Federal Employees Health Benefits Program: Removal of Ineligible Individuals From Existing Enrollments, 86902-86904 [2016-28788]

Agencies

• Office of Personnel Management

[Federal Register Volume 81, Number 231 (Thursday, December 1, 2016)]
[Proposed Rules]
[Pages 86902-86904]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-28788]



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Vol. 81

Thursday,

No. 231

December 1, 2016

Part IV





 Office of Personnel Management





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5 CFR Part 890





 Federal Employees Health Benefits Program: Removal of Ineligible 
Individuals From Existing Enrollments; Proposed Rule

Federal Register / Vol. 81 , No. 231 / Thursday, December 1, 2016 / 
Proposed Rules

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OFFICE OF PERSONNEL MANAGEMENT

5 CFR Part 890

RIN 3206-AN09


Federal Employees Health Benefits Program: Removal of Ineligible 
Individuals From Existing Enrollments

AGENCY: Office of Personnel Management.

ACTION: Proposed rule.

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SUMMARY: The United States Office of Personnel Management (OPM) is 
issuing a notice of proposed rulemaking to amend Federal Employees 
Health Benefits (FEHB) Program regulations to provide a process for 
removal from FEHB enrollments of certain identified individuals who are 
found not to be eligible as family members. This process would apply to 
individuals for whom there is a failure to provide adequate 
documentation of eligibility when requested.

DATES: Comments are due on or before January 30, 2017.

ADDRESSES: Send written comments to Padma Shah, Senior Policy Analyst, 
Planning and Policy Analysis, U.S. Office of Personnel Management, Room 
4312, 1900 E Street NW., Washington, DC; or FAX to (202) 606-0004 Attn: 
Padma Shah. You may also submit comments using the Federal eRulemaking 
Portal: https://www.regulations.gov. Follow the instructions for 
submitting comments.

FOR FURTHER INFORMATION CONTACT: Padma Shah at (202) 606-0004.

SUPPLEMENTARY INFORMATION: OPM is proposing to amend the Federal 
Employees Health Benefits (FEHB) Program regulations to (1) provide 
that proof of family member eligibility may be required for coverage 
under an FEHB Program self plus one or self and family enrollment and 
(2) to establish the circumstances under which individuals covered 
under an existing self plus one or self and family FEHB enrollment will 
be removed from such enrollment and the processes for removal, where 
the enrollee does not provide adequate documentation of eligibility. 
Currently, under Sec.  890.302 of title 5, all eligible family members 
are covered under a self and family enrollment. A family member's 
coverage terminates, subject to a temporary extension of coverage, on 
the day he or she ceases to be an eligible family member, as provided 
by Sec.  890.304. For example, if an enrollee's child reaches age 26, 
coverage terminates. Currently, the regulations do not address the 
removal of an erroneously-covered ineligible individual from an 
existing self plus one or self and family enrollment.
    The proposed regulation amends Sec.  890.302 to provide that proof 
of family member eligibility must be provided upon request by a 
carrier, employing office, or OPM. OPM plans to provide further 
guidance on requirements for proof of family member eligibility through 
sub-regulatory guidance, including Benefits Administration Letters and 
Carrier Letters.
    The proposed regulation also updates Sec.  890.308 of title 5 to 
provide processes for removal of individuals who are determined to be 
ineligible as family members. This change reflects OPM's enhanced 
effort to ensure that individuals covered under existing FEHB 
enrollments meet legal and regulatory eligibility requirements.
    The proposed process for removal of erroneously-covered ineligible 
family members from an existing enrollment is modeled on the process 
for removal of ineligible enrollees in Sec.  890.308(a). The proposed 
regulation allows the removal to be initiated by the FEHB insurance 
carrier that operates the enrollee's plan, OPM as administrator of the 
FEHB Program, or the enrollee's employing office. If an enrollee 
disagrees with an initial determination of ineligibility, the enrollee 
may request reconsideration and submit appropriate documentation of 
eligibility to either the employing office or OPM depending on the 
circumstances.
    In the case of a carrier-initiated removal, an enrollee's 
reconsideration request must be filed with the enrollee's employing 
office. The proposed rule provides that the employing office shall 
provide notice to the carrier that the enrollee is seeking 
reconsideration of the carrier's initial determination.
    The proposed regulation provides that if OPM, the employing office, 
or the carrier, as applicable, finds the documentation to establish 
eligibility, the individual will continue to be covered as a family 
member under the enrollment without a gap in coverage, as appropriate. 
The proposed regulation provides that appropriate documentation of an 
enrollment includes, but is not limited to, copies of birth 
certificates, marriage certificates and, if applicable, other proof 
such as that the individual lives with and is supported by the 
enrollee. OPM plans to provide more specific information on what 
constitutes adequate documentation in forthcoming sub-regulatory 
guidance. OPM solicits comments on what may constitute appropriate 
documentation of family member eligibility.
    If the enrollee does not submit appropriate documentation within 
the required timeframe, or the documentation is determined to be 
inadequate to establish eligibility, the removal of the family member 
will be prospective with limited exceptions. The proposed regulation 
provides that in the case of fraud or intentional misrepresentation of 
material fact on the part of the enrollee as prohibited by the terms of 
the FEHB plan, removals may be retroactive to the date of 
ineligibility.
    The regulation also provides that temporary extension of coverage 
and conversion and temporary continuation of coverage will be 
administered in accordance with Sec.  890.401 and Subparts H and K of 
this part and that any eligibility under these regulations will not 
extend beyond the date the entitlement would have ended if the 
individual had been removed on the date of loss of eligibility. 
Subparts H and K state that family members have 60 days from the date 
of the event causing the loss of coverage to enroll. Those timeframe 
are applicable to individuals who are removed from an enrollment under 
this regulation.
    The regulation also provides that if acceptable proof of 
eligibility of an individual removed under this regulation is 
subsequently provided and a family member is found to have been 
eligible, coverage will be reinstated retroactively so that there is no 
gap in coverage, as appropriate.
    Regulatory Impact Analysis: OPM has examined the impact of this 
proposed rule as required by Executive Order 12866 and Executive Order 
13563, which directs agencies to assess all costs and benefits of 
available regulatory alternatives and, if regulation is necessary, to 
select regulatory approaches that maximize net benefits (including 
potential economic, environmental, public, health, and safety effects, 
distributive impacts, and equity). A regulatory impact analysis must be 
prepared for major rules with economically significant effects of $100 
million or more in any 1 year. This rule is not considered a major rule 
because it provides a process for removal of erroneously enrolled 
ineligible and eligible family members from self and family 
enrollments, which we do not estimate to have widespread applicability 
under the FEHB Program.

