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Title 5 Part 894

Title 5 → Chapter I → Subchapter B → Part 894

Electronic Code of Federal Regulations e-CFR

Title 5 Part 894

e-CFR data is current as of November 7, 2019

Title 5Chapter ISubchapter B → Part 894


Title 5: Administrative Personnel


PART 894—FEDERAL EMPLOYEES DENTAL AND VISION INSURANCE PROGRAM


Contents

Subpart H—Special Provisions for TRICARE-Eligible Individuals (TEI)

§894.801   Am I eligible for FEDVIP based on my eligibility to enroll in a TRICARE dental or health plan?
§894.802   Am I a TEI for a FEDVIP dental plan (TEI-D) if I am eligible to enroll or be covered under the TRICARE Retiree Dental Program?
§894.803   Am I a TEI for a FEDVIP vision plan (TEI-V) based on my concurrent enrollment in a TRICARE health plan?
§894.804   Am I a sponsor for a FEDVIP dental or vision plan?
§894.805   I am not a TEI-D or TEI-V, but I am a sponsor. Am I eligible to cover my TEI family members?
§894.806   Can a retiree or Retired Reserve member enroll and cover TEI family members in a FEDVIP dental plan?
§894.807   Can an active duty member enroll or be covered under a FEDVIP vision plan?
§894.808   I am a TEI family member. Can I enroll myself in FEDVIP?
§894.809   Who is a TEI certifying family member, and may I be the enrollee if I accept this responsibility?
§894.810   If I enroll for self plus one, may I decide which TEI family member to cover?
§894.811   I am a TEI family member of a sponsor who is a retiree or Retired Reserve member who is not on active duty. My sponsor is a TEI-D but is not enrolled in a FEDVIP dental plan. Can I enroll in a FEDVIP dental plan even though my sponsor is eligible to enroll but is not enrolled?
§894.812   I am a widow or widower TEI family member. Can I enroll my TEI child who is a TEI family member without enrolling myself in FEDVIP?
§894.813   I am a TEI former spouse. Am I eligible to enroll in a FEDVIP vision plan?
§894.814   Is a foster child included in the definition of TEI family member?
§894.815   I am a sponsor. Am I responsible to notify the Administrator and my TEI family members when my FEDVIP dental or vision eligibility and/or enrollment status changes?
§894.816   If I return from active duty and retire, what happens to my TEI family members' enrollment in their FEDVIP vision plan?
§894.817   If I am a retiree who is a TEI-V and I return to active duty, what happens to my TEI family members' enrollment in their FEDVIP vision plan?

Subpart I—Benefits in Underserved Areas

§894.901   Will benefits be available in underserved areas?

Authority: 5 U.S.C. 8962; 5 U.S.C. 8992; Subpart C also issued under section 1 of Pub. L. 110-279, 122 Stat. 2604; Pub. L. 114-328.

Source: 73 FR 50184, Aug. 26, 2008, unless otherwise noted.

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Subpart A—Administration and General Provisions

§894.101   Definitions.

This part is written as if the reader were an applicant or enrollee. Accordingly, the terms “you,” “your,” etc., refer, as appropriate, to the applicant or enrollee.

Acquiring an eligible child means one of the following:

(1) Birth of a child;

(2) Adoption of a child;

(3) Acquisition of a foster child as described in §890.101(a)(8) of this chapter;

(4) Acquisition of a stepchild who lives with the enrollee in a regular parent-child relationship;

(5) Establishment of a recognized natural child;

(6) Residence change of the enrollee's stepchild or recognized natural child who moves in with the enrollee; and

(7) An otherwise eligible child becoming unmarried due to divorce or annulment of marriage, or death.

Administrator means the entity with which the Office of Personnel Management contracts to manage the enrollment and premium payment process for the Federal Employees Dental and Vision Insurance Program (FEDVIP).

Annuitant means an individual defined at 5 U.S.C. 8901(3). Generally, the term means a former employee who is entitled to an immediate annuity or a disability annuity under a retirement system established for employees. The term also generally includes those receiving a survivor annuity due to the death of a Federal employee or annuitant (survivor annuitants) and those receiving compensation from the Office of Workers' Compensation Programs (compensationers). The term does not include former employees who retire with a deferred annuity under 5 U.S.C. 8413, or former spouses of annuitants.

Carrier means a company with which the Office of Personnel Management contracts to provide dental and/or vision benefits.

Child means:

(1) Except as discussed in paragraph (4) of this definition, a child is one of the following:

(i) A child born within marriage;

(ii) An adopted child;

(iii) A stepchild or foster child who lives with the enrollee in a regular parent-child relationship; or

(iv) A recognized natural child.

(2) This definition does not include a grandchild (unless the grandchild meets all the requirements of a foster child as stated in §890.101(a)(8) of this chapter).

(3) The child must be unmarried and under age 22. A child age 22 or over is eligible if the child is incapable of self-support because of a physical or mental disability that existed before the child reached age 22.

(4) With respect to a TEl, child means a TEI child.

Compensation has the same meaning as found under subchapter I of chapter 81 of title 5, United States Code, which is payable because of an on-the-job injury or disease.

Compensationer means an individual who is receiving compensation and who the Department of Labor determines is unable to return to duty.

Covered position means a position in which an employee is not excluded from FEDVIP eligibility by law or regulation.

Days means calendar days.

Dependent means an unmarried child who is living with or receiving regular and substantial support from the enrollee.

Employee means an individual defined in 5 U.S.C. 8901. For the purposes of this subpart, the term employee additionally means an employee of the United States Postal Service and an employee of the District of Columbia courts.

Enrollee means the individual in whose name the FEDVIP enrollment is carried. There is one FEDVIP enrollment for each enrollee in a dental plan, and/or in a vision plan and that enrollment may include family members who may be covered by the enrollment. The term enrollee includes individuals eligible to enroll based upon a status described at subpart C of this part, who enroll and are covered. With respect to the Federal workforce, enrollee generally means an employee or annuitant. With respect to a TEI, enrollee generally means the sponsor who is a TEI with respect to a FEDVIP plan; but if the sponsor is not a TEI, or for FEDVIP dental benefits if the sponsor defined at 894.804 is not enrolled and meets a condition at §894.309(a)(3)(iii), then enrollee means the TEI certifying family member. A TEI former spouse may be an enrollee only for a self-only FEDVIP vision plan. An enrollee may enroll and elect a FEDVIP dental and/or vision plan, option, and type of enrollment, except as provided at §894.309.

Enrollment reconsideration means the Administrator's review of its initial enrollment decision to determine if it followed the law and regulations correctly in making the initial decision concerning FEDVIP eligibility.

Family member means a spouse (including a spouse under a valid common law marriage) and/or unmarried dependent child(ren) under age 22 or beyond age 22, if incapable of self-support because of mental or physical disability which existed before reaching age 22, as defined at 5 U.S.C. 8901(5). With respect to a TEI, the term family member means a TEI family member.

OPM means the Office of Personnel Management.

OWCP means the Office of Workers' Compensation Programs, U.S. Department of Labor.

Premium conversion means the payment of FEDVIP premiums using pre-tax dollars. See §892.102 of this chapter for a discussion of how premium conversion works.

QLE means a qualifying life event.

Recognized natural child means a biological child born outside of marriage. A recognized natural child is an eligible family member if the child lives with the enrollee or receives financial support from the enrollee.

