[Federal Register Volume 63, Number 213 (Wednesday, November 4, 1998)]
[Rules and Regulations]
[Pages 59457-59460]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-29330]
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Rules and Regulations
Federal Register
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This section of the FEDERAL REGISTER contains regulatory documents
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Federal Register / Vol. 63, No. 213 / Wednesday, November 4, 1998 /
Rules and Regulations
[[Page 59457]]
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OFFICE OF PERSONNEL MANAGEMENT
5 CFR Part 890
RIN 3206-AH61
Federal Employees Health Benefits Program: Disenrollment
AGENCY: Office of Personnel Management.
ACTION: Final rule.
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SUMMARY: The Office of Personnel Management (OPM) is issuing final
regulations that are consistent with existing administrative procedures
requiring employing offices to provide information about enrollees in
the Federal Employees Health Benefits (FEHB) Program to the carriers of
the FEHB plans in which they are enrolled. Carriers are also required
to use the information provided by employing offices to reconcile their
enrollment records. These regulations will regularize the conditions
that would allow carriers to disenroll individuals when their employing
office of record does not show them as enrolled in the carrier's plan
and the carrier is otherwise unable to verify the enrollment. The
purpose of these regulations is to facilitate reconciliation of carrier
and employing office enrollment records, especially in cases where the
carrier has not previously received a notice showing an enrollment no
longer is valid.
EFFECTIVE DATE: December 4, 1998.
FOR FURTHER INFORMATION CONTACT: Jay D. Fritz (202) 606-0004.
SUPPLEMENTARY INFORMATION: On November 28, 1997, OPM issued proposed
regulations in the Federal Register (62 FR 63282) that would amend part
890 to allow carriers of FEHB plans to disenroll individuals when (1)
the payroll office of record with the carrier is unable to provide
information about the enrollment, (2) the carrier receives reliable
information that an individual with a self only enrollment has died,
(3) a child survivor annuitant becomes age 22, unless the carrier has
information indicating that the child is eligible for continued
coverage because the child is incapable of self support due to a
physical or mental disability, and (4) a former employee notifies the
carrier that he or she has separated from Federal employment under
circumstances that do not entitle him or her to an immediate annuity.
OPM received comments from six insurance carriers, one Government
agency, and one health plan trade association. Seven of the commenters
were in favor of the proposed regulations although each had specific
areas of concern. One commenter was opposed to the proposed
regulations. We will address the areas of concern below. We have tried
to list these issues in the same order as the regulations to which they
pertain.
One commenter suggested that we modify 5 CFR 890.107(a) to indicate
that lawsuits filed over disenrollments are to be filed against the
employing office. We believe that lawsuits involving disenrollments are
the equivalent of lawsuits to compel enrollments which are adequately
addressed at Sec. 890.107(a).
One commenter requested that carriers be allowed to cancel an
inactive contract in a situation where two identification numbers
belong to one individual, the carrier determines which coverage should
be active, and information about the incorrect enrollment is not
available from the employing office. We believe this is strictly an
enrollment issue that needs to be resolved between the employing office
and the carrier and is outside the scope of these regulations.
Several commenters expressed concerns over the responsibilities of
employing offices in responding to a carrier's request to provide
documentation necessary to resolve enrollment discrepancies. Two
commenters requested that employing offices be required to respond
within a certain time frame to a carrier's request to provide
documentation necessary to resolve an enrollment discrepancy. Two other
commenters suggested the regulations indicate that if the employing
office has not responded to a carrier's request for information within
a set amount of time, the carrier may proceed with issuing a
disenrollment notification. We are modifying the regulations to
indicate that if a carrier has not received requested information from
the employing office within 31 days of the request, they may proceed
with issuing the disenrollment notice.
One commenter suggested that we change Sec. 890.308(a)(1) to
indicate that an enrollee will be disenrolled 31 ``calendar'' days
after the date of the disenrollment notice since the term ``calendar''
is used elsewhere in the regulations. We are making this modification
in the interest of clarity.
