Issue Briefs

Following is OPM guidance on changes in the FEHB program effective in 2011 due to the health insurance reform law enacted earlier this year.

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1. What does "health care reform" mean?

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, also known as health care reform. One of the provisions of health care reform extends family health insurance coverage to children until age 26.

2. Does health care reform extend Federal Employees Health Benefits (FEHB) coverage to children until they turn 26?

Yes. Previously, children of Federal enrollees lost health coverage when they turned 22 (plus a 31-day temporary extension of coverage). Beginning January 1, 2011, children of Federal enrollees will be covered by their parent’s FEHB Self and Family enrollment until their 26th birthday (plus a 31-day temporary extension of coverage), even if the child previously lost coverage because he or she turned 22.

3. Does health care reform extend FEHB coverage to my married child?

Yes. Beginning January 1, 2011, your child under the age of 26, whether married or unmarried, is covered under your Self and Family enrollment. However, your child’s spouse and/or child are not covered.

4. Can I get my child age 22 through 25 covered by FEHB sooner than January 1, 2011?

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No. The current law governing the FEHB Program specifically prohibits us from providing coverage prior to January 1, 2011.

Eligibility

5. My child is under age 26 and married. Is my child covered under my FEHB Self and Family enrollment?

Yes. Beginning January 1, 2011, your married or unmarried child under age 26 is covered under your Self and Family enrollment. However, your child’s spouse and/or child are not covered.

6. I have grandchildren. Are they covered under my FEHB Self and Family enrollment?

No. A grandchild is not an eligible family member, unless the child qualifies as your foster child. For rules on foster children, see question 14.

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7. My child lost FEHB coverage because he turned 22. Is he covered under my FEHB Self and Family enrollment?

Yes. Beginning January 1, 2011, your child is covered under your Self and Family enrollment up to his 26th birthday, even if he previously lost coverage because he turned 22.

8. My child does not live with me. Is he covered under my FEHB Self and Family enrollment?

Yes. Your child is not required to live with you to be covered under your Self and Family enrollment.

9. My child is not a dependent on my tax return. Is my child covered under my FEHB Self and Family enrollment?

Yes. There is no requirement that your child be a dependent for income tax purposes, nor does your child have to be financially dependent upon you, to be covered under your Self and Family enrollment.

10. My child is under age 26 but is not a student. Is my child covered under my FEHB Self and Family enrollment?

Yes. There is no requirement that your child be a student to be covered under your Self and Family enrollment.

11. My child is under age 26 and has been uninsured since turning 22. Is my child covered under my FEHB Self and Family enrollment?

Yes. Beginning January 1, 2011, your child will be covered under your Self and Family enrollment until his or her 26th birthday. There is no continuous insurance requirement.

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12. My child has a pre-existing condition. Will my child be covered under my FEHB Self and Family enrollment?

Yes. The FEHB Program does not allow its participating health carriers to deny or delay medical benefits or coverage based on a pre-existing condition.

13. Is my stepchild covered under my FEHB Self and Family enrollment?

Yes. Beginning January 1, 2011, your stepchild is covered under your Self and Family enrollment until his or her 26th birthday. Your stepchild is not required to live with you or be financially dependent upon you.

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14. Is my foster child covered under my FEHB Self and Family enrollment?

It depends. Beginning January 1, 2011, foster children, even if married, can be covered under their foster parent’s Self and Family enrollment until their 26th birthday. To be considered a foster child for health benefits purposes, the following requirements must be met:

the child must live with you;

the parent-child relationship must be with you, not solely the child’s biological parent;

you must be the primary source of financial support for the child; and

you must expect to raise the child to adulthood.

You must sign a certification stating that your foster child meets all the requirements. Contact your agency or Retirement System for more information.

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Enrollment

15. I have an FEHB Self and Family enrollment. Do I need to do anything to get my child under age 26 back on my FEHB enrollment?

Yes; although your child is automatically covered under your Self and Family enrollment, you must notify your health plan to update their enrollment records. Your health plan will send you instructions before Open Season. Your health plan may ask for information such as your child’s name, date of birth, and Social Security Number. If you do not receive these instructions by November 15th, contact your plan at the customer service number on your ID card.

Do not complete an SF 2809 or use an agency self-service system to add your newly eligible child.

16. I get paid biweekly. I have a Self Only enrollment, or I am not currently enrolled in an FEHB plan. How do I get my child under age 26 covered effective January 1, 2011?

Use a Standard Form (SF) 2809 or an agency self-service enrollment system to change your enrollment to, or to enroll in, Self and Family.

Indicate that you have a "change in family status" Qualifying Life Event (QLE). Most employees should use QLE code ‘1C.’