Regulatory Flexibility Act

    I certify that this regulation will not have a significant economic 
impact on a substantial number of small entities because the regulation 
only affects health insurance benefits of Federal employees and 
annuitants.

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Regulatory Review

    This rule has been reviewed by the Office of Management and Budget 
in accordance with Executive Orders 13563 and 12866.

Federalism

    We have examined this rule in accordance with Executive Order 
13132, Federalism, and have determined that this rule will not have any 
negative impact on the rights, roles, and responsibilities of State, 
local, or Tribal governments.

Paperwork Reduction Act

    The Paperwork Reduction Act of 1995 (44 U.S.C. chapter 35; see 5 
CFR part 1320) requires that the U.S. Office of Management and Budget 
(OMB) approve all collections of information by a Federal agency from 
the public before they can be implemented. Respondents are not required 
to respond to any collection of information unless it displays a 
current valid OMB control number. OPM is not proposing any additional 
collections in this rule.

List of Subjects on 5 CFR Part 890

    Administrative practice and procedure, Government employees, Health 
insurance.

U.S. Office of Personnel Management.
Beth F. Cobert,
Acting Director.

    For the reasons set forth in the preamble, OPM proposes to amend 
part 890 of Title 5 of the Code of Federal Regulations as follows:

PART 890--FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

0
1. The authority citation for part 890 continues to read as follows:

    Authority: 5 U.S.C. 8913; Sec. 890.301 also issued under sec. 
311 of Public Law 111-03, 123 Stat. 64; Sec. 890.111 also issued 
under section 1622(b) of Public Law 104-106, 110 Stat. 521; Sec. 
890.112 also issued under section 1 of Public Law 110-279, 122 Stat. 
2604; 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 101, 104 Stat. 2064, as amended; Sec. 890.102 also issued under 
sections 11202(f), 11232(e), 11246(b) and (c) of Public Law 105-33, 
111 Stat. 251; and section 721 of Public Law 105-261, 112 Stat. 
2061; Public Law 111-148, as amended by Public Law 111-152.

0
2. In Sec.  890.302 revise paragraph (a)(1) to read as follows:


Sec.  890.302   Coverage of family members.

    (a)(1) An enrollment for self plus one includes the enrollee and 
one eligible family member. An enrollment for self and family includes 
all family members who are eligible to be covered by the enrollment. 
Proof of family member eligibility may be required, and must be 
provided upon request, to the carrier, the employing office or OPM. 
Except as provided in paragraph (a)(2) of this section, no employee, 
former employee, annuitant, child or former spouse may enroll or be 
covered as a family member if he or she is already covered under 
another person's self plus one or self and family enrollment in the 
FEHB Program.
* * * * *
0
3. Amend Sec.  890.308 by revising the section heading, adding headings 
to paragraphs (a), (b), (c), (d) and adding paragraphs (e), (f), and 
(g) to read as follows:


Sec.  890.308   Disenrollment and removal from enrollment.

