';


Title 5 Part 894 → Subpart H

Title 5 → Chapter I → Subchapter B → Part 894 → Subpart H

Electronic Code of Federal Regulations e-CFR

Title 5 Part 894 → Subpart H

e-CFR data is current as of September 18, 2019

Title 5Chapter ISubchapter BPart 894 → Subpart H


Title 5: Administrative Personnel
PART 894—FEDERAL EMPLOYEES DENTAL AND VISION INSURANCE PROGRAM


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


Contents
§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?

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

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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]

return arrow Back to Top

§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.

return arrow Back to Top

§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).

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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]

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top

§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.

return arrow Back to Top