Another commenter believes that 31 calendar days is not sufficient
time for an enrollee to respond to a carrier's disenrollment notice. We
feel that 31 days is enough time for an individual to either contact
the employing office or supply the carrier with appropriate
documentation to resolve an enrollment discrepancy. If for some reason
an individual does not provide documentation within the 31 calendar day
time frame and he or she is disenrolled, the disenrollment will be
voided and coverage reinstated retroactively upon presentation of the
documentation.
Several commenters suggested that OPM and the carriers create a
standard disenrollment notification letter and a standard letter
advising individuals of conversion rights and TCC eligibility when
applicable. OPM agrees and will work administratively with the carriers
on creating these standard letters.
Two commenters expressed concern that after an individual receives
a disenrollment notice, the individual is to deliver appropriate
documentation resolving the discrepancy to the carrier instead of the
employing office. The commenters feel that if the employing office does
not see the documentation, they will not correct their records and the
discrepancy will arise again in the next reconciliation. OPM believes
that appropriate documentation should be sent to the carrier instead of
the employing office since the carrier is taking the action to
disenroll the individual and can rescind that action. We also expect
that in many cases the individual will contact the employing office for
assistance upon receipt of the
[[Page 59458]]
disenrollment notice, resulting in correction of employing office
records. In addition, the standard disenrollment letter will advise
individuals to send appropriate documentation to both their carrier and
their employing office.
Two commenters inquired about the effective date of an individual's
disenrollment. One questioned the disenrollment date when the carrier
and the employing office are unable to reconcile the enrollment, and
the other questioned the disenrollment date when the carrier receives
reliable evidence that an enrollee with a self only enrollment has died
but the date of death is unknown. In the first case, the disenrollment
date will be 31 calendar days after the disenrollment notice is sent to
the enrollee as the carrier would not have any knowledge as to when the
employing office of record ceased forwarding premiums for that
individual. In the second case, we are modifying the regulations to
indicate that disenrollment would be effective the last day of the pay
period in which the carrier received notice of the death.
One commenter requested that OPM give carriers discretion to delay
disenrollments in appropriate cases. It is our intention for carriers
to use the disenrollment process with appropriate discretion in all
cases, but especially in cases where the carrier believes an individual
is eligible for coverage but needs time to forward documentation. We
are modifying the regulations to allow carriers this discretion.
One commenter asked if carriers should convey an individual's
disenrollment date to the employing office when the individual is
disenrolled 31 days after written notification is sent. We do not
believe carriers should be required to make this notification. Since
prior attempts at contact by the carrier have been ineffectual, it is
unlikely they would know the office of record to which to send the
notification.
One commenter suggested that we clarify the procedures for an
individual disputing a disenrollment notice from a carrier. We are
modifying the regulations so that after a carrier receives information
from an individual attempting to resolve an enrollment discrepancy, the
carrier will communicate its decision on the information to both the
employing office and the individual. Only at the point where the
information is determined to be inadequate to resolve the enrollment
discrepancy should the reconsideration process with the individual's
employing office begin.
One commenter suggested that employing offices be required to
notify the carrier of a request made by an individual for
reconsideration of a disenrollment decision. The commenter believes
that the carrier may have information that bears on the enrollment
issue. We are modifying the regulations to incorporate this
requirement.
One commenter suggested that we clarify the regulations to indicate
that if an employing office overturns a carrier's disenrollment
determination upon reconsideration, the enrollment will be reinstated
retroactively. OPM agrees and we are modifying the regulations for
clarity, as all reinstatements of enrollment under these regulations
will be made retroactively.
We are also revising the regulations to remove the requirement that
reconsideration decisions be issued to the carriers in writing. After a
reconsideration decision is made, agencies are still to issue a written
notice of its final decision to the individual, however, agencies
should contact the carrier by telephone with the reconsideration
decision. We have made this change since currently much enrollment
activity is handled between the agencies and carriers by telephone. In
the case of reconsideration decisions to reinstate FEHB enrollment, we
do not want individuals to remain disenrolled while a carrier waits for
a written notice to be forwarded from the agency. Through use of the
telephone, an individual that is eligible for FEHB coverage may be
quickly reinstated.