Regular parent-child relationship means that the enrollee is exercising parental authority, responsibility, and control over the child; is caring for, supporting the child; and is making the decisions about the child's education and medical care.

Sponsor generally means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on his or her direct affiliation with the uniformed services (including members of the National Guard and Reserves), in accordance with §894.804.

Stepchild means:

(1) Except as provided in paragraph (2) of this definition, the child of an enrollee's spouse or domestic partner and shall continue to refer to such child after the enrollee's divorce from the spouse, termination of the domestic partnership, or death of the spouse or domestic partner, so long as the child continues to live with the enrollee in a regular parent-child relationship.

(2) Your spouse's child born within or outside marriage or his or her adopted child. The child of your spouse shall continue to be considered your stepchild after your divorce from your spouse or the death of your spouse so long as the child continues to live with you in a regular parent-child relationship.

TEI means TRICARE-eligible individual for FEDVIP dental benefits (TEI-D) or a TRICARE-eligible individual for FEDVIP vision benefits (TEI-V).

TEI certifying family member means, where the sponsor is not an enrollee under §894.309, the TEI family member who may accept responsibility to self-certify as an enrollee in accordance with §894.809.

TEI child means an individual who is a TEI and who meets the definition of dependent in 10 U.S.C. 1072(2)(D) or (I) with respect to a sponsor.

TEI family member means a TEI who is a dependent with respect to a sponsor, as defined in 10 U.S.C. 1072(2)(A) (spouse), 10 U.S.C. 1072(2)(B) (unremarried widow), 10 U.S.C. 1072(2)(C) (unremarried widower), 10 U.S.C. 1072(2)(D) (child), or 10 U.S.C 1072(2)(I) (unmarried person).

TEI former spouse means a TEI who is an unremarried former spouse as defined in 10 U.S.C. 1072(2)(F), (G), or (H) and is entitled to medical care under 10 U.S.C. 1086(c) or (d).

TRICARE-eligible individual (TEI) means a TRICARE-eligible individual for FEDVIP dental benefits (TEI-D) or a TRICARE-eligible individual for FEDVIP vision benefits (TEI-V), as the case may be.

TRICARE-eligible individual for FEDVIP dental benefits (TEI-D) means an individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to enroll or be covered under the TRICARE Retiree Dental Program, 10 U.S.C. 1076c(b) in accordance with §894.802.

TRICARE-eligible individual for FEDVIP vision benefits (TEI-V) means an individual who is eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan in accordance with §894.803.

Type of enrollment means one of the following:

(1) Self only;

(2) Self plus one; or

(3) Self and family.

[73 FR 50184, Aug. 26, 2008, as amended at 78 FR 64879, Oct. 30, 2013; 81 FR 86906, Dec. 2, 2016; 83 FR 32193, July 12, 2018; 83 FR 58177, Nov. 19, 2018; 84 FR 1599, Feb. 5, 2019; 84 FR 26544, June 7, 2019]

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§894.102   If I have a pre-existing dental or vision condition, may I join FEDVIP?

Yes. Pre-existing conditions do not exclude you from coverage under FEDVIP. The Administrator may not deny an individual the right to enroll solely because of a preexisting dental or vision condition.

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§894.103   How do I enroll?

You may enroll through an Administrator contracted by OPM to facilitate the enrollment process. Your Federal agency, retirement system, or OWCP office will advise you of the enrollment process available to you.

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§894.104   Who makes enrollment decisions and reconsiderations?

The Administrator makes enrollment decisions and the Administrator reviews requests for reconsideration of an enrollment decision. The Administrator's initial enrollment decision denying enrollment or an opportunity to change coverage must be in writing and must inform you about your right to reconsideration.

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§894.105   Who may correct an error in my enrollment?

(a) The Administrator may correct administrative errors about the processing of your enrollment or changes in enrollment.

(b) OPM may order correction of an administrative error if it receives evidence that it would be against equity (fairness) and good conscience not to order the correction. This decision is made at the discretion of OPM and is not subject to review.

(c) If the correction gives you retroactive coverage, you must pay the premiums for all periods of the retroactive coverage. These premiums will not be on a pre-tax basis (they are not subject to premium conversion).

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§894.106   Special provisions for TRICARE-eligible individuals (TEI).

Generally, applicable provisions of this part are effective for TEIs. Provisions that are specific to Federal employees, annuitants and their family members do not apply to TEIs. See §894.101 for application of defined terms to TEIs and subpart H of this part for special provisions for TEIs, which governs in the event of ambiguity.

[83 FR 58178, Nov. 19, 2018]

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Subpart B—Coverage and Types of Enrollment

§894.201   What types of enrollments are available under FEDVIP?

FEDVIP has three types of enrollment:

(a) Self only, which covers only the enrolled employee or annuitant;

(b) Self plus one, which covers the enrolled employee or annuitant plus one eligible family member; and

(c) Self and family, which covers the enrolled employee or annuitant and all eligible family members.

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§894.202   If I enroll for self plus one, may I decide which family member to cover?

Yes, if you enroll for self plus one, you must state at the time you enroll which eligible family member you want to cover under your enrollment.

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§894.203   If I have a self plus one enrollment, when may I change which family member I want to cover or change to self only?

You may change your covered family member under a self plus one enrollment or change to self only coverage in the following situations:

(a) During the annual open season;

(b) If your covered family member dies during the year; or

(c) If your covered family member loses eligibility during the year.

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§894.204   May I be enrolled in more than one dental or vision plan at a time?

You may be enrolled or be covered in a FEDVIP dental plan and a separate FEDVIP vision plan at the same time. But no one may enroll or be covered as a family member in a FEDVIP dental or vision plan if he or she is covered under another person's FEDVIP dental or vision self plus one or self and family enrollment, except as provided under §890.302(a)(2) through (4) of this chapter, with respect to dual enrollments. If two parents of a TEI child are entitled to be a sponsor, they must choose one parent to be the child's sponsor. Dual enrollments of TEIs are permitted as provided under §890.302(a)(2) through (4) of this chapter as applied with respect to TEI family members.

[83 FR 58178, Nov. 19, 2018]

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Subpart C—Eligibility

§894.301   Am I eligible to enroll in the FEDVIP?

You are eligible if—

(a) You meet the definition of employee in 5 U.S.C. 8901(1), unless you are in an excluded position;

(b) You are an employee of the United States Postal Service or the District of Columbia courts; or

(c)(1) You were employed by the Architect of the Capitol as a Senate Restaurants employee the day before the food services operations of the Senate Restaurants were transferred to a private business concern; and

(2) You accepted employment by the business concern and elected to continue your Federal retirement benefits and your FEDVIP coverage. You continue to be eligible for FEDVIP coverage as long as you remain employed by the business concern or its successor.

[75 FR 20514, Apr. 20, 2010]

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§894.302   What is an excluded position?

Excluded positions are described in 5 U.S.C. 8901(1)(i), (ii), (iii), and (iv) and 5 CFR 890.102(c), except that employees of the United States Postal Service and District of Columbia courts are not excluded positions.

You are in an excluded position if you are:

(a) An employee of a corporation supervised by the Farm Credit Administration, if private interests elect or appoint a member of the board of directors.

(b) An employee who is not a citizen or national of the United States and your permanent duty station is outside the United States. Exception: You are eligible if you met the definition of employee on September 30, 1979, by service in an Executive agency, the United States Postal Service, or the Smithsonian Institution in the area that was then known as the Canal Zone.

