5 C.F.R. PART 891—RETIRED FEDERAL EMPLOYEES HEALTH BENEFITS
Title 5 - Administrative Personnel
Authority: 80 Stat. 607; 5 U.S.C. 8913.
Source: 33 FR 12516, Sept. 4, 1968, unless otherwise noted.
This part does not apply to the Federal Employees Health Benefits Program which is governed by part 890 of this chapter. Part 890 of this chapter does not apply to the Retired Federal Employees Health Benefits Program which is governed by this part. In this part: (a) Annuity means the periodic payment due a former employee or his/her survivors by reason of past service, but does not include compensation paid under subchapter I of chapter 81 of title 5, United States Code. (b) Annuity period means the period for which an installment of annuity is paid. (c) Bureau of Employees' Compensation means the Bureau of Employees' Compensation, Department of Labor. (d) Carrier means a voluntary association, corporation, partnership, or other nongovernmental organization which lawfully offers a health benefits plan. (e) Compensation means monthly compensation paid under subchapter I of chapter 81 of title 5, United States Code, and includes compensation payable every 4 weeks. (f) Elect means to file with the retirement office under which retired or with the Bureau of Employees' Compensation, as the case may be, a properly completed form, prescribed by OPM for the purpose, giving notice of intention (1) to subscribe to the uniform plan, (2) to receive a Government contribution toward the cost of a private health benefits plan, or (3) not to participate in the program. (g) Employee means an appointive or elective officer or employee in or under the executive, judicial, or legislative branch of the United States Government, including a Government-owned or controlled corporation (but not including any corporation under the supervision of the Farm Credit Administration, of which corporation any member of the board of directors is elected or appointed by private interests), or of the government of the District of Columbia, and includes an Official Reporter of Debates of the Senate and a person employed by the Official Reporters of Debates of the Senate in connection with the performance of their official duties, and an employee of Gallaudet College, but does not include (1) a member of a “uniformed service” as that term is defined in section 1072 of title 10, United States Code, (2) a noncitizen employee whose permanent-duty station is located outside a State of the United States or the District of Columbia, or (3) an employee of the Tennessee Valley Authority. (h) Government means the Government of the United States of America and the government of the District of Columbia. (i) Health benefits plan means an individual or group insurance policy or contract, medical or hospital service arrangement, membership or subscription contract, or similar agreement provided by a carrier for a stated periodic premium or subscription charge for the purpose of providing, paying for, or reimbursing expenses for hospital care, surgical or medical diagnosis, care, and treatment, drugs and medicines, remedial care, or other medical supplies and services, or any combination of these. (j) Immediate annuity means (1) as applied to a retired employee, an annuity which begins to accrue not later than 1 month after the date of the separation from the service on which title to the annuity is based; and (2) as applied to a survivor, an annuity which begins to accrue not later than 1 month (i) after the date of death of the employee or annuitant whose service forms the basis for the annuity, or (ii) after the birth of a posthumous child of such an employee or annuitant. (k) Member of family means a former employee's spouse and any unmarried child (1) under 19 years of age (including (i) an adopted child, and (ii) a stepchild or recognized natural child who lives with the former employee in a regular parent-child relationship or did so at the time of the former employee's death); or (2) regardless of age who is incapable of self-support because of mental or physical disability that existed before the child became 19 years of age. As used in this paragraph, Former employee means the former employee on whose service title to annuity is based. (l) Private health benefits plan means a health benefits plan other than the uniform plan. (m) Retired employee includes (1) a former employee retired under subchapter III of chapter 83 of title 5, United States Code, or other retirement system for civilian employees of the Government (not including the social security system), (2) an employee or former employee receiving compensation under subchapter I of chapter 81 of title 5, United States Code, and (3) persons who are entitled to annuity or compensation as members of the family of a deceased employee or of a deceased retired employee qualifying under paragraphs (m) (1) and (2) of this section. (n) Retirement office means (1) any office responsible for the administration of a retirement system for civilian employees of the Government; and (2) the Bureau of Employees' Compensation. (o) Service means service which is creditable for the purposes of subchapter III of chapter 83 of title 5, United States Code. (p) Survivor means a person who is entitled to annuity or compensation as a member of the family of a deceased employee or deceased retired employee. (q) Uniform plan means the health benefits plan for which OPM contracts pursuant to section 3, 74 Stat. 849. (a) General conditions of eligibility. (1) A retired employee who is enrolled or covered by the enrollment of another under part 890 of this chapter, or who is covered by the election of another