One commenter suggested the regulations require that employing
offices issue reconsideration decisions within a set time frame. We
believe reconsideration should be in accordance with the existing
processes developed within each individual employing office to process
reconsideration requests under 5 CFR 890.104(c).
Two commenters expressed concern over retroactive enrollments in
health maintenance organizations for individuals who received routine
services from non-network providers during the period covered by the
retroactive enrollment. When these situations arise, OPM requests that
carriers review each occurrence on a case-by-case basis. In situations
of true hardship, where services could not be deferred until the
enrollment problem was resolved, we would expect the carriers to
provide coverage for the non-network services in question.
Several commenters were concerned about our proposal allowing
carriers, upon receiving from a reliable source information of the
death of an enrollee with a self only enrollment, to disenroll the
individual. We are modifying the regulations to include certain
examples of what OPM considers reliable information that an enrollee
has died. We are also eliminating the requirement that carriers attempt
to notify the affected individual or a family member of the
disenrollment. Upon additional review, we have determined that an
attempt to notify the affected individual or a member of their family
is unnecessary. If, however, the enrollee is not deceased and attempts
to receive services, we expect the carrier to cover the services, void
the disenrollment and reinstate coverage retroactively.
One commenter noted that a child survivor annuitant must be a full-
time student in order to continue their health benefits enrollment
beyond age 18, while the regulations only address the disenrollment of
child survivor annuitants who reach age 22. While we are aware of the
possibility that some child survivor annuitants under age 22 would not
be eligible for FEHB coverage, we do not want carriers attempting to
disenroll them. Members of this segment of the population are
frequently dropped from, and reinstated to, the annuity rolls. Each
time they move on or off the annuity rolls, their eligibility for FEHB
enrollment changes. It would be difficult, if not impossible, for
carriers to determine when these individuals would lose entitlement to
an annuity and, consequently, their FEHB coverage. We will rely on the
retirement system to keep carriers apprised of the enrollment
eligibility of members of this group.
Two commenters suggested that we require the carriers to give
notice of conversion rights when a child survivor annuitant covered
under a self only enrollment loses entitlement to an annuity and is
disenrolled. OPM agrees that notice of conversion rights be given to
these individuals. However, the notice will be included in the written
notice of disenrollment and specific regulatory language is not needed.
Carriers must send the written notice of disenrollment to the
individual prior to the individual's 22nd birthday.
We are removing the specific regulatory requirement that an
enrollee who notifies the carrier that he or she has separated from
Federal employment be notified of their right to convert to a non-group
contract and possible eligibility to enroll under temporary
continuation of coverage. In its place, we are requiring that the
carrier provide the enrollee with a written notice of disenrollment
prescribed or approved by OPM. This notice will contain the information
on conversion and temporary continuation of coverage.
One commenter expressed concern that the regulations do not specify
any
[[Page 59459]]
grounds under which a child survivor annuitant might request
reconsideration of a carrier's decision to disenroll the individual.
The grounds that an individual would have for requesting
reconsideration would be that the person is over age 22, but is
incapable of self-support. In cases where the retirement system is
provided with evidence of the situation stated above, they would order
the carrier to reinstate coverage retroactively.
One commenter suggested that we change the regulations to allow
child survivor annuitants 60 calendar days from the date of the
carrier's disenrollment notice to file a request for reconsideration.
To provide consistency among the time frames for filing reconsideration
requests, we are modifying the regulations to allow 60 calendar days
instead of the current 30 calendar days.
One commenter asserted that by allowing carriers to disenroll
individuals, OPM is relinquishing its responsibilities in administering
the FEHB Program and increasing the workload burden on the employing
offices. OPM disagrees. The regulations will facilitate reconciliation
of carrier and employing office enrollment records. Under these
regulations, carriers may disenroll individuals only if the carrier has
not received a notice terminating the enrollment or the individual has
died, lost eligibility, or left Federal employment. We are modifying
the regulations to give the carriers more discretion so they are not
forced to disenroll an individual if they feel it would not be
appropriate. We expect that few individuals would either reach the end
of the disenrollment process without their enrollment status becoming
clear or be otherwise incorrectly disenrolled. As a result, there would
be few reconsideration requests filed with employing offices. However,
if an employing office should find that it is receiving a large number
of reconsideration requests, it may find that its training and
procedures on transmitting enrollment transactions and performing
enrollment reconciliations need to be reviewed and strengthened.