You can make the change or enroll between December 1, 2010 and March 2, 2011. Your child will be covered beginning January 1, 2011. If you enroll or make the change after January 1, 2011, your child will be covered retroactively to January 1 and you will pay premiums retroactively to the effective date of the enrollment or change.

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Be aware that if you enroll or change your enrollment as an Open Season change, for most employees, it will take effect on January 2, 2011.

Contact your agency for more information.

17. I get paid monthly. I have a Self Only enrollment, or I am not currently enrolled in an FEHB plan. How do I get my child under age 26 covered effective January 1, 2011?

Use a Standard Form (SF) 2809 or an agency self-service enrollment system to change your enrollment to, or to enroll in, Self and Family during Open Season. Your Open Season change or enrollment will be effective January 1, 2011.

Be aware that retirees who are not currently enrolled in FEHB cannot enroll in FEHB, even if they have a newly eligible child. Retirees must have met certain eligibility requirements to continue their health benefits into retirement. However, if you are retired and you suspended your enrollment, you may reenroll in the FEHB program at Open Season. You can find more information at www.opm.gov/insure/retirees/index.asp?AnswerId=89.

Contact your agency or Retirement System for more information.

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18. I receive benefits from the Office of Workers’ Compensation (OWCP) and have a Self Only enrollment. How do I get my child under age 26 covered effective January 1, 2011?

Use a Standard Form (SF) 2809 to change your enrollment to Self and Family.

Indicate that you have a "change in family status" Qualifying Life Event (QLE). OWCP recipients should use QLE code ‘2B.’

You can make the change between December 1, 2010 and March 2, 2011. Your child will be covered beginning January 1, 2011. If you enroll or make the change after January 1, 2011, your child will be covered retroactively to January 1 and you will pay premiums retroactively to the effective date of the change.

Be aware that if you change your enrollment as an Open Season change, for OWCP recipients, it will take effect on January 16, 2011.

Contact your OWCP District Office for more information.

19. My child will turn age 22 before January 1, 2011. How can I prevent a break in his health insurance coverage?

Under FEHB law, enrollees’ children who turn 22 are automatically covered for an additional 31 days under their parent’s enrollment. Your child will have 60 days from his 22nd birthday to:

Enroll in Temporary Continuation of Coverage (TCC); or

Convert to an individual policy with your current health plan.

For more information on TCC, see the TCC category below.

20. My child will turn age 26 after January 1, 2011. What happens on his 26th birthday?

Your child will no longer be covered under your Self and Family enrollment on his 26th birthday. On his 26th birthday, your child will get a 31-day temporary extension of coverage. Under the FEHB Program, your child will have 60 days from his 26th birthday to:

Enroll in Temporary Continuation of Coverage (TCC); or

Convert to an individual policy with your current health plan.

For more information on TCC, see the TCC category below.

21. My child lost coverage under my FEHB Self and Family enrollment when she turned 22. She will turn age 26 before January 1, 2011. Can she enroll in Temporary Continuation of Coverage (TCC)?

No. Children can only enroll in TCC within 60 days of losing their coverage under their parent’s FEHB enrollment. Your child lost FEHB coverage over three years ago. Since your daughter will turn 26 before January 1, 2011, she will not be eligible for FEHB under your enrollment; therefore, she will not eligible for TCC.

For more information on TCC, see questions 26-27.

22. I already have a Self and Family enrollment. Will adding my child under age 26 increase my premiums?

No. A Self and Family premium does not change based on the number of family members on your enrollment. If you are already enrolled in Self and Family when your child under age 26 is added, covering your child will not increase your premium costs.

23. My state has a law requiring health plans to cover certain children until age 30. Does this mean I can get my child covered by FEHB until age 30?

No. The FEHB Program is a Federal program and preempts state law requirements.

24. Can I remove my child from my FEHB Self and Family enrollment?

No. Your child will remain covered until his or her 26th birthday

25. Who is responsible for the out-of-pocket health expenses of my child age 22 through 25?

It depends. Generally, the adult child is responsible for any out-of-pocket health expenses charged by the health care provider. You can work with your provider to determine who pays for the out-of-pocket expenses incurred by your adult child. We cannot guarantee that the provider will not seek payment from you if your adult child fails to pay.

Temporary Continuation of Coverage (TCC)

26. My child under age 26 is currently enrolled in TCC. Will she be covered under my FEHB Self and Family enrollment effective January 1, 2011 and what will happen to her TCC enrollment?

Your child will be covered under your Self and Family enrollment beginning January 1, 2011. Please note that your child’s TCC enrollment will not automatically end when she regains coverage under your Self and Family enrollment. To avoid paying for unnecessary TCC, she may cancel her enrollment on or after the date her coverage under your Self and Family enrollment begins (probably January 1, 2011). When she turns 26, she will become eligible for TCC again.