retired employee under this part, is ineligible to subscribe to the uniform plan or to receive a Government contribution toward the cost of a private health benefits plan. (2) A retired employee is ineligible to subscribe to the uniform plan if his/her annuity or compensation is not sufficient to cover the necessary withholding. (3) An annuitant who enrolled under §890.601, and who later cancels such enrollment, is ineligible to subscribe to the uniform plan or to receive a Government contribution toward the cost of a private health benefits plan. (b) Retired employees (other than survivors) entitled to annuity. A retired employee (other than a survivor) who is entitled to an annuity is eligible for the benefits provided by this part if— (1) He/She retired before his/her first pay period beginning after June 30, 1960; (2) He/She retired on immediate annuity; (3) He/She had at least 12 years of creditable service, or retired under a disability provision of his/her retirement system; (4) He/She retired from employment which was not in the Tennessee Valley Authority or in a corporation under the supervision of the Farm Credit Administration, of which corporation any member of the board of directors was elected or appointed by private interests; and (5) At the time of retirement, he/she was a citizen, or a noncitizen having a permanent-duty station within the several States or the District of Columbia on the day before retirement. For the purpose of this paragraph, an employee is considered to have retired before his/her first pay period beginning after June 30, 1960, if his/her annuity began to accrue before his/her first pay period after June 30, 1960, or if he/she was eligible under paragraph (d) of this section until the date his/her annuity began to accrue. (c) Survivors entitled to annuity. A survivor who is entitled to annuity is eligible for the benefits provided by this part if he/she is: (1) In receipt of immediate annuity as the survivor of (i) an employee who died before his/her first pay period beginning after June 30, 1960; or (ii) a retired employee whose annuity began to accrue before his/her first pay period beginning after June 30, 1960; (2) The survivor of (i) an employee who had at least 5 years' creditable service, (ii) a former employee who retired having at least 12 years' creditable service and received an immediate annuity, or (iii) a former employee who retired under a disability provision of his/her retirement system; and (3) Not receiving annuity as the survivor of a person who at the time of the retirement or death, as the case may be, on which annuity is based, was an employee of the Tennessee Valley Authority or of any corporation under the jurisdiction of the Farm Credit Administration of which corporation any member of the board of directors was elected or appointed by private interests, or was a noncitizen having a permanent-duty station outside the several States and the District of Columbia. (d) Retired employees (other than survivors) entitled to compensation. A retired employee (other than a survivor) who is entitled to compensation is eligible for the benefits provided by this part if— (1) He/She is receiving monthly compensation for an injury sustained or illness contracted before his/her first pay period beginning after June 30, 1960; (2) He/She is held by the Secretary of Labor to be unable to return to duty; (3) He/She is receiving compensation based on employment which was not in the Tennessee Valley Authority or in a corporation under the supervision of the Farm Credit Administration, of which corporation any member of the board of directors was elected or appointed by private interests; and (4) At the time of sustaining the injury or contracting the illness, as the case may be, on which compensation is based, he/she was a citizen, or a noncitizen having a permanent-duty station within the several States or the District of Columbia at that time. (e) Family members entitled to compensation. A member of a family who is receiving compensation is eligible for the benefits provided by this part if he/she is: (1) A survivor beneficiary of (i) an employee who completed 5 years of service and died as a result of injury or illness which is compensable under subchapter I of chapter 81 of title 5, United States Code, and which was sustained or contracted before his/her first pay period beginning after June 30, 1960, or (ii) a former employee who was separated after having completed at least 5 years of service and who died while receiving monthly compensation under that subchapter on account of injury sustained or illness contracted before his/her first pay period beginning after June 30, 1960, and who has been held by the Secretary of Labor to have been unable to return to duty; and (2) Not receiving compensation as the survivor of a person who at the time of sustaining the injury or contracting the illness, as the case may be, on which compensation is based, was an employee of the Tennessee Valley Authority or of any corporation under the jurisdiction of the Farm Credit Administration of which corporation any member of the board of directors was elected or appointed by private interests, or was a noncitizen having a permanent-duty station outside the several States and the District of Columbia. (f) Determinations of eligibility. The Associate Director for Compensation of OPM, on request, shall determine the eligibility of a retired employee, or class of retired employees, to make the elections and receive the Government contributions provided for by this part. [33 FR 12516, Sept. 4 1968, as amended at 43 FR 35018, Aug. 8, 1978] (a) The Office of Worker's