(c) An employee of the Tennessee Valley Authority.

(d) An individual first employed by the Government of the District of Columbia on or after October 1, 1987, except employees of the District of Columbia Courts and those employees defined at §890.102 (c)(8) of this chapter.

(e) Serving under an appointment limited to 1 year or less. Exceptions: You are eligible if:

(1) You are an acting postmaster;

(2) You are a Presidential appointee appointed to fill an unexpired term;

(3) You are an employee with a provisional appointment, as defined in §316.401 and §316.403 of this chapter; or

(4) You have completed 1 year of current continuous employment, excluding any break in service of 5 days or less.

(f) Expected to work fewer than six months in each year. Exception: you are eligible if you receive an appointment of at least one year's duration as an Intern under §213.3402(a) of this chapter. To qualify, you must be expected to be in a pay status for at least one-third of the total period of time from the date of the first appointment to the completion of the work-study program.

(g) An intermittent employee (a non-full-time employee without a prearranged regular tour of duty).

(h) A beneficiary or patient employee in a Government hospital or home.

(i) Paid on a contract or fee basis. Exception: You are eligible if you are a United States citizen, and you are appointed by a contract between you and the Federal employing authority. To qualify, your contract must require your personal service, and you must be paid on the basis of units of time.

(j) Paid on a piecework basis. Exception: You are eligible if your work schedule provides for full-time or part-time service, and you have a regularly scheduled tour of duty.

(k) The following positions are not excluded positions:

(1) An employee appointed to perform “part-time career employment,” as defined in section 3401 (2) of title 5, U.S.C., and 5 CFR part 430, subpart B; or

(2) An employee serving under an interim appointment established under §772.102 of this chapter.

[73 FR 50184, Aug. 26, 2008, as amended at 75 FR 20514, Apr. 20, 2010; 79 FR 532, Jan. 6, 2014; 81 FR 58382, Aug. 25, 2016]

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§894.303   What happens to my enrollment if I transfer to an excluded position?

(a) If you have FEDVIP coverage and you transfer to a position excluded under §894.302(a) through (d), your enrollment stops.

(b) If you have FEDVIP coverage and you transfer to a position excluded under §894.302(e) through (j) with no break in service of more than 3 days, your enrollment is not affected. If you have a break in service of more than 3 days, your enrollment stops.

(c) If you did not elect to enroll in FEDVIP and then transfer to an excluded position, you lose all rights to enroll at that time.

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§894.304   Am I eligible to enroll if I'm retired or receiving workers' compensation?

If you are retired, receiving workers' compensation, or are a survivor annuitant, you are eligible if you meet the definition of annuitant in 5 U.S.C. 8901(3).

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§894.305   Am I eligible to enroll if I am a former spouse receiving an apportionment of annuity?

No. Former spouses receiving an apportionment of annuity are not eligible to enroll in FEDVIP. However, a TEI former spouse is eligible to enroll in a FEDVIP vision plan as long as he or she remains unremarried.

[83 FR 58178, Nov. 19, 2018]

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§894.306   Are foster children eligible as family members?

Generally, foster children are eligible for coverage as family members under FEDVIP. However, a foster child is excluded from the definition of a TEI family member, except a foster child who is a ward in the legal custody of a sponsor. A pre-adoptive child and an eligible ward in the legal custody of a sponsor are eligible as TEI family members.

[84 FR 26544, June 7, 2019]

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§894.307   Are disabled children age 22 or over eligible as family members?

(a) Except as provided at paragraph (b) of this section, a child age 22 or over is an eligible family member if the child is incapable of self-support because of a physical or mental disability that existed before the child reached age 22.

(b) A TEI child is a TEI family member as long as the TEI child is under the age of 21 or 23 as provided at 10 U.S.C. 1072(2)(D) or (I), and, if disabled during the age of eligibility, the TEI child remains a TEI family member regardless of age as long as the TEI child meets the standard for incapacity and support at 10 U.S.C. 1072(2)(D)(iii) or incapacity and dependency at 10 U.S.C. 1072(2)(I)(ii)(III), (iii), (iv) and (v).

[83 FR 58178, Nov. 19, 2018]

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§894.308   How do I establish the dependency of my recognized natural child?

(a) Dependency is established for a recognized natural child who lives with the enrollee in a regular parent-child relationship, a recognized natural child for whom a judicial determination of support has been obtained, or a recognized natural child to whose support the enrollee makes regular and substantial contributions.

(b) The following are examples of proof of regular and substantial support. More than one of the following proofs may be required to show support of a recognized natural child who does not live with the enrollee in a regular parent-child relationship and for whom a judicial determination of support has not been obtained:

(1) Evidence of eligibility as a dependent child for benefits under other State or Federal programs;

(2) Proof of inclusion of the child as a dependent on the enrollee's income tax returns;

(3) Canceled checks, money orders, or receipts for periodic payments from the enrollee for or on behalf of the child.

(4) Evidence of goods or services which show regular and substantial contributions of considerable value;

(5) Any other evidence which OPM shall find to be sufficient proof of support or of paternity or maternity.

[78 FR 64879, Oct. 30, 2013]

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§894.309   I am a TEI-D or TEI-V. Am I eligible to enroll in FEDVIP, and cover my TEI family members?

(a) FEDVIP dental plan. (1) A sponsor who is a TEI-D is eligible to enroll and cover TEI-D family members under the enrollment.

(2) A sponsor who is a TEI-D but who does not enroll even though eligible, is not an enrollee and cannot enroll or cover TEI family members.

(3) A TEI certifying family member who is a TEI-D is eligible to enroll and to cover TEI-D family members under the enrollment when:

(i) The sponsor is not a TEI-D;

(ii) The sponsor is deceased; or

(iii) The sponsor is a TEI-D described at §894.804(b)(1) or (2) who does not enroll (therefore is not an enrollee and cannot cover TEI family members) and the sponsor:

(A) Receives dental services from the Department of Veterans Affairs (VA);

(B) Has employer-sponsored dental coverage without a family coverage option; or

(C) Has a medical or dental condition that prevents him or her from obtaining dental benefits.

(b) FEDVIP vision plan. (1) A sponsor who is a TEI-V is eligible to enroll and cover TEI-V family members.

(2) A TEI certifying family member who is a TEI-V is eligible to enroll and cover TEI-V family members under the enrollment when:

(i) The sponsor is not a TEI-V; or

(ii) The sponsor is deceased.

(3) A TEI former spouse is eligible to enroll for self only, but may not elect a self plus one or self and family type of enrollment and may not cover family members, even if they are TEI family members.

[83 FR 58178, Nov. 19, 2018]

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Subpart D—Cost of Coverage

§894.401   How do I pay premiums?

(a) Employees pay premiums through payroll allotments.

(b) Annuitants and survivor annuitants pay premiums through annuity allotments.

(c) Compensationers pay premiums through allotments from compensation payments.

(d) In limited circumstances, individuals may make direct premium payments. See §894.405.

(e) A sponsor, TEI certifying family member, TEI former spouse, or TEI who is an unremarried survivor pays premiums the following ways:

(1) A sponsor or TEI certifying family member who receives uniformed services pay or uniformed services retirement pay shall pay premiums through deduction from payroll (including uniformed services retirement pay deduction).