She may cancel her TCC enrollment by sending a signed request specifying her desired cancellation date to:

USDA, National Finance Center

DPRS Billing Unit

PO Box 61760

New Orleans, LA 70161-1760

If you have additional questions, contact the National Finance Center at 800-242-9630 or nfc.dprs@usda.gov.

27. My daughter under age 26 lost coverage under my Self and Family enrollment when she turned 22. She now has a TCC Self and Family enrollment to cover her husband and son. Can she keep her TCC enrollment?

Yes. However, your daughter will be covered under two enrollments: your enrollment and her TCC. Because no person is entitled to receive benefits under more than one enrollment, both you and your daughter must notify your respective insurance carriers of the names of the persons to be covered under each enrollment. Your daughter may not file claims nor receive benefits under both enrollments.

Retirees

28. I am retired and have a FEHB Self and Family enrollment. Will my child under age 26 be covered under my FEHB enrollment?

Yes. Your child under age 26 will be covered under your Self and Family enrollment. The health care reform law applies to employees and retirees. You must notify your health plan to update their enrollment records. Your health plan will send you instructions before Open Season. Your health plan may ask for information such as your child’s name, date of birth, and Social Security Number. If you do not receive these instructions by November 15th, contact your plan at the customer service number on your ID card.

29. I am retired and have a FEHB Self Only enrollment. Can I switch to a Self and Family enrollment to cover my child who is under age 26?

Yes. You can change your enrollment in FEHB during Open Season. Your Open Season change will be effective January 1, 2011. Use a Standard Form (SF) 2809 or an agency self-service enrollment system to change your enrollment to, or to enroll in, Self and Family during Open Season. Your Open Season change or enrollment will be effective January 1, 2011.

Be aware that retirees who are not currently enrolled in FEHB cannot enroll in FEHB, even if they have a newly eligible child. Retirees must have met certain eligibility requirements to continue their health benefits into retirement. However, if you are retired and you suspended your enrollment, you may reenroll in the FEHB program at Open Season. You can find more information at www.opm.gov/insure/retirees/index.asp?AnswerId=89.

Contact your Retirement System for more information.

30. I am retired and not currently enrolled in the FEHB Program. If I have a child who will be eligible on January 1, 2011, can I enroll in the FEHB Program?

No. Retirees who are not currently enrolled in FEHB cannot enroll in FEHB, even if they have a child who will be newly eligible on January 1, 2011. Retirees must have met certain eligibility requirements to continue their health benefits into retirement. However, if you are retired and you suspended your enrollment, for example, to use TRICARE, you may reenroll in the FEHB program at Open Season. You can find more information at www.opm.gov/insure/retirees/index.asp?AnswerId=89.

31. I am a retiree in interim pay status. Will my child under age 26 be covered under my FEHB Self and Family enrollment?

It depends. When you retire, your agency makes an initial determination about whether you are eligible to continue your health benefits into retirement. When your retirement application is processed, OPM will make a final determination about whether you are eligible to continue your health benefits into retirement. As long as you are eligible to continue FEHB into retirement and you have a Self and Family enrollment under FEHB, your child is covered until his or her 26th birthday effective January 1, 2011.

However, if your agency’s initial determination was that you are eligible, and OPM’s final determination is that you are not eligible, then your FEHB coverage will be terminated retroactively to the date of your retirement. If your coverage is terminated, you will have the opportunity to enroll in Temporary Continuation of Coverage (TCC). If you enroll in TCC, you will not have a gap in coverage. If you enroll in TCC and have a Self and Family enrollment under FEHB, your child is covered until his or her 26th birthday effective January 1, 2011.

Disabled Children Incapable of Self-Support

32. Does health care reform affect the FEHB eligibility of disabled children incapable of self-support?

Yes. Prior to health care reform, children over age 22 who are incapable of self-support due to a disability that began before age 22 were eligible for FEHB coverage. Beginning January 1, 2011, children over age 26 who are incapable of self-support due to a disability that began before age 26 are eligible for FEHB coverage.

Contact your agency or Retirement System for additional information.

33(a). My child became incapable of self-support due to a disability that began before age 26 and prior to January 1, 2011. Will my child be eligible to be covered under my Self and Family FEHB enrollment?

If your agency determines your child is incapable of self-support because of a mental or physical disability that occurred before age 26 (regardless of his current age), he or she is covered under your Self and Family enrollment beginning January 1, 2011. Your agency will determine if your child meets the criteria for being incapable of self-support.

33(b).Will my FEHB plan pay for services my child received before January 1, 2011?

No. The plan can only pay for services incurred while your child was covered as an eligible family member.

Two Married Federal Employees

34. I am a Federal employee who has a Self Only enrollment. My spouse is a Federal employee who also has a Self Only enrollment. My spouse is changing her enrollment to Self and Family to cover our child under age 26. Can I keep my Self Only enrollment?