Compensation Program is responsible only for retired employees who are receiving compensation from the Office and is responsible even though the retired employee has retired under another retirement office from which he/she is not currently receiving annuity. If the retired employee is currently receiving annuity from another retirement office, that retirement office, rather than the Office of Worker's Compensation Program, will have the responsibilities imposed on retirement offices by this part for that retired employee. (b) Retirement offices are responsible, in accordance with regulations and instructions issued by OPM, for withholding from the annuity or compensation of each retired employee within the jurisdiction of the retirement office who elects to subscribe to the uniform plan his/her share of the cost, for forwarding the amount withheld to the Retired Federal Employees Health Benefits Fund, and for reporting to OPM amounts required for Government contribution for these retired employees. (c) Retirement offices are responsible, in accordance with regulations and instructions issued by OPM, for reporting to OPM amounts required for Government contributions to retired employees within the jurisdiction of the retirement office who have elected to receive a Government contribution toward the cost of a private health benefits plan, and for paying the Government contributions to these retired employees. (d) Retirement offices are responsible for advising retired employees within the jurisdiction of the retirement office of the rights and obligations of retired employees under this part. (e) When one or more of the family members is a child 19 years of age or older who is incapable of self-support because of mental or physical disability which existed before the child became 19 years of age, the appropriate retirement office shall obtain the necessary evidence and make a determination of incapacity. (f) Retirement offices are responsible, in accordance with regulations and instructions issued by OPM, for verifying continuing eligibility of retired employees to receive Government contributions. OPM may order correction of administrative errors at any time upon a showing satisfactory to OPM that it would be against equity and good conscience not to do so. [45 FR 23637, Apr. 8, 1980] (a) Who may file. A retired employee may request OPM to reconsider its initial decision that he/she is not eligible to make an election or to receive a Government contribution under the part or that he/she may not enroll another individual as a family member. (b) Initial OPM decision. An OPM decision shall be considered an initial decision as used in §891.106(a) of this part, when rendered by OPM in writing and stating the right to reconsideration. However, a decision initially rendered at the highest level of review available within OPM will not be subject to reconsideration. (c) Reconsideration. A request for reconsideration must be made in writing, must include the claimant's name, address, date of birth, claim number, if appropriate, and reasons for the request. (d) Time limit. A request for reconsideration of an initial OPM decision must be filed within 30 calendar days from the date of OPM's initial decision. OPM may extend the time limit on filing when the individual shows that he/she was not notified of the time limit and was not otherwise aware of it, or that he/she was prevented by circumstances beyond his/her control from making the request within the time limit. (e) Final decision. After reconsideration, OPM shall issue a final decision which shall be in writing and shall fully set forth the findings and conclusions of OPM. [45 FR 23637, Apr. 8, 1980] (a) The original period for election by each eligible retired employee was during the months of March and April 1961. Failure to elect when eligible to do so is deemed an election not to participate in the program unless the failure is determined by the retirement office to be for cause beyond the control of the retired employee. In any case in which annuity or compensation is being paid to a payee in behalf of a retired employee, the payee shall make the election for the retired employee. (b) (1) A retired employee may elect to participate in the program for self alone or for self and family. (2) Survivors, if actually or constructively living in the same household, have only one right of election among them. The election shall be made by the payee. The fact that one payee is receiving annuity or compensation for all members of the family is prima facie evidence that they are living in the same household. The existence of more than one payee is prima facie evidence that each payee and the survivors in whose behalf the payee is receiving annuity or compensation constitute a separate household, and each payee may elect for the survivors in whose behalf he is receiving annuity or compensation, but where a family is receiving annuity or compensation through more than one payee, one payee, with the consent of the other payees, may elect for the whole family. (3) A retired employee may not be covered under more than one election. (4) A retired employee who is entitled to more than one annuity or to compensation and annuity is entitled to only one election. (c) Each retired employee who elects to receive a Government contribution toward the cost of a private health benefits plan shall file with his election a certificate of the carrier, on the form prescribed by OPM for the purpose, that he is a subscriber to a health benefits plan. OPM, or the appropriate retirement office, at any time may require that a retired employee renew the certificate, or may