(2) A sponsor or TEI certifying family member who is not described in paragraph (e)(1) of this section, and a TEI former spouse or TEI who is an unremarried survivor shall pay premiums through:

(i) Automatic bank withdrawal; or

(ii) Direct premium payments.

[73 FR 50184, Aug. 26, 2008, as amended at 83 FR 58179, Nov. 19, 2018]

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§894.402   Do the premiums I pay reflect the cost of providing benefits?

The premiums you pay shall reasonably and equitably reflect the cost of the benefits provided.

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§894.403   Are FEDVIP premiums paid on a pre-tax basis?

(a) Your FEDVIP premiums are paid on a pre-tax basis (called premium conversion) if you are an active employee, your salary is sufficient to make the premium allotments, and your agency will be able to make pre-tax allotments.

(b) Your FEDVIP premiums are not paid on a pre-tax basis if:

(1) You are an employee in nonpay status or an employee whose salary is not high enough to make premium allotments, or your agency is unable to make pre-tax allotments;

(2) You are an annuitant, a survivor annuitant, or a compensationer;

(3) Your enrollment change was made effective retroactively which resulted in additional premium withholdings, unless it is as a result of birth or adoption of a child.

(4) You have been approved to pay premiums directly to the Administrator.

(5) You are a TEI.

[73 FR 50184, Aug. 26, 2008, as amended at 78 FR 64879, Oct. 30, 2013; 83 FR 32193, July 12, 2018; 83 FR 58179, Nov. 19, 2018]

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§894.404   May I opt out of premium conversion?

No, all enrolled employees whose salary is sufficient to make premium allotments and whose agency is able to make pre-tax allotments must participate in premium conversion.

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§894.405   What happens if I go into nonpay status or if my pay/annuity is insufficient to cover the allotments?

(a) If your pay, annuity, or compensation is too low to cover the premium allotments, or if you go into a nonpay status, contact the Administrator to arrange to pay your premiums directly to the Administrator.

(b) If you do not make the premium payments, your FEDVIP coverage will stop. You will not be able to reenroll until the next open season after:

(1) You are in pay status; or

(2) Your pay is sufficient to make the premium allotments.

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§894.406   What happens if my uniformed services pay or uniformed services retirement pay is insufficient to cover my FEDVIP premiums, or I go into a nonpay status?

(a) You must contact the Administrator to arrange to pay your premiums by direct premium payment or automatic bank withdrawal to the Administrator.

(b) If you do not make the premium payments, your FEDVIP coverage will stop. You will not be able to reenroll until the next open season after:

(1) You are in pay status; or

(2) Your uniformed services pay or uniformed services retirement pay (retired, retainer, or equivalent) is sufficient to make the premium payment.

[83 FR 58179, Nov. 19, 2018]

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Subpart E—Enrollment and Changing Enrollment

§894.501   When may I enroll?

You may enroll:

(a) During the annual open season;

(b) Within 60 days after you first become eligible as:

(1) A new employee;

(2) A previously ineligible employee who transfers to a covered position;

(3) A new survivor annuitant, if not already covered under FEDVIP;

(4) A sponsor who is a TEI;

(5) A TEI certifying family member, but only if, on your first date of eligibility to enroll, your sponsor is not a TEI or is deceased, or for FEDVIP dental coverage, if your sponsor is defined at §890.309(a)(3)(iii); or

(6) A TEI former spouse.

(c) Within 60 days of when you return to service following a break in service of at least 30 days;

(d) From 31 days before you or an eligible family member loses other dental/vision coverage to 60 days after a QLE that allows you to enroll;

(e) From 31 days before you get married to 60 days after;

(f) Within 60 days after returning to Federal employment after being on leave without pay if you did not have Federal dental or vision coverage prior to going on leave without pay, or your coverage was terminated or canceled during your period of leave without pay;

(g) For a TEI, within 60 days of your uniformed services pay or uniformed services retirement pay being restored after having being reduced, forfeited, or terminated.

[73 FR 50184, Aug. 26, 2008, as amended at 75 FR 20514, Apr. 20, 2010; 79 FR 41405, July 16, 2014; 83 FR 58179, Nov. 19, 2018]

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§894.502   What are the Qualifying Life Events (QLEs) that allow me to enroll or become covered in FEDVIP outside of open season?

You may enroll or become covered outside of open season if you are otherwise eligible to enroll and:

(a) You or a family member or TEI family member lose other dental/vision coverage;

(b) Your annuity or compensation is restored after having been terminated;

(c) You return to pay status after being on leave without pay due to deployment to active military duty;

(d) You get married;

(e) You return to Federal employment after being on leave without pay if you did not have Federal dental or vision coverage prior to going on leave without pay, or your coverage was terminated or canceled during your period of leave without pay;

(f) You are a TEI and your uniformed services pay or uniformed services retirement pay is restored after having been reduced, forfeited, or terminated; or

(g) You are not a TEI and you marry a TEI and can be covered as a TEI family member; or, you are not a TEI and you marry a non-TEI sponsor that is on active duty and can be covered as a TEI certifying family member. However, upon remarriage, a TEI former spouse or TEI surviving spouse or widow loses status as a TEI with respect to a former or deceased sponsor.

[73 FR 50184, Aug. 26, 2008, as amended at 79 FR 41405, July 16, 2014; 83 FR 58179, Nov. 19, 2018]

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§894.503   Are belated enrollments or changes allowed?

(a) The time limit for enrolling or changing your enrollment may be extended up to 3 months after the date you became newly eligible or had a QLE or after the end of an open season. To qualify, you must demonstrate to the Administrator that you were not able to enroll or change your enrollment on time for reasons beyond your control.

(b) If the Administrator allows you to make a belated enrollment or enrollment change, you must enroll or change within 30 days after the Administrator notifies you of its determination.

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§894.504   When is my enrollment effective?

(a) Open season enrollments are effective on the date set by OPM.

(b) If you enroll when you first become eligible your enrollment is effective the 1st day of the pay period following the one in which the Administrator receives your enrollment, but no earlier than December 31, 2006.

(c) If you are a TEI and enroll or are enrolled during the open season, your enrollment is effective no earlier than January 1, 2019.

(d) A QLE enrollment or change is effective the 1st day of the pay period following the date of your QLE.

(e)(l) A belated open season enrollment or change is effective retroactive to the date it would have been effective if you had made a timely enrollment or request for a change.

(2) Any belated enrollment or change outside of open season that goes beyond the allowable 60 day enrollment timeframe is effective retroactive to the 1st day of the pay period following the one in which you became newly eligible or the date of your QLE.

(3) You are responsible for any retroactive premiums due to a belated enrollment or request for a change.

[73 FR 50184, Aug. 26, 2008, as amended at 83 FR 58179, Nov. 19, 2018]

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§894.505   Are retroactive premiums paid with pre-tax dollars (premium conversion)?

Retroactive premiums are not paid under premium conversion, except when you are changing your enrollment retroactively as a result of birth or adoption of a child. Any additional withholdings for retroactive premiums that are due must be made with after-tax dollars. The Administrator will bill you directly for any retroactive premiums that must be paid with after-tax dollars.

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§894.506   How often will there be open seasons?

There will be an annual open season for FEDVIP at the same time as the annual Federal Benefits Open Season.

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§894.507   After I'm enrolled, may I change from one dental or vision plan or plan option to another?