Regulatory Flexibility Act
I certify that these regulations will not have a significant
economic impact on a substantial number of small entities because they
primarily affect administrative procedures for Federal agencies and
health benefit carriers that participate in the FEHB Program.
Executive Order 12866, Regulatory Review
This rule has been reviewed by the Office of Management and Budget
in accordance with Executive Order 12866.
List of Subjects in 5 CFR Part 890
Administrative practice and procedure, Government employees, Health
facilities, Health insurance, Health professions, Hostages, Iraq,
Kuwait, Lebanon, Reporting and recordkeeping requirements, Retirement.
Office of Personnel Management.
Janice R. Lachance,
Director.
Accordingly, OPM is amending 5 CFR Part 890 as follows:
PART 890--FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
1. The authority citation for part 890 continues to read as
follows:
Authority: 5 U.S.C. 8913; Sec. 890.803 also issued under 50
U.S.C. 403p, 22 U.S.C. 4069c and 4069c-1; subpart L also issued
under sec. 599C of Pub. L. 101-513, 104 Stat. 2064, as amended;
Sec. 890.102 also issued under sections 11202(f), 11232(e), and
11246 (b) and (c) of Pub. L. 105-33, 111 Stat. 251.
2. In subpart A, Sec. 890.110 is added to read as follows:
Sec. 890.110 Enrollment reconciliation.
(a) Each employing office must report to each carrier or its
surrogate on a quarterly basis the names of the individuals who are
enrolled in the carrier's plan in a format and containing such
information as required by OPM.
(b) The carrier must compare the data provided with its own
enrollment records. When the carrier finds in its aggregate enrollment
records individuals whose names do not appear in the report from the
employing office of record, the carrier must request the employing
office to provide the documentation necessary to resolve the
discrepancy.
3. In subpart C, Sec. 890.308 is added to read as follows:
Sec. 890.308 Disenrollment.
(a)(1) Except as otherwise provided in this section, a carrier that
cannot reconcile its record of an individual's enrollment with agency
enrollment records or does not receive documentation necessary to
resolve the discrepancy from the employing office within 31 days of a
request must provide written notice to the individual that the
employing office of record does not show him or her as enrolled in the
carrier's plan and that he or she will be disenrolled 31 calendar days
after the date of the notice unless the enrollee provides appropriate
documentation to resolve the discrepancy. Appropriate documentation
includes, but is not limited to, a copy of the Standard Form 2809
(basic enrollment document) (or a letter confirming an electronic
transaction), the Standard Form 2810 transferring the enrollment into
the gaining employing office (or the equivalent electronic submission),
copies of earnings and leave statements or annuity statements showing
withholdings for the health benefits plan, or a document or other
credible information from the enrollee's employing office stating that
the individual is entitled to continued enrollment in the plan and that
the premiums are being paid. After receiving documentation from the
enrollee, the carrier must notify both the enrollee and the employing
office of record of their decision on the information.
(2) If the carrier does not receive documentation required under
paragraph (a)(1) of this section within the specified time frame, the
carrier should disenroll the individual, without further notice.
(3) The enrollee may request his or her employing office to
reconsider the carrier's decision to disenroll the individual. The
request for reconsideration must be made in writing and must include
the enrollee's name, address, Social Security Number or other personal
identification number, name of carrier, reason(s) for the request, and,
if applicable, retirement claim number. The employing office must
notify the carrier when a request for reconsideration of the decision
to disenroll the individual is made.
