HI 00801.071 FEHBA eligibility preclusion

A. General

The Federal Employees Health Benefits Act (FEHBA) of 1959 made health insurance coverage, including coverage for physician services, available to almost all persons who were in Federal employment after 6/30/60, and to their spouses and to persons receiving an annuity as the widow or widower of such a Federal employee. This 1959 FEHB Act should not be confused with the Retired Federal Employees Health Benefits Act (RFEHBA) enacted on 9/8/60. The RFEHB Act provided health insurance for those annuitants who could not then (in 1960) obtain FEHB coverage because their Federal employment ended before 7/60. Under a 1974 amendment to the FEHB Act (P.L. 93-246), annuitants who are enrolled for or eligible to enroll for coverage under the RFEHB Act may elect and be awarded FEHBA coverage effective no earlier than 7 /1/74.

Coverage under RFEHBA does not necessarily preclude HI entitlement. However, persons may in certain cases be precluded from deemed insured HI entitlement based on FEHBA eligibility or enrollment, as explained in B. below.

B. Application of the FEHBA preclusion

A claimant is precluded from becoming entitled to HI under the deemed insured provision if:

  1. He had FEHB coverage on 2/16/65; or

  2. He had FEHB coverage in the first month in which all the entitlement requirements of HI 00801.047, including the application requirement, were met; or

  3. He could have had FEHB coverage in such first month if he (or his spouse) had taken advantage of a right to enrollfor and maintain FEHB coverage as a Federal employee after 2/15/65.

However, if FEHB coverage was, or would have had to be, terminated because Federal employment ended, the FEHB preclusion does not prevent a claimant from qualifying for HI for months after the month in which the employment ended.

C. FEHB bginning later than HI

Where a person's FEHB coverage begins later than his HI, it does not terminate or preclude HI. Such a situation would rarely occur except where a retiree with RFEHB coverage, who has qualified for HI under the transitional “deemed insured” provision, converts his RFEHB to FEHB coverage. As explained in A. above, the annuitant's FEHB can begin no earlier than 7/74; if his HI began before the first month of FEHB coverage it will not be affected. Under B. above, FEHB coverage precludes HI entitlement only where it exists as of the first month in which all requirements of HI 00801.047 are met; FEHB coverage beginning after these requirements for HI are met does not preclude or terminate entitlement to HI under the deemed insured provision.

Example 1:

Mr. Greeb was entitled to HI under the deemed insured provision beginning 4/ 68, the month he attained age 65. His HI will not be affected when he converts his RFEHB to FEHB coverage.

Example 2:

Mr. Jones first files for HI under the deemed insured provision on 12/15/ 74 at age 73. (He could have filed and been entitled to HI at any time since 1966.) He retired before 7/60, has no QC's (and needs none for HI). Though previously enrolled under an RFEHB plan, he had applied for and was awarded FEHB coverage beginning 7/74. Since his HI application is effective 12 months prior to the month of filing, i.e., 12/73, he may be entitled to HI effective 12/73. The fact that he had FEHB in 8/74 does not preclude his entitlement to HI. However, if he first filed for HI in 8/75 or later and had FEHB coverage for the first month for which this HI application is effective (8/74), the FEHBA preclusion applies and his application must be disallowed.


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http://policy.ssa.gov/poms.nsf/lnx/0600801071
HI 00801.071 - FEHBA eligibility preclusion - 04/16/2015
Batch run: 04/16/2015
Rev:04/16/2015