(a) You may change from one dental plan to another, and/or from one vision plan to another, or you may change from one plan option to another option in that same plan:

(1) During the annual open season;

(2) When you get married (except for TEIs who are unremarried survivors, TEI former spouses, and TEI children); or

(3) For employees, when you return to Federal employment after being on leave without pay if you did not have Federal dental or vision coverage prior to going on leave without pay, or your coverage was terminated or canceled during your period of leave without pay.

(b)(1) If you are enrolled in a dental or vision plan with a geographically restricted service area, and you or a covered eligible family member or TEI family member move out of the service area, you may change to a different dental or vision plan that serves that area.

(2) You may make this change at any time before or after the move, once you or a covered eligible family member or TEI family member has a new address.

(3) The enrollment change is effective the first day of the pay period following the pay period in which you make the change.

(4) You may not change your type of enrollment unless you also have a QLE that allows you to change your type of enrollment.

[83 FR 58179, Nov. 19, 2018]

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§894.508   When may I increase my type of enrollment?

(a) You may increase your type of enrollment:

(1) during the annual open season; or

(2) If you have a QLE that is consistent with increasing your type of enrollment.

(b) Increasing your type of enrollment means going from:

(1) Self only to self plus one;

(2) Self only to self and family; or

(3) Self plus one to self and family.

(c) You may increase your type of enrollment during the time period beginning 31 days before the QLE and ending 60 days after the QLE.

(d) Your new type of enrollment is effective the 1st day of the pay period following the pay period in which you make the change.

(e) You may not change from one dental or vision plan to another, except as stated in §894.507.

[73 FR 50184, Aug. 26, 2008, as amended at 79 FR 41406, July 16, 2014]

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§894.509   What are the QLEs that are consistent with increasing my type of enrollment?

(a) Marriage; except for a TEI who is an unremarried survivor, widow or widower; TEI former spouse; and TEI child(ren);

(b) Acquiring an eligible child or TEI child; or

(c) Loss of other dental or vision coverage by an eligible family member or TEI family member.

[83 FR 58179, Nov. 19, 2018]

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§894.510   When may I decrease my type of enrollment?

(a) You may decrease your type of enrollment

(1) During the annual open season; or

(2) If you have a QLE that is consistent with decreasing your type of enrollment,

(b) Decreasing your type of enrollment means going from:

(1) Self and family to self plus one;

(2) Self and family to self only; or

(3) Self plus one to self only.

(c)(1) Except as provided in paragraph (c)(2) of this section, you may decrease your type of enrollment only during the period beginning 31 days before your QLE and ending 60 days after your QLE.

(2) You may make any of the following enrollment changes at any time beginning 31 days before a QLE listed in §894.511(a):

(i) A decrease in your self plus one enrollment;

(ii) A decrease in your self and family enrollment to a self plus one enrollment, when you have only one remaining eligible family member or TEI family member; or

(iii) A decrease in your self and family enrollment to a self only enrollment, when you have no remaining eligible family members or TEI family members.

(d)(1) Except as provided in paragraph (d)(2) of this section, your change in enrollment is effective the first day of the first pay period following the one in which you make the change.

(2) If you are making an enrollment change described in paragraph (c)(2) of this section, your change in enrollment is effective on the first day of the first pay period following the QLE on which the enrollment change is based.

(e) You may not change from one dental or vision plan or option to another, except as stated in §894.507(b).

[73 FR 50184, Aug. 26, 2008, as amended at 75 FR 20514, Apr. 20, 2010; 83 FR 58180, Nov. 19, 2018]

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§894.511   What are the QLEs that are consistent with decreasing my type of enrollment?

(a) Loss of an eligible family member or TEI family member due to:

(1) Divorce;

(2) Death; or

(3) Loss of eligibility of a previously enrolled child or TEI child.

(b) You are an employee, annuitant or compensationer and your spouse deploys to active military service.

[83 FR 58180, Nov. 19, 2018]

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§894.512   What happens if I leave Federal Government and then return?

(a) Your FEDVIP coverage terminates at the end of the pay period in which you separate from government service. Exception: If you separate for retirement or while in receipt of workers' compensation as defined in §894.701, your FEDVIP coverage continues.

(b)(1) If you return to Federal service after a break in service of fewer than 30 days, and you were not previously enrolled in FEDVIP, you may not enroll until the next open season or unless you have a QLE that allows you to enroll.

(2) If you return to Federal service after a break in service of fewer than 30 days, and you were previously enrolled in FEDVIP, you may reenroll in the same plan(s) and plan option and with the same type of enrollment you had before you separated. Exceptions:

(i) If you were enrolled in a dental or vision plan with a restricted geographic service area, and you have since moved out of the plan's service area, you may change to a different dental or vision plan that serves that area.

(ii) If you have since gained or lost an eligible family member, you may change your type of enrollment consistent with the change in the number of eligible family members.

(3) If you return to Federal service as a new hire after a break in service of 30 days or more, you may enroll if you were not previously enrolled, change your dental or vision plan, and/or change your type of enrollment.

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§894.513   Do I have to elect FEDVIP coverage each year in order to remain covered?

No. If you do not change or cancel your enrollment, and if your enrollment does not terminate pursuant to this part, then your current enrollment will continue into the next year. Before open season, you should review the plan brochure for any changes in benefits and premiums for the next year.

[83 FR 58180, Nov. 19, 2018]

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Subpart F—Termination or Cancellation of Coverage

§894.601   When does my FEDVIP coverage stop?

(a) If you no longer meet the definition of an eligible employee or annuitant, or TEI, your FEDVIP coverage stops at the end of the pay period in which you were last eligible.

(b) If you go into a period of nonpay or insufficient pay (or insufficient uniformed services pay or uniformed services retirement pay) and you do not make direct premium payments, your FEDVIP coverage stops at the end of the pay period for which your agency, retirement system, OWCP, uniformed services or uniformed services retirement system last deducted your premium payment.

(c) If you are making direct premium payments or payments by automatic bank withdrawal, and you stop making the payments, your FEDVIP coverage stops at the end of the pay period for which you last made a payment.

(d) If you cancel your enrollment during an open season, your FEDVIP coverage stops at midnight of the day before the effective date of an open season change as set by OPM.

(e) If you are enrolled with a combination dental and vision carrier with a restricted service area, and you move outside the carrier's service area to a service area that does not offer a combination carrier and you change to a dental only or vision only carrier, your existing combination plan coverage will stop at midnight of the day before the effective date of your new plan coverage.

(f) If your FEDVIP carrier discontinues participation in the program at the end of the contract year, then you must change to another carrier during the open season, unless OPM establishes a different time. If the discontinuance is at a time other than the end of the contract year, OPM will establish a time and effective date for you to change your carrier. If you do not change your carrier within the time set by OPM, your coverage will stop at midnight of the day before the effective date set by OPM for coverage with another carrier.

(g) If your status as a uniformed services retiree discontinues and you become a uniformed services member on active duty, your FEDVIP dental and/or vision plan enrollment terminates and your coverage stops at the end of the last pay period for which the premium payment was made from your uniformed services retirement pay. You will still be the sponsor but no longer the enrollee, and your TEI certifying family member would have to reenroll in vision and cover all TEI family members. As sponsor, you must notify your family members of changes in your eligibility and enrollment status changes. See §894.815.

(h) If your status as a uniformed services member on active duty discontinues and you become a uniformed services retiree, the FEDVIP vision plan enrollment of your TEI family members terminates and coverage for your TEI family members will stop at the end of the pay period for which the last premium payment was made. As the sponsor who is an enrollee, you would have to enroll yourself and reenroll all TEI family members. As sponsor, you must notify your family members of changes in your eligibility and enrollment status changes. See §894.815.

