and effective dates.
§ 890.1106 Coverage.
§ 890.1107 Length of temporary continuation of coverage.
§ 890.1108 Opportunities to change enrollment; effective dates.
§ 890.1109 Premium payments.
§ 890.1110 Termination of enrollment or coverage.
§ 890.1111 Employing office responsibilities.
§ 890.1112 Denial of continuation of coverage due to involuntary separation for gross misconduct.
§ 890.1113 The administrative charge.