(4) A request for reconsideration of the carrier's decision must be
filed within 60 calendar days after the date of the carrier's
disenrollment notice. The time limit on filing may be extended when the
individual shows that he or she was not notified of the time limit and
was not otherwise aware of it, or that he or she was prevented by
circumstances beyond his or her control from making the request within
the time limit.
(5) After reconsideration, the employing office must issue a
written notice of its final decision to the individual and notify the
carrier of the decision. The notice must fully set forth the findings
and conclusions on which the decision was based. If upon
reconsideration the employing office determines the individual is
entitled to continued enrollment in the plan, the disenrollment under
paragraph (a)(2) of
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this section is void and coverage is reinstated retroactively.
(6) If, at any time after the disenrollment has occurred, the
employing office or OPM determines that another section of this part
applies to the individual's enrollment or the carrier discovers or
receives appropriate documentation showing that another section of this
part applies to the individual's enrollment, the disenrollment under
paragraph (a)(2) of this section is void and coverage is reinstated
retroactively.
(b) When a carrier receives, from any reliable source, information
of the death of an enrollee with a self only enrollment, the carrier
may take action to disenroll the individual on the date set forth in
Sec. 890.304(a)(1)(iv) or Sec. 890.304(b)(4), as appropriate. When the
date of death is unknown, the carrier may take action to disenroll the
individual on the date which is the last day of the pay period in which
information of the death is received. Reliable sources include, but are
not limited to, claims for hospital or physician costs incurred at time
of death and correspondence returned from the Postal Service noting
that the addressee is deceased. If, at any time after the disenrollment
has occurred, the employing office or OPM determines that another
section of this part applies to the individual's enrollment or the
carrier discovers or receives appropriate documentation showing that
another section of this part applies to the individual's enrollment,
the disenrollment under this paragraph (b) is void and coverage is
reinstated retroactively.
(c)(1) When a child survivor annuitant covered under a self only
enrollment reaches age 22, the carrier may take action to disenroll the
individual effective with the date set forth in Sec. 890.304(c)(1)
unless records with the carrier indicate that the child is incapable of
self support due to a physical or mental disability. The carrier must
provide the enrollee with a written notice of disenrollment prescribed
or approved by OPM prior to the date set forth in Sec. 890.304(c)(1).
(2) The child survivor annuitant may request the retirement system
to reconsider the carrier's decision to disenroll the individual. The
request for reconsideration must be made in writing and include the
enrollee's name, address, Social Security Number or other identifier,
name of carrier, reason(s) for the request, and the survivor annuity
claim number. The retirement system must notify the carrier when a
request for reconsideration of the carrier's decision to disenroll the
individual is made.
(3) A request for reconsideration of the carrier's decision must be
filed with the retirement system within 60 calendar days from the date
of the carrier's disenrollment notice. The time limit on filing may be
extended when the individual shows that he or she was not notified of
the time limit and was not otherwise aware of it, or that he or she was
prevented by circumstances beyond his or her control from making the
request within the time limit.
(4) After reconsideration, the retirement system must issue a
written notice of its final decision to the child survivor annuitant
and notify the carrier of the decision. The notice must fully set forth
the findings and conclusions on which the decision was based. If upon
reconsideration the retirement system determines that he or she is
entitled to continued enrollment in the plan, the disenrollment under
paragraph (c)(1) of this section is void and coverage is reinstated
retroactively.
(5) If, at any time after the disenrollment has occurred, the
employing office or OPM determines that another provision of this part
applies to the individual's enrollment or the carrier discovers or
receives appropriate documentation showing that another section of this
part applies to the individual's enrollment, the disenrollment under
paragraph (c)(1) of this section is void and coverage is reinstated
retroactively.
(d) When an enrollee notifies the carrier that he or she has
separated from Federal employment and is no longer eligible for
enrollment, the carrier must disenroll the individual on the last day
of the pay period in which the separation occurred, if known, otherwise
the carrier must disenroll the employee on the date the employee
provides as the date of separation. The carrier must provide the
enrollee with a written notice of disenrollment prescribed or approved
by OPM.
[FR Doc. 98-29330 Filed 11-3-98; 8:45 am]
BILLING CODE 6325-01-P
