5 C.F.R. § 890.302 Coverage of family members.
Title 5 - Administrative Personnel
(a)(1) An enrollment for self and family includes all family members who are eligible to be covered by the enrollment. Except as provided in paragraphs (a) (2), (3), and (4) of this section, no employee, former employee, annuitant, child, or former spouse may enroll or be covered as a family member if he or she is covered under another person's self and family enrollment in the FEHB Program. (2) Dual enrollment—spouse. (i) To protect the interests of the children, an employee or annuitant may enroll in his or her own right in a self and family enrollment even though his or her spouse also has a self and family enrollment. Generally, such dual enrollments are permitted only where two employees or annuitants are married, each with children from prior marriages who do not live with them, or are legally separated, with each spouse retaining custody of his or her own children by a prior marriage. To ensure that no person receives benefits under more than one enrollment, each enrollee must tell the insurance carrier which family members are covered under his or her enrollment. These individuals are not covered under the other enrollment. (ii) To protect the interests of legally separated Federal employees, annuitants and their children, a legally separated employee or annuitant may enroll in his or her own right in a self only or self and family enrollment even though his or her spouse also has a self and family enrollment. To ensure that no person receives benefits under more than one enrollment, each enrollee must tell the insurance carrier which family members are covered under his or her enrollment. These individuals are not covered under the other enrollment. (3) Dual enrollment—child. (i) When natural parents are divorced or legally separated and children are included as family members under the enrollment of both natural parents or of a natural parent and a step-parent, the children are entitled to receive benefits under only one enrollment. Each enrollee must notify his or her insurance carrier of the name(s) of the child(ren) to be covered under his or her enrollment that are not named under the other enrollment. (ii) When an employee who is under age 22 and covered under a parent's self and family enrollment becomes the parent of a child, the employee may elect to enroll for self and family coverage. Because the employee is entitled to receive benefits under only one enrollment, each enrollee must notify his or her insurance carrier of the names of the persons to be covered under his or her enrollment that are not named under the other enrollment. (4) Dual enrollment—spouse and child. Where a situation such as that in paragraph (a)(2) of this section occurs (that is, two employees or annuitants are married, but each has children from prior marriages who do not live with them) and there are also children who are the issue of the marriage, an employee or annuitant may enroll in his or her own right in a self and family enrollment even though his or her spouse also has a self and family enrollment. Because no person is entitled to receive benefits under more than one enrollment, each enrollee must notify his or her insurance carrier of the names of the family members to be covered under his or her enrollment that are not covered under the other enrollment. (b) Proof of dependency. (1) A child is considered to be dependent on an enrolled employee or annuitant or a former employee or child enrolled under §890.1103 of this part if he or she is: (i) A legitimate child; (ii) An adopted child; (iii) A stepchild, foster child, or recognized natural child who lives with the enrollee in a regular parent-child relationship. (iv) A recognized natural child for whom a judicial determination of support has been obtained; or (v) A recognized natural child to whose support the enrollee makes regular and substantial contributions. (2) The following are examples of proof of regular and substantial support. More than one of the following proofs may be required to show support of a recognized natural child who does not live with the enrollee in a regular parent-child relationship and for whom a judicial determination of support has not been obtained. (i) Evidence of eligibility as a dependent child for benefits under other State or Federal programs; (ii) Proof of inclusion of the child as a dependent on the enrollee's income tax returns; (iii) Canceled checks, money orders, or receipts for periodic payments from the enrollee for or on behalf of the child. (iv) Evidence of goods or services which show regular and substantial contributions of considerable value; (v) Any other evidence which OPM shall find to be sufficient proof of support or of paternity or maternity. (c) Exceptions. Coverage as a family member may be denied: (1) If evidence shows that the enrollee did not recognize the child as his or her own, despite a willingness to support the child, or (2) If evidence calls the child's paternity or maternity into doubt, despite the enrollee's recognition and support of the child. (d) Child incapable of self-support. When an individual enrolls for a family that includes a child who has become 22 years of age and is incapable of self-support, the employing office must require such enrollee to submit a physician's certificate verifying the child's disability. The certificate must— (1) State that the child is incapable of self-support because of a physical or mental disability that existed before the child became 22 years of age and that can be expected to continue for more than 1 year; (2) Include a statement of the name of the child, the nature of the disability, the period of time it has existed, and its probable future course and duration; and, (3) Be signed by the physician and show the physician's office address. The employing office must require the enrollee to submit the certificate on or before the date the child becomes 22 years of age. However, the employing office may accept otherwise satisfactory evidence of incapacity that is not timely filed. (e) Renewal of certificates of incapacity. The employing office must require an enrollee who has submitted a certificate of incapacity to renew that certificate on the expiration of the minimum period of disability certified. (f) Determination of incapacity. (1) Except as provided in paragraph (f)(2) of this section, the employing office shall make determinations of incapacity. (2) Either the employing office or the carrier may make a determination of incapacity if a medical condition, as specified by OPM, exists that would cause a child to be incapable of self-support during adulthood. (g) Meaning of unmarried. A child who has never married or whose marriage has been annulled, or a child who is divorced or widowed is considered to be unmarried. [33 FR 12510, Sept. 4, 1968, as amended at 43 FR 52460, Nov. 13, 1978; 45 FR 76088, Nov. 18, 1980; 46 FR 35082, July 7, 1981; 49 FR 1047, Jan. 9, 1984; 51 FR 15748, Apr. 28, 1986; 53 FR 45070, Nov. 8, 1988; 54 FR 52338, Dec. 21, 1989; 55 FR 22891, June 5, 1990; 59 FR 60296, Nov. 23, 1994; 62 FR 38437, July 18, 1997]
Title 5: Administrative Personnel
PART 890—FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
Subpart C—Enrollment
§ 890.302 Coverage of family members.