take such other action as it considers desirable to verify the continuing eligibility of the retired employee to receive a Government contribution. The appropriate retirement office may suspend the Government contribution when there is a reasonable doubt of the retired employee's continuing eligibility to receive the Government contribution. (d) In the discretion of the retirement office, a representative of the retired employee having a written authorization to do so may elect for him. (e) A person who was not eligible, during the months of March and April 1961, to elect to subscribe to the uniform plan or to receive a Government contribution toward the cost of a private health benefits plan, may apply to the appropriate retirement office when he becomes eligible. If the retirement office determines that he is eligible, it shall notify the retired employee that he is eligible to make an election in accordance with paragraphs (a) to (d) of this section within 60 days of the date of the notice. If the retirement office determines that a retired employee was unable, for cause beyond his control, to make an election within the time limits prescribed by this section, it shall notify the retired employee that he is eligible to make an election in accordance with paragraphs (a) to (d) of this section within 60 days of the date of the notice. Elections made under this paragraph are effective, for a retired employee receiving annuity and a survivor receiving compensation, on the first day of the third month following the month in which the retirement office receives the election. Withholdings and contributions are effective for months beginning on and after the first day of the second month following the month in which the retirement office receives the election. For any other retired employee receiving compensation, changes of election made under this paragraph are effective on the first day of the third 4-week period following the 4-week period in which the Bureau of Employees' Compensation receives the election, and withholdings and contributions are effective beginning with the second 4-week period following receipt of the election. This paragraph does not apply to retired employees who have been, at any time, covered by the election of another under this part. (f) Retired employees and survivors who, on January 1, 1973, were enrolled for either basic coverage only or major medical coverage only of the Uniform Plan are, effective January 1, 1973, automatically enrolled in basic plus major medical coverage of the Uniform Plan. [33 FR 12516, Sept. 4, 1968, as amended at 37 FR 20845, Dec. 20, 1972] (a) When used in this section, “month” includes the 4-week period for which a retired employee (other than a survivor) receives compensation. (b) A retired employee shall change his election in accordance with the following table: (c) An annuitant may change his or her election in accordance with the following table by notifying his or her retirement system at any time: [33 FR 12516, Sept. 4, 1968, as amended at 43 FR 35018, Aug. 8, 1978] (a) When used in this section, “month” includes the 4-week period for which a retired employee (other than a survivor) receives compensation. (b) When compensation is entirely suspended or annuity is entirely waived or suspended, Government contributions are suspended. If the election is to subscribe to the uniform plan, and the annuity or compensation is suspended, or the annuity is waived to the extent that the retired employee's share of the cost cannot be withheld, withholdings and Government contributions are suspended, but the subscription continues. (c) If the waiver or suspension covers 3 months or less, Government contributions and withholdings for the period of waiver or suspension shall be made when annuity payment is resumed. If the waiver or suspension covers more than 3 months, the retired employee's election is terminated effective at the end of the third month of waiver or suspension. A terminated election is renewed when annuity or compensation payment is resumed. When a terminated election is renewed pursuant to this paragraph, withholdings and Government contributions shall be made for the first 3 months of the waiver or suspension. Withholdings and Government contributions shall be made for annuity or compensation accruing after the election is renewed. (d) If title of a retired employee to annuity or compensation is terminated, his eligibility under this part is terminated. (e) If the eligibility of a retired employee is terminated and other members of the same family continue to be eligible under this part, the election of the former retired employee continues for the remainder of the family unless and until changed in accordance with §891.202. (a) For retired employees and survivors receiving an annuity. (1) Each month, an amount equal to the current monthly premium paid by an individual for supplementary medical insurance under title XVIII of the Social Security Act (Medicare) for such month shall be paid by the Office of Personnel Management, through the appropriate retirement office, to each retired employee or survivor who: (i) Is in receipt of annuity for such month; (ii) Is eligible for coverage under this part; and (iii) Elects to receive a Government contribution toward his or her cost of coverage for: (A) A private health insurance plan in which he or she is a subscriber for self-only; or (B) Supplementary medical insurance under Medicare. (2) Each month, an amount equal to the current monthly premium paid by an individual for supplementary medical insurance under title XVIII of the Social Security Act (Medicare) for such month