[73 FR 50184, Aug. 26, 2008, as amended at 83 FR 58180, Nov. 19, 2018]

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§894.602   May I cancel my enrollment at any time?

No. You may only cancel your enrollment during an open season. Exceptions: You may cancel your dental and/or vision enrollment if you transfer to an eligible position with a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premiums. You may also cancel upon your deployment or your spouse's deployment to active military duty. These cancellations will become effective at the end of the pay period that you submit your request.

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§894.603   Is there a temporary extension of coverage and conversion right when my coverage stops or when a covered family member loses eligibility?

No. There is no temporary extension of coverage, or Temporary Continuation of Coverage (TCC), or right to convert to an individual dental or vision policy when your FEDVIP coverage stops or when a family member or TEI family member loses eligibility under FEDVIP.

[83 FR 58180, Nov. 19, 2018]

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Subpart G—Annuitants and Compensationers

§894.701   May I keep my dental and/or vision coverage when I retire or start receiving workers' compensation?

(a) Your FEDVIP coverage continues if you retire on an immediate annuity or on a disability annuity, or start receiving compensation from OWCP.

(b) If you retire on a Minimum Retirement Age +10 annuity that you elect to postpone in accordance with 5 U.S.C. 8412(g), your FEDVIP coverage will stop when you separate from service. However, you may enroll again within 60 days of when your annuity starts.

(c) If you retire on a deferred annuity in accordance with 5 U.S.C. 8413, your FEDVIP coverage stops and you are not eligible to enroll.

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§894.702   May I participate in open season and make changes to my enrollment as an annuitant or compensationer?

Yes. Annuitants and compensationers may participate in open season and make enrollment changes under the same circumstances as active employees.

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§894.703   How long does my coverage as an annuitant or compensationer last?

Your coverage as an annuitant or compensationer continues as long as you continue receiving an annuity or compensation and pay your premiums, unless you cancel your coverage during an open season or terminate coverage due to insufficient annuity or compensation.

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§894.704   What happens if I retire and then come back to work for the Federal Government?

(a) If you have FEDVIP coverage as an annuitant, and you become reemployed in an eligible position in Federal service, you must contact the Administrator so it can send the request for allotments to your agency so your agency can start making the allotments from your pay.

(b) If you did not enroll in FEDVIP coverage as an annuitant and become reemployed in an eligible Federal position, you have 60 days to enroll in FEDVIP.

(c) If you enroll as an employee the Administrator will stop sending requests for allotments from your annuity.

(d) If your reemployment terminates, you must notify the Administrator within 30 days to have your allotments withheld from your annuity payments. Otherwise, your FEDVIP coverage will terminate due to non-payment of premiums.

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Subpart H—Special Provisions for TRICARE-Eligible Individuals (TEI)

Source: 83 FR 58180, Nov. 19, 2018, unless otherwise noted.

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§894.801   Am I eligible for FEDVIP based on my eligibility to enroll in a TRICARE dental or health plan?

(a) The U.S. Department of Defense (DOD) is responsible for regulating eligibility for obtaining medical and dental care under the TRICARE Program, pursuant to 10 U.S.C. chapter 55. The FEDVIP laws at 5 U.S.C. chapter 89A was amended by the National Defense Authorization Act for Fiscal Year 2017, Public Law 114-328, to allow individuals who were eligible for coverage under the TRICARE Retiree Dental Program (TRDP) in accordance with DOD rules to obtain dental coverage in a FEDVIP dental plan. Public Law 114-328 also added a provision allowing certain individuals who are concurrently enrolled for medical care in specified TRICARE health plans to obtain FEDVIP vision coverage.

(b) Categories of individuals who were eligible for TRDP and who are eligible to be covered under a FEDVIP dental plan are set forth in §894.802. Categories of individuals who may be covered under specified TRICARE health plans and, if so covered, are eligible to be covered under a FEDVIP vision plan, are set forth in §894.803. Individuals eligible for FEDVIP coverage are referred to as TRICARE eligible individuals (TEI).

(c)(1) FEDVIP rules provide an enrollee with the right to select:

(i) A dental and/or a vision plan; and

(ii) Type of enrollment that may cover the eligible individual in a self only enrollment or the eligible individual with one or more family members in a self plus one or self and family enrollment.

(2) For TRICARE eligible individuals (TEI), this means that:

(i) If the sponsor is both a TEI and enrolled, the sponsor may be an enrollee and may cover the sponsor and TEI family members under the plan.

(ii) If a sponsor is not eligible to enroll (or pursuant to §894.309(a)(3)(iii) is not enrolled), a TEI who is a TEI family member may self-certify to serve as enrollee instead, and may cover other TEI family members.

(d) If a FEDVIP dental or vision plan has a specific geographic enrollment area, TEI family members must live or work in that area in order to be enrolled for coverage. An enrollee whose TEI family members are located in different geographic locations may select a plan that is nationwide/international in scope in order to obtain accessible coverage.

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§894.802   Am I a TEI for a FEDVIP dental plan (TEI-D) if I am eligible to enroll or be covered under the TRICARE Retiree Dental Program?

A TRICARE-eligible individual for FEDVIP dental benefits (TEI-D) means an individual who is eligible to be enrolled and/or who may be covered under the TRICARE Retiree Dental Program (TRDP) pursuant to 10 U.S.C. 1076c(b) as set forth in 32 CFR 199.3 and 199.22. Individuals covered under any of the following programs are excluded and are not TEI-D: TRICARE Young Adult provisions of 10 U.S.C. 1110b; Transitional Assistance Management Program (TAMP), 10 U.S.C. 1145(a)); Continued Health Care Benefit Program (CHCBP); 10 U.S.C. 1078a; or Foreign Military (including NATO) sponsor/family coverage.

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§894.803   Am I a TEI for a FEDVIP vision plan (TEI-V) based on my concurrent enrollment in a TRICARE health plan?

(a) Except as provided in paragraphs (b) and (c) of this section, a TEI-V is an individual who is concurrently enrolled in and/or covered pursuant to:

(1) 10 U.S.C. 1076d (TRICARE Reserve Select (TRS));

(2) 10 U.S.C. 1076e (TRICARE Retired Reserve (TRR));

(3) 10 U.S.C. 1079(a) (uniformed services active duty family members concurrently enrolled in TRICARE Select or TRICARE Prime);

(4) 10 U.S.C. 1086(c) (uniformed services retirees and retiree family members or former spouses concurrently enrolled in TRICARE Select or TRICARE Prime); or

(5) 10 U.S.C. 1086(d) (TRICARE for Life (TFL)), as set forth in 32 CFR 199.3. The provisions of TFL require Medicare eligible retirees and individual Medicare eligible retiree family members or former spouses to enroll in Medicare Part B (requires payment of applicable premiums), otherwise they are not a TEI-V.

(b) An individual covered under any of the following programs is not aTEI-V:

(1) TRICARE Young Adult provisions of 10 U.S.C. 1110b;

(2) Transitional Assistance Management Program (TAMP), 10 U.S.C. 1145(a);

(3) Continued Health Care Benefit Program (CHCBP), 10 U.S.C. 1078a; or

(4) Foreign Military (including NATO) sponsor/family coverage.

