TN 57 (02-23)

HI 00801.081 Establishing FEHBA Eligibility

A. Employee or spouse

If an individual files for deemed insured HI and indicates they are a Federal employee (or the spouse of a Federal employee) covered under FEHBA, the claim should be disallowed. If a Federal employee or the spouse of one states that they are not covered, they should be questioned regarding the nature of their employment. If it can be determined from the claimant that the claimant is not a “Federal employee” as defined in HI 00801.076 no further development is required. However, have the claimant sign a statement regarding the nature of their employment.

If there is a question as to FEHBA eligibility and the claimant (or the claimant's spouse) is currently employed by a Federal agency, contact the agency (through the parallel DO). Ask the agency whether the employee is or could be covered under the Federal Employees Health Benefits Act of 1959. Be sure to identify the employee properly. Providing all other requirements are met. HI entitlement may be established for the claimant if the agency's reply indicates that the claimant (or spouse) could not be enrolled under FEHBA. If the reply indicates the claimant (or spouse) is or could have been covered, the application for HI must be denied. Be sure the file contains an RC or other report of the information received from the Federal agency.

B. Annuitant or spouse

Ordinarily, we will accept an annuitant's statement regarding status under FEHBA. However, where the employment on which the annuity is based ended after 2/15/65, verify any statement that the annuitant could not be covered under the 1959 Act if:

  1. 1. 

    there was more than 12 years employment or the retirement was for disability; and

  2. 2. 

    the employment was not one of the types listed in HI 00801.076A. or B. which is excluded from FEHBA coverage; and

  3. 3. 

    there was an annuity immediately payable upon termination of the employment which was sufficient to cover the cost of the premium.

If the above conditions exist, have the individual contact the agency (in most cases this will be the U.S. Civil Service Commission, Washington, D.C. 20415, or the Bureau of Employees Compensation, Washington, D.C. 20211) from which one receives annuity. The individual should request a letter showing whether or not they could have been covered under FEHBA had they or spouse enrolled. Advise the individual to include the annuity number in any correspondence. A copy of the agency's letter should be included in file.

To Link to this section - Use this URL:
HI 00801.081 - Establishing FEHBA Eligibility - 02/01/2023
Batch run: 02/01/2023