shall be contributed, by the Office of Personnel Management, for each retired employee or survivor who is in receipt of annuity and who has elected to enroll for self-only in the uniform plan. (3) Each month, an amount equal to twice the current monthly premium paid by an individual for supplementary medical insurance under title XVIII of the Social Security Act (Medicare) for such month shall be paid by the Office of Personnel Management, through the appropriate retirement office, for each retired employee or survivor who: (i) Is in receipt of an annuity for such month; (ii) Is eligible for coverage under this part; and (iii) Elects to receive a Government contribution toward the cost of coverage for self and family under: (A) A private plan or plans; or (B) Supplementary medical insurance under Medicare. (4) Each month, an amount equal to twice the current monthly premium paid by an individual for supplementary medical insurance under title XVIII of the Social Security Act (Medicare) for such month shall be contributed, by the Office of Personnel Management, for each retired employee or survivor who is in receipt of annuity and who has elected to enroll for self and family in the uniform plan. (b) For retired employees and survivors receiving compensation. (1) For each retired employee or survivor who is in receipt of compensation and who meets the requirements of paragraph (a)(1) of this section, other than the requirement of being in receipt of an annuity, the Office of Personnel Management shall contribute, through the Office of Workers' Compensation Programs, an amount equal to 93 (2) For each retired employee or survivor who is in receipt of compensation and who has elected to enroll for self-only in the uniform plan, the Office of Personnel Management shall contribute, during each 4-week period in which payment of such compensation is made, an amount equal to 93 (3) For each retired employee or survivor who is in receipt of compensation and who meets the requirements of paragraph (a)(3) of this section, other than the requirement of being in receipt of an annuity, the Office of Personnel Management shall contribute, through the Office of Workers' Compensation Programs, an amount equal to 186 (4) For each retired employee or survivor who is receiving compensation and has elected to enroll for self and family in the uniform plan, the Office of Personnel Management shall contribute, during each 4-week period in which payment of such compensation is made, an amount equal to 186 (5) If the current monthly rate for supplementary medical insurance under Medicare changes to a new rate within a 4-week period in which compensation is paid, the amount to be contributed for that 4-week period will be a prorated amount determined by: (i) Multiplying the number of days in the 4-week pay period occurring at the former monthly rate (the rate in effect at the beginning of the pay period) by the former rate for a 4-week pay period; (ii) Multiplying the number of days in the 4-week pay period occurring at the new rate (the rate in effect at the end of the 4-week pay period) by the new 4-week rate; (iii) Adding the products of paragraphs (b)(5) (i) and (ii) of this section; and (iv) Dividing the sum by 28 and rounding to the nearest cent, counting one-half cent and over as a whole cent. (c) So that the Government contribution provided under this section is paid or contributed in advance, it shall be included in the payment of annuity or compensation for the month or pay period immediately preceding the month or pay period for which the Government contribution is due. (d) An election to subscribe to the uniform plan constitutes an agreement by the retired employee or survivor that the retirement office may withhold from his or her annuity or compensation his or her share of the cost of the plan, as provided by this part. (e) The Government shall contribute to the Retired Federal Employees Health Benefits Fund two percent of the total Government contribution authorized by this section for payment of expenses incurred by the Office of Personnel Management in administering this part. [45 FR 30611, May 9, 1980] The appropriate retirement office shall withhold from the annuity or compensation of each of its retired employees who has elected to subscribe to the uniform plan so much as is necessary to pay his share of the cost of his subscription. The withholdings shall be forwarded, in accordance with OPM instructions, to the Retired Employees Health Benefits Fund. The uniform plan shall be open to all eligible retired employees and members of their families, without regard to race, sex, health status, or age. It shall not deny or limit benefits because of any preexisting condition. It shall offer basic plus major medical coverage. It shall provide a 31-day extension of coverage on termination of subscription other than by change of election or termination of the contract. A person confined in hospital for care or treatment on the 31st day of the extension of coverage shall be entitled to continuation of the benefits of the contract during the continuance of the confinement, but not beyond the 60th day following the end of the extension of coverage. The uniform plan shall be experience-rated. [33 FR 12516, Sept. 4, 1968, as amended at 43 FR 35018, Aug. 8, 1978] In the most recent year for which data are available, the carrier of the uniform plan shall have made at least 1 percent of all group health insurance benefit payments in the United States. If the carrier is an insurance company, it must be licensed to issue group health insurance in all the States of the United States and the District of Columbia.