(c) An active duty member of the uniformed services under 10 U.S.C. 1074(a) is not a TEI-V.

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§894.804   Am I a sponsor for a FEDVIP dental or vision plan?

(a) Generally, the sponsor is the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on his or her direct affiliation with the uniformed services, including military members of the National Guard and Reserves. Relationship to a sponsor conveys TEI status to a TEI family member. If two parents of a TEI child are entitled to be a sponsor, see restriction on dual enrollment at §894.204.

(b) Sponsor for a FEDVIP dental plan means:

(1) Retiree. A member or former member of a uniformed service who is entitled to uniformed services retirement pay. To determine a sponsor's enrollee status for a FEDVIP dental plan, see §894.309 and the definition of TEI-D;

(2) Retired Reserve member under the age of 60 (“Gray Area Retiree”). To determine sponsor's enrollee status for a FEDVIP dental plan, see §894.309 and the definition of TEI-D;

(3) Medal of Honor recipient who is not otherwise entitled to dental benefits; or

(4) Deceased Member described in paragraph (b)(1) or (2) of this section who died after retiring from active duty and a deceased member who was a Medal of Honor recipient described in paragraph (b)(3) of this section.

(c) Sponsor for a FEDVIP vision plan includes:

(1) Retiree. A member or former member of a uniformed service who is entitled to uniformed services retirement pay.

(2) Retired Reserve member under the age of 60 (“Gray Area Retiree”);

(3) Medal of Honor recipient who is enrolled in TRICARE Select or TRICARE

Prime and who is not on active duty;

(4) Member of the uniformed services (active or Reserve Component) on active duty for more than 30 days. An active duty member of the uniformed services under 10 U.S.C. 1074(a) is not a TEI-V and is not an enrollee for a FEDVIP vision plan, see §894.309 and definition of TEI-V;

(5) Ready Reserve member;

(6) Deceased member described at paragraphs (c)(1) through (5) of this section; or

(7) Deceased Reserve Component member (deceased in the line of duty).

[83 FR 58180, Nov. 19, 2018, as amended at 84 FR 1599, Feb. 5, 2019]

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§894.805   I am not a TEI-D or TEI-V, but I am a sponsor. Am I eligible to cover my TEI family members?

(a) FEDVIP dental plan. (1) No, a sponsor must be both a TEI-D and an enrollee, in order to cover TEI family members in a FEDVIP dental plan.

(2) However, a TEI certifying family member may enroll and cover TEI family members in a FEDVIP dental plan if the sponsor described at §894.804 is a retiree or Retired Reserve Member who is a TEI-D, but who is not enrolled and the retiree or Retired Reserve Member:

(i) Receives VA dental services;

(ii) Has employer-sponsored dental coverage without a family coverage option; or

(iii) Has a medical or dental condition that prevents him or her from obtaining dental benefits. See §894.309.

(b) FEDVIP vision plan. (1) No, a sponsor must be both a TEI-V and an enrollee in order to enroll and cover TEI family members in his or her FEDVIP vision plan.

(2) However, a TEI certifying family member may enroll TEI family members. A uniformed services member (active or Reserve Component) on active duty for more than 30 days described in §894.804(c)(4) is not a TEI-V and is not eligible to enroll and cover TEI family members. See §894.309.

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§894.806   Can a retiree or Retired Reserve member enroll and cover TEI family members in a FEDVIP dental plan?

Generally, yes, since a retiree or Retired Reserve member who is a sponsor is also a TEI-D. However, if a retiree or Retired Reserve member who is eligible to enroll does not in fact enroll, then the member is not an enrollee and cannot cover TEI family members. A TEI certifying family member may serve as enrollee only if the member does not enroll and meets at least one of the following conditions:

(a) Receives VA dental services;

(b) Has employer-sponsored dental coverage without a family coverage option; or

(c) Has a medical or dental condition that prevents him or her from obtaining dental benefits. See description of eligibility in §894.309(a)(3)(iii).

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§894.807   Can an active duty member enroll or be covered under a FEDVIP vision plan?

No, a uniformed services member on active duty is not a TEI-V and may not enroll or be covered under a FEDVIP vision plan. However, an active duty member is a sponsor, therefore their TEI family members may be eligible to enroll in a vision plan. See definition of TEI for FEDVIP vision benefits (TEI-V) in §894.101.

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§894.808   I am a TEI family member. Can I enroll myself in FEDVIP?

Generally, you are not eligible to enroll yourself as a TEI family member. Only an enrollee designated at subpart C of this part may enroll in FEDVIP and select a plan, option, and type of enrollment (self only, self plus one, or self and family) that may cover TEI family members. There is only one FEDVIP dental enrollment and one FEDVIP vision enrollment associated with a sponsor and either the sponsor or a TEI certifying family member may be the enrollee, who may enroll, and cover TEI family members under the enrollment, in accordance with §894.309.

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§894.809   Who is a TEI certifying family member, and may I be the enrollee if I accept this responsibility?

(a) TEI certifying family member means, where the sponsor is not an enrollee under §894.309, the TEI family member in order of precedence, as set forth in paragraph (b) of this section, who may accept responsibility to self-certify as the enrollee by enrolling and, if appropriate, covering the sponsor's TEI family members by electing a self plus one or self and family type of enrollment. Accepting responsibility to self-certify as the enrollee includes consulting all TEI family members regarding their preference for coverage under the enrollment, electing an appropriate plan, option, and type of enrollment.

(b) The following order of precedence governs which TEI family member may self-certify as the enrollee:

(1) An unremarried surviving spouse of a retiree or Medal of Honor recipient, if any, is the TEI certifying family member who may enroll and cover surviving TEI child(ren) of the retiree.

(2) If there is no unremarried surviving spouse of a retiree or Medal of Honor recipient, the surviving TEI child of a retiree who accepts responsibility to self-certify as the enrollee is the TEI certifying family member who may enroll and cover other surviving child(ren) who are TEI family member(s) of the deceased retiree.

(3) The TEI family member who is a spouse is the TEI certifying family member who may enroll and cover other TEI family member(s).

(4) If there is no spouse, the TEI family member who accepts responsibility to self-certify as the enrollee is the TEI certifying family member who may enroll and cover other TEI family member(s).

(c) In the event that the TEI family member or TEI certifying family member is a minor child or a disabled adult dependent, a legal guardian may exercise the TEI's rights on his or her behalf.

(d) Accepting responsibility to self-certify as the enrollee means that you accept the Administrator's authority to make reconsideration decisions under §894.104 and OPM's authority to correct enrollments under §894.105.

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§894.810   If I enroll for self plus one, may I decide which TEI family member to cover?

Generally, yes, as specified in §894.202. However, if you are an enrollee and you do not elect a type of enrollment that covers a TEI family member, that TEI family member will not have FEDVIP coverage or benefits. A TEI family member who is not a TEI certifying family member may not self-certify and enroll himself or herself as a TEI family member in a FEDVIP plan. Note however, that a TEI family member may seek reconsideration of an erroneous enrollment under §894.104, and the Administrator and OPM retain authority to correct enrollments under §894.105.

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§894.811   I am a TEI family member of a sponsor who is a retiree or Retired Reserve member who is not on active duty. My sponsor is a TEI-D but is not enrolled in a FEDVIP dental plan. Can I enroll in a FEDVIP dental plan even though my sponsor is eligible to enroll but is not enrolled?

