Certain events can lead to the termination of FEHB coverage.
Separation before retirement eligibility and FEHB
Those who separate from federal service before eligibility to retire and receive a deferred annuity starting at age 62 are not eligible to enroll in the FEHB program. You may have coverage under the program as a family member based on your spouse’s enrollment, but you can never have an enrollment based on a deferred annuity.
If your annuity terminates (for example, when a disability retiree recovers or is restored to earning capacity), your enrollment will end on the last day of the month for which you are entitled to an annuity. However, coverage will be extended for 31 days without cost to you.
If you are a disability retiree whose annuity terminated as described above, you will retain your health benefits coverage if you are entitled to apply for an immediate annuity, i.e., one that begins when your disability annuity stops. You will receive complete information concerning your right to do so if your disability annuity terminates.
If you are under age 60 and your disability annuity is reinstated due to loss of earning capacity or a recurrence of the disability for which you retired, you will be given an opportunity to have health benefits coverage reinstated if you were enrolled at the time your disability annuity previously terminated.
If you are entitled to a deferred annuity after your disability annuity terminates, you cannot retain your health benefits coverage as a retiree.
Under certain conditions, your annuity will terminate if you are reemployed in the federal service. If this occurs, your health benefits enrollment will be transferred to your employing agency. If you are so reemployed, you should immediately notify OPM at PO Box 45, Boyers, PA 16017-0045.
Be sure to refer to your retirement claim number (CSA number) and provide OPM with a copy of the personnel document showing your appointment, if possible, or the full name and address of your employing agency.
Widow(er)s or Former Spouse Survivor Annuitants
If you remarry before age 55, your survivor annuity and health benefits enrollment will end on the last day of the month preceding the month in which you remarry (subject to the extension of coverage). If you are enrolled in self and family coverage, the enrollment will continue for any eligible children as long as one of them is entitled to receive a survivor annuity (but you will not be covered). If you remarry before age 55, you must immediately notify OPM at the above address.
Be sure to provide OPM with a copy of your marriage certificate and refer to your survivor annuity claim number (CSF number).
If you remarry after age 55, your survivor annuity and health benefits coverage will continue. Your new spouse and his or her children cannot receive health benefits coverage under your survivor annuitant enrollment.
However, if you are a widow(er) survivor annuitant who also is receiving an annuity based on your own federal career, you may be eligible to transfer your enrollment to your retirement annuity in order to provide coverage for your new spouse and his or her children.
If you are receiving health benefits coverage as a former spouse, your coverage also will terminate if:
- you lose entitlement to survivor annuity benefits under the terms of the court order which provided your benefits; OR
- you do not pay the full cost of the enrollment by the payment due date (if premiums are not being withheld from your survivor annuity)
If you are a widow(er) whose annuity and health benefits coverage terminated due to remarriage before age 55, see below for information on how your coverage and annuity can be reinstated if the marriage ends. If you are a former spouse whose annuity and health benefits coverage terminated due to remarriage before age 55, your survivor annuity and health benefits coverage cannot be reinstated if your marriage ends.
Child Survivor Annuitants
FEHB coverage as a child generally ends at age 26. If you are receiving a monthly annuity, and you lose coverage because the survivor who was paying for the coverage cancels or changes the enrollment to self only, OPM will offer you the opportunity to elect temporary continuation of coverage or convert to an individual contract.
What if FEHB Coverage Ends
31-Day Extension of Coverage
In order to give you the opportunity to convert to a nongroup health benefits contract, your coverage will continue for 31 days after your enrollment ends for any reason except voluntary cancellation. If you are confined to a hospital on the 31st day of your extension, your benefits will continue while you are confined, up to a maximum of 60 additional days. These extensions are without cost to you. They also apply to any family member who loses coverage under your enrollment for any reason except your voluntary cancellation of the enrollment.
Conversion to a Nongroup Contract
If you are a retiree, a widow or widower survivor annuitant, a former spouse survivor annuitant, or a child of a deceased federal employee or retiree who has coverage under the FEHB program in your own name, and your enrollment terminates for any reason other than by your voluntary cancellation, you are entitled to convert to a nongroup health benefits contract issued by the carrier of the plan in which you were enrolled. Nongroup conversion policies are issued without evidence of insurability. You must pay the entire premium for a nongroup contract.
Normally, within 60 days of the date your enrollment terminates, OPM will send you a notice of termination and your right to convert. This does not apply to family members who lose eligibility for coverage.
Temporary Continuation of FEHB Coverage
Employees who separate from federal service and who are not eligible to remain enrolled in the FEHB—primarily, those separating before retirement eligibility—are eligible for temporary continuation of coverage of up to 18 months. In addition, children who lose FEHB coverage as family members and former spouses who lose coverage because of divorce or annulment and who are not eligible to enroll in the FEHB program under the Spouse Equity law may, under certain circumstances, qualify for TCC for up to 36 months after the qualifying event occurs.
The cost of TCC is the full health benefits premium (both the enrollee and government shares) plus an administrative charge of 2 percent. However, DoD continues to pay the employer share for certain employees involuntarily separated by reduction in force.
To enroll in TCC, you (or your child or former spouse, as applicable) must submit SF-2809, available from agency personnel offices or at www.opm.gov/forms within 60 days of the event.
If an FEHB claim is denied
If a claim for payment for service is denied, your plan will reconsider its denial on receipt of a written request within one year of the denial. The written request should state, in terms of applicable plan brochure provisions, the reasons you believe that the denied claim for payment or service should have been paid or provided. Within 30 days after receipt of your request for reconsideration, the plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If this information is not supplied within 60 days, the plan will base its decision on the information it has on hand.
If the plan affirms its denial, you have a right to a review by OPM to determine whether the plan has acted in accordance with its contract. Before seeking OPM review of a claim, these are some of the things you should keep in mind, according to OPM:
- Submit bills from providers for payment to the plan along with the appropriate claim form; do not send bills to the address below or any other office within OPM except in connection with a disputed claim.
- Providers may use this procedure only on behalf of and with the specific written consent of the member and are required to demonstrate that the member has assigned all of his or her rights to the provider with regard to that particular claim.
- You should first check with your provider or facility to be sure the plan was billed correctly; for instance, that the correct procedure code(s) was used, complications were correctly indicated on the billing or operative reports, etc.
Along with your request for review, you must send a copy of the plan’s reconsideration decision. To obtain OPM review, write to: OPM, Retirement and Insurance Service, Office of Insurance Programs.
OPM must receive a request for review, along with a copy of your letter to the plan and its reply within 90 days of the plan’s affirmation of the denial.
You may ask OPM for review if the plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information. In this case, OPM must receive a request for review within 120 days of your request to the plan for reconsideration or the date you were notified that the plan needed additional information. In your request for review, show (1) the date of your request to the plan, or (2) the dates the plan requested and you provided additional information.
If you decide to seek judicial review of the denial of a claim, you must file suit no later than December 31 of the third year after the year in which the care or service was provided. Suits may not be brought prior to exhaustion of administrative remedies. Federal law governs claims for relief that relate to benefits under the plan. Damages recoverable under federal law are limited to the amount of benefits in dispute. Such legal actions must be brought against OPM. These actions are limited to the record that was before OPM and that was the basis of the OPM decision to disallow the benefit, thus affirming the plan’s decision.
If you request OPM to review a denial of a claim for payment or service, OPM or its contractors are authorized to use the information collected from you and the plan to determine if the plan acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/or the plan in support of OPM’s decision on the disputed claim.