Title 5: Administrative Personnel
PART 891—RETIRED FEDERAL EMPLOYEES HEALTH BENEFITS
Section Contents
§ 891.101 Relationship to part 890 of this chapter.
§ 891.102 Definitions.
§ 891.103 Eligibility.
§ 891.104 Responsibilities of retirement offices.
§ 891.105 Correction of errors.
§ 891.106 Reconsideration.
§ 891.201 Election.
§ 891.202 Change of election.
§ 891.301 Suspension and termination.
§ 891.401 Government contributions.
§ 891.402 Withholdings.
§ 891.501 Standards for uniform plan.
§ 891.502 Standards for carrier of uniform plan.
Subpart A—Administration and General Provisions
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§ 891.101 Relationship to part 890 of this chapter.
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§ 891.102 Definitions.
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§ 891.103 Eligibility.
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§ 891.104 Responsibilities of retirement offices.
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§ 891.105 Correction of errors.
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§ 891.106 Reconsideration.
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Subpart B—Election and Change of Election
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§ 891.201 Election.
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§ 891.202 Change of election.
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Table of Required Changes---------------------------------------------------------------------------------------------------------------- Type of election to Event requiring change which requirement Change required Effective date of applies change----------------------------------------------------------------------------------------------------------------(1) Loss of member of family by death Election for self and Change to self alone... First day of month or otherwise, leaving only one family for uniform or following the event person covered by the election. private health requiring change. benefits plan. Changes in withholdings and contributions are effective for annuity or compensation accruing for the month in which the event requiring change occurs.(2) Termination of subscription to a Election for self and ......do............... Do. private health benefits plan for all family for private persons covered by the election but health benefits plan. the retired employee making the election \1\.(3) Termination of subscription to a Election for self alone Change to not Do. private health benefits plan for all or for self and family participating persons covered by the election \1\. for private health (optional change may benefits plan. be made in accordance with paragraph (c) of this section).----------------------------------------------------------------------------------------------------------------\1\ If the termination is immediately succeeded by a similar subscription in another private health benefits plan a change of election is not required, but the retired employee shall file a certificate of the new carrier that he is a subscriber. A form for the certificate may be obtained from the retirement office.
Table of Optional Changes---------------------------------------------------------------------------------------------------------------- Type of election from which Change permitted changing Effective date of change----------------------------------------------------------------------------------------------------------------(1) Change to not participating.......... Election for self alone or self First day of month specified in and family for uniform or private notice to retirement system, or health benefits plan. first day of month following receipt of notice by retirement system, whichever is later. Changes in withholdings and contributions are effective for annuity or compensation accruing for the month preceding the effective date of the change.(2) Change to self alone in same plan.... Election for self and family for Do. uniform plan or private health benefits plan.(3) Change to private health benefits Election for self alone or self Do. plan for self alone or self and family. and family for uniform plan.(4) Change to self and family in same Election for self alone for First day of fourth month plan. uniform or private health following the month in which benefits plan. notice is received by retirement system. Changes in withholdings and contributions are effective for annuity or compensation accruing for the third month following month in which notice is received by the retirement system.(5) Change to self alone or self and Election not to participate....... Do. family for uniform plan or private health benefits plan.----------------------------------------------------------------------------------------------------------------
Subpart C—Suspension and Termination
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§ 891.301 Suspension and termination.
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Subpart D—Contributions and Withholdings
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§ 891.401 Government contributions.
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§ 891.402 Withholdings.
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Subpart E—Standards for Uniform Plan and Carrier
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§ 891.501 Standards for uniform plan.
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§ 891.502 Standards for carrier of uniform plan.
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