No. You cannot keep your Self Only enrollment if your spouse has a Self and Family enrollment.

Children Who Have Other Insurance

35(a). My child who is under age 26 has non-FEHB health insurance through his employer or school. Will he be covered under my FEHB Self and Family enrollment?

Yes. Beginning January 1, 2011, even when your child under age 26 has health insurance through his employer or school, he is covered under your Self and Family enrollment.

35(b). Then which insurance plan will pay benefits for an illness or injury?

Generally, your child’s employer/school health insurance will pay claims first as the primary insurer. To the extent that the primary insurer does not fully cover the illness or injury, the FEHB plan may make additional payments, depending on the extent of coverage under the FEHB plan’s benefits structure. This is known as "coordination of benefits." Both plans must be contacted to let them know that he has other insurance coverage.

35(c). My child doesn’t need coverage under my FEHB Self and Family enrollment. Will he be covered anyway?

Yes, effective January 1, 2011 a child under age 26 is covered under an existing Self and Family FEHB enrollment.

Children Who Are Federal Employees

36. I’m a 25-year-old Federal employee and am enrolled in the FEHB Program. My father is a Federal employee with a Self and Family enrollment under FEHB. Will I be covered under his enrollment and what will happen to my enrollment?

With two exceptions explained below, if your father has a Self and Family enrollment, you will be covered under his enrollment. Because no person is entitled to receive benefits under more than one enrollment, you must cancel your enrollment using an SF 2809 during Open Season. Be sure your agency puts this reason for your cancellation in the ‘remarks’ section of the SF 2809. When you turn 26, this will be a Qualifying Life Event allowing you to re-enroll in the FEHB program.

The two exceptions that would allow you to keep your own enrollment are if:

you have your own family (spouse and/or children) that you choose to cover under your Self and Family enrollment; or

you live outside the coverage area of your parent’s plan.

If one of the above exceptions applies and you choose to keep your own enrollment, then because no person is entitled to receive benefits under more than one enrollment, you must notify your respective insurance carriers of the names of the persons to be covered under each enrollment. You may not file claims nor receive benefits under both enrollments.

37. I am under age 26 and I will start working for the Federal government in 2011. My parent has a Self and Family enrollment through FEHB. Can I enroll in my own FEHB plan?

It depends. You can only enroll in your own FEHB plan if:

you have your own family (spouse and/or children); or

you live outside the coverage area of your parent’s plan.

If you do not enroll in your own FEHB plan because you are covered under your parent’s plan, be sure your agency puts this reason in the ‘Remarks’ section of the SF 2809 when you elect not to enroll. Turning age 26 will be a Qualifying Life Event allowing you to enroll in the FEHB program under your own enrollment.

38. I start working for the Federal government in 2011. My parent has family coverage through her private employer. Can I enroll in my own FEHB plan?

Yes. You can enroll in your own FEHB plan.

Other Federal Benefits Programs

39(a). I have a flexible spending account under the Federal Flexible Spending Account Program (FSAFEDS). Will FSAFEDS cover the health care expenses of my child until age 26?

Yes. Beginning January 1, 2011, an employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a child through the end of the calendar year in which the child turns 26. Please note that this is a different date than the date FEHB eligibility terminates. (Beginning January 1, 2011, children of Federal enrollees will be covered by their parent’s FEHB Self and Family enrollment until their 26th birthday (plus a 31-day temporary extension of coverage)).

39(b). Who is an eligible child under FSAFEDS?

Beginning January 1, 2011 the definition of a child includes any natural child, stepchild, adopted child, eligible foster child, or child placed with you for legal adoption, even if you cannot claim that child as a dependent on your federal tax return. (PLEASE NOTE: This is not the same definition of child eligibility used under FEHB.) For more information about child eligibility under FSAFEDS, see https://www.fsafeds.com/fsafeds/SummaryOfBenefits.asp#AdultChild26.

40. I have dental and/or vision insurance through the Federal Employees Dental and Vision Insurance Program (FEDVIP). Is my child age 22 through 25 covered under my FEDVIP enrollment?

No. Health care reform does not affect eligibility for children under FEDVIP.

41. I have life insurance through the Federal Employees Group Life Insurance Program (FEGLI). I am enrolled in FEGLI Option C, providing coverage for my spouse and eligible dependent children. Is my child age 22 through 25 covered under FEGLI Option C?

No. Health care reform does not affect eligibility for children under FEGLI.

42. I have long-term care insurance through the Federal Long-Term Care Insurance Program (FLTCIP). Can my child age 22 through 25 apply for Long-Term Care Insurance?

Yes. Health care reform does not impact child eligibility under FLTCIP. All adult children (at least 18 years old, including adopted or stepchildren) of living employees or annuitants are eligible to apply.