    (a) Carrier Disenrollment: Enrollment Reconciliation. * * *
* * * * *
    (b) Carrier Disenrollment: Death of Enrollee. * * *
* * * * *
    (c) Carrier Disenrollment: Child Survivor Annuitant. * * *
* * * * *
    (d) Carrier Disenrollment: Separation from Federal Employment. * * 
*
* * * * *
    (e) Carrier Removal from Enrollment: Family Members (1) A carrier 
may request verification from the enrollee at any time of eligibility 
of an individual who is covered as a family member of the enrollee in 
accordance with Sec.  890.302. To verify eligibility, the carrier shall 
send the enrollee a request for appropriate documentation of the 
individual's relationship to the enrollee with a copy to the enrollee's 
employing office. The request shall contain a written notice that the 
individual will no longer be covered 60 calendar days after the date of 
the notice unless the enrollee or the employing office provides 
appropriate documentation as requested. If the carrier does not receive 
the requested documentation within the specified time frame or if based 
on the documentation provided the individual is found not to be 
eligible, written notice of removal must be sent to the enrollee, with 
a copy to the employing office, including an explanation of the process 
for seeking reconsideration. The time limit may be extended when the 
enrollee shows that he or she is prevented by circumstances beyond his 
or her control from providing timely documentation.
    (2) Appropriate documentation includes, but is not limited to, 
copies of birth certificates, marriage certificates, and, if 
applicable, other proof including that the individual lives with the 
enrollee and the enrollee is the individual's primary source of 
financial support.
    (3) The effective date of a removal shall be prospective unless the 
record shows that the enrollee or the individual has committed fraud or 
made an intentional misrepresentation of material fact as prohibited by 
the terms of the plan.
    (4) A request for reconsideration of the carrier's initial decision 
must be filed with the enrollee's employing office within 60 calendar 
days after the date of the initial decision. The employing office must 
notify the carrier when a request for reconsideration of the decision 
to remove the individual from the enrollment is made. The time limit 
for filing may be extended when the enrollee 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. 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, the family member's name, the name of carrier, reason(s) for 
the request, and, if applicable, retirement claim number.
    (5) The employing office must issue a written notice of its final 
decision to the enrollee, and notify the carrier of the decision, 
within 30 days of receipt of the request for reconsideration. The 
notice must fully set forth the findings and conclusions on which the 
decision was based.
    (6) If an enrollee or individual provides acceptable proof of 
eligibility of an individual subsequent to removal, coverage under the 
enrollment shall be reinstated retroactively so that there is no gap in 
coverage, as appropriate.
    (f) Employing Office and OPM. (1) An enrollee's employing office or 
OPM may request verification of eligibility from the enrollee of an 
individual who is covered as a family member of the enrollee in 
accordance with Sec.  890.302 at any time. To verify eligibility, the 
employing office or OPM shall send a request for appropriate 
documentation of the individual's status to the enrollee. The request 
shall contain a written notice that the individual will no longer be 
covered 60 calendar days after the date of the notice unless the 
enrollee provides appropriate documentation as requested. If the 
employing office or OPM does not receive the requested documentation 
within the specified

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time frame, or if based on the documentation provided the individual is 
found not to be eligible, the employing office or OPM shall direct the 
carrier to remove the individual from the enrollment and the employing 
office or OPM shall provide written notice to the enrollee including an 
explanation of the process for seeking reconsideration. The time limit 
may be extended when the enrollee shows that he or she is prevented by 
circumstances beyond his or her control from providing timely 
documentation.
    (2) Appropriate documentation includes, but is not limited to, 
copies of birth certificates, marriage certificates, and, if 
applicable, other proof including that the individual lives with the 
enrollee and that the enrollee is the individual's primary source of 
financial support.
    (3) The effective date of the removal shall be prospective unless 
the record shows that the enrollee or the individual has committed 
fraud or made an intentional misrepresentation of material fact as 
prohibited by the terms of the plan.
    (4) The enrollee may request reconsideration of an employing office 
or OPM's decision to remove the individual from the enrollment within 
60 days of the initial decision. The enrollee may request 
reconsideration of an employing office decision to the employing office 
or an OPM decision to OPM. The employing office or OPM must notify the 
carrier when a request for reconsideration of the decision to remove 
the individual from the enrollment is made. The time limit for filing 
may be extended when the enrollee 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. 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, the 
family member's name, the name of carrier, reason(s) for the request, 
and, if applicable, retirement claim number. The employing office or 
OPM must notify the carrier when a request for reconsideration of the 
decision to remove the individual from the enrollment is made.
    (5) The employing office or OPM must issue a written notice of its 
final decision to the enrollee, and notify the carrier of the decision, 
within 30 days of receipt of the request for reconsideration. The 
notice must fully set forth the findings and conclusions on which the 
decision was based.
    (6) If an enrollee or family member provides acceptable proof of 
eligibility of an individual subsequent to removal, coverage under the 
enrollment shall be reinstated retroactively so that there is no gap in 
coverage, as appropriate.
    (g) If an individual is removed from an enrollment pursuant to 
paragraph (e) or (f) of this section, the individual may be eligible 
for a 31-day temporary extension of coverage, conversion and/or 
temporary continuation of coverage in accordance with Sec.  890.401 and 
subparts H and K of this part. Any entitlement to coverage under Sec.  
890.401 and subparts H and K shall not extend beyond the date that 
entitlement would have ended if the individual had been removed on the 
date of loss of eligibility.

[FR Doc. 2016-28788 Filed 11-30-16; 8:45 am]
BILLING CODE 6325-63-P