Generally, if your sponsor is a TEI-D, he or she must enroll in a FEDVIP dental plan in order to cover TEI family members. As an exception, however, a TEI family member can accept the responsibility to self-certify and enroll in a FEDVIP dental plan as a TEI certifying family member, and cover other TEI family members, if the sponsor who is a TEI-D (eligible for FEDVIP dental benefits) is not enrolled and the sponsor meets at least one of the following conditions identified in §894.309(a)(3)(iii):

(a) The retiree sponsor receives VA dental services;

(b) The retiree sponsor has employer-sponsored dental coverage without a family coverage option; or

(c) The retiree sponsor has a medical or dental condition that prevents him or her from obtaining dental benefits.

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§894.812   I am a widow or widower TEI family member. Can I enroll my TEI child who is a TEI family member without enrolling myself in FEDVIP?

No. A widow or widower who is a TEI family member is the TEI certifying family member. Because there is no available sponsor, you are the enrollee, and must either:

(a) Enroll yourself and the TEI child in a self plus one enrollment; or

(b) Enroll all TEI family members in a self and family enrollment, in order for the TEI child to receive FEDVIP coverage.

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§894.813   I am a TEI former spouse. Am I eligible to enroll in a FEDVIP vision plan?

Yes, you are eligible to enroll in a FEDVIP vision plan only. A TEI former spouse is not eligible to enroll in a FEDVIP dental plan. You are a TEI-V, and you are an enrollee, however your type of enrollment is limited to self only. You may not enroll a child, even if the child is a TEI child. The TEI child will have his or her opportunity for FEDVIP dental and/or vision coverage through your ex-spouse sponsor, or TEI certifying family member as the case may be. It is possible for a minor TEI child to be the TEI certifying family member eligible to enroll as an enrollee. If this is the case, you (or the TEI child's legal guardian if not you) may effectuate that enrollment by accepting responsibility on behalf of the TEI child to self-certify as enrollee by enrolling and, if appropriate, covering other TEI family members of the sponsor. Accepting responsibility to self-certify as enrollee on behalf of the TEI child includes consulting all of the TEI family members of the TEI certifying family member regarding their preference for coverage under the enrollment, electing an appropriate plan, option and type of enrollment, and paying the premium on behalf of the TEI child and other TEI family members for the enrollment.

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§894.814   Is a foster child included in the definition of TEI family member?

Generally, a foster child is excluded from coverage as they are not defined to be a TEI family member. However, a pre-adoptive child, adopted child, and an eligible ward in the legal custody of a sponsor, including a foster child who is a ward in the legal custody of a sponsor, are considered TEI family members.

[84 FR 26544 June 7, 2019]

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§894.815   I am a sponsor. Am I responsible to notify the Administrator and my TEI family members when my FEDVIP dental or vision eligibility and/or enrollment status changes?

Yes, as sponsor, you must notify the Administrator and your TEI family members of changes in your eligibility and enrollment status. Status as an enrollee, with a right to the enrollment, depends upon your sponsor status and eligibility as a TEI, and the enrollment action you have taken. Failure to notify the Administrator and your TEI family members of a change in status within the uniformed services that affects your eligibility to enroll may result in invalid continued enrollment, or an unexpected termination of enrollment, for your TEI family members, for which you will be responsible.

(a) Example 1. (1) Status change from non-enrollee to enrollee.

(2) You are on active duty (not TEI and not an enrollee in a dental or vision plan). Your TEI certifying family member may enroll and cover TEI family members in a FEDVIP plan. Upon a change in your status to a retiree or Retired Reserve member (who is not on active duty), you become a TEI and may enroll yourself and TEI family members in a FEDVIP plan. Your TEI certifying family member is no longer the enrollee, and you must notify the Administrator of your change in status. The Administrator will send the TEI certifying family member notice that his or her enrollment is terminated, and notify them that their sponsor (i.e. you), may enroll, and may cover TEI family members on the new enrollment.

(b) Example 2. (1) Status change from non-enrollee to enrollee.

(2) You are a retiree or a retired Reserve member and as a TEI-D you are eligible for, but not enrolled in, a FEDVIP dental plan and you satisfy at least one of the conditions at §894.309(a)(3)(iii). You are not an enrollee because you are not enrolled, and therefore cannot cover TEI family members. Your TEI certifying family member may enroll and cover TEI family members in a FEDVIP dental plan. Upon a change in your status causing you to no longer satisfy one of the conditions, your TEI certifying family member is no longer the enrollee, and you must notify the Administrator. The Administrator will send your TEI certifying family member notice that their enrollment is terminated, and notify them that their sponsor (i.e. you), may enroll, and may cover TEI family members on the new enrollment.

(c) Example 3. (1) Status change from enrollee to non-enrollee.

(2) You are a retiree or Retired Reserve member (who is not on active duty), and you go on active duty. You lose TEI status and you are no longer eligible to be an enrollee. You must notify the Administrator of your change in status. The Administrator will terminate your enrollment and notify you that a TEI certifying family member may accept responsibility to self-certify as enrollee by enrolling and, if appropriate, covering other TEI family members by electing self plus one or self and family type of enrollment for only a FEDVIP vision plan. You are responsible to notify your covered TEI family members that your enrollment will terminate, and of their opportunity to accept responsibility to self-certify as enrollee.

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§894.816   If I return from active duty and retire, what happens to my TEI family members' enrollment in their FEDVIP vision plan?

As a uniformed services member on active duty, you are the sponsor but you are not eligible to enroll in a FEDVIP vision plan and you cannot be the enrollee. A TEI certifying family member may be the enrollee while you are on active duty. Upon your retirement, however, you become eligible to enroll as a TEI-V and TEI-D, and the current enrollee status of your TEI certifying family member ends. As sponsor, you are responsible for notifying the Administrator and your TEI family members of your change in status. The TEI family members' enrollment will be terminated and as a TEI-V and TEI-D who is both sponsor and enrollee, you may enroll yourself and cover TEI family members. See §894.601.

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§894.817   If I am a retiree who is a TEI-V and I return to active duty, what happens to my TEI family members' enrollment in their FEDVIP vision plan?

If you and your TEI family members are enrolled in a FEDVIP vision plan while you are retired, and you return to active duty, you will no longer be eligible to enroll in a FEDVIP vision plan and cannot continue to be the enrollee even though you are the sponsor. The current enrollment for you and your TEI family members will terminate and your coverage stops at the end of the pay period for which the premium payment was made from your uniformed services retirement pay. A TEI certifying family member may accept responsibility to self-certify as the enrollee by enrolling and, if appropriate, covering other TEI family members. You are responsible for notifying your covered TEI family members that your enrollment will terminate and of their opportunity to accept responsibility to self-certify as the enrollee. Once the TEI certifying family member enrolls, and covers your TEI family members, they can remain enrolled in a FEDVIP vision plan for the duration of your active duty service. See §894.601.

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Subpart I—Benefits in Underserved Areas

Source: 83 FR 58180, Nov. 19, 2018, unless otherwise noted.

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§894.901   Will benefits be available in underserved areas?

(a) Dental and vision plans under FEDVIP will include underserved areas in their service areas and provide benefits to enrollees in underserved areas.

(b) In any area where a FEDVIP dental or vision plan does not meet OPM access standards, including underserved areas, enrollees may receive services from non-network providers.

(c) Contracts under FEDVIP shall include access standards as defined by OPM and payment levels for services to non-network providers in areas that do not meet access standards.

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