Changes to Federal Benefits Eligibility Due to Health Reform and Open Season Decisions
Changes to the Federal Employees Health Benefits (FEHB) Program Eligibility Due to Health Reform
Changes in FEHB Program Dependent Eligibility
Beginning January 1, 2011…
- Children are covered under their parent’s FEHB health plan’s Self and Family enrollment until age 26.
- The law provides that this provision is effective beginning the first plan year following 6 months after enactment – for FEHB that is January 1.
Children Covered Under a Self and Family Enrollment
| Beginning January 1, 2011 |
|
| Is my child covered until her 26th birthday? |
Yes |
| Is my married child covered until her 26th birthday? |
Yes |
| Is the spouse of my married child covered until her 26th birthday? |
No |
| Is my child who lost coverage because he turned 22 covered until his 26th birthday? |
Yes |
| My daughter doesn’t live with me. Is she covered until her 26th birthday? |
Yes |
| My daughter isn’t financially dependent on me? Is she covered until her 26th birthday?
|
Yes |
| My son is no longer a dependent on my tax return. Can he be covered until his 26th birthday? |
Yes |
| My son has a pre-existing condition. Is he covered until his 26th birthday? |
Yes |
| My son has his own private insurance. Can he be covered until his 26th birthday?
|
Yes |
| My daughter is not a student. Can she be covered until her 26th birthday? |
Yes |
Stepchildren Covered Under a .Self and Family Enrollment
| Beginning January 1, 2011 |
|
| Is my stepchild covered until his 26th birthday? |
Yes |
| Does my stepchild have to live with me? |
No |
| Does my stepchild have to be financially dependent on me? |
No |
Disabled Children Incapable of Self-Support Covered Under a Self and Family Enrollment
| Beginning January 1, 2011 |
|
| If my child becomes incapable of self-support due to a disability that begins at age 24, will he remain on my enrollment after his 26th birthday? |
Yes |
| Will my FEHB plan pay for services my 24 year old child received before January 1, 2011? |
No |
Foster Children Covered Under .a Self and Family Enrollment
Foster children are covered until age 26 if the following five requirements are met:
- The child must live with you;
- The parent-child relationship must be with you, not solely the child’s biological parent;
- You must be the primary source of financial support for the child;
- You must expect to raise the child to adulthood; and
- You must sign a certification stating your foster child meets all the requirements.
Temporary Continuation of Coverage (TCC)
A former employee or former spouse:
- May add children under age 26 (even if married) back on a Self and Family enrollment.
- For Self Only enrollments, TCC enrollees may change to Self and Family during Open Season through the National Finance Center (NFC).
- If not changing plans, enrollee or child contacts the health plan with enrollment information.
- If the child has a spouse and/or children, the spouse and/or children are not eligible.
A child who lost coverage under parent’s FEHB enrollment:
- Is eligible again under parent’s Self and Family enrollment.
- May cancel TCC if no longer needed.
- Child may keep their TCC to cover their own spouse and/or child
- Is again eligible for 36 months of TCC on his 26th birthday.
Retirees
Children under age 26 can be covered under the retiree’s Self and Family enrollment.
A retiree who has a Self Only enrollment can change to a Self and Family enrollment during Open Season.
How to Get Your Newly Eligible Children Covered in the FEHB Program
Self and Family Enrollments
If you have a Self and Family enrollment:
- If you do not change to another health plan or option during Open Season, your newly eligible child(ren) will automatically be covered on January 1, 2011.
- You should contact your FEHB plan to provide information on the newly eligible child(ren).
- Your FEHB plan will send you a letter with instructions.
- You DO NOT complete an SF 2809 or use an agency self-service enrollment system to add a child to an existing Self and Family enrollment.
Self Only Enrollments
If you have a Self Only enrollment:
- You must change enrollment to Self and Family to cover your newly eligible children.
Not Enrolled in FEHB
Employees who are not currently enrolled in the FEHB Program must enroll for Self and Family.
Effective Dates
Qualifying Life Event (QLE)
- A QLE change may be made from 31 days before to 60 days after the event causing the change in family status (January 1)
- The change will take effect on the first day of the pay period that includes January 1.
Open Season
- The first day of the first pay period that begins on or after January 1, 2011.
- For most Federal employees this will be
January 2, 2011.
- For retirees this will be January 1, 2011.
Changes to the Federal Flexible Spending Account Program (FSAFEDS) Eligibility Due to Health Reform
Coverage of OTC Medicines or Drugs
Beginning 1/1/11, currently eligible OTC products that are medicines or drugs will not be eligible for reimbursement unless enrollee has a prescription.
Insulin is exception.
Other currently eligible OTC items that are not medicines or drugs will not require a prescription in 2011.
Expanded Coverage for Child’s Eligible Expenses
Beginning 1/1/11, employee enrolled in FSAFEDS may request reimbursement for eligible expenses incurred by a
- Natural child
- Stepchild
- Adopted child
- Eligible foster child or
- A child placed with employee for legal adoption
Prior to 1/1/11, eligible children limited to those who could be claimed as a dependent on Federal tax return.
ACA has extended the age of a child who may incur eligible expenses.
Expenses of employee’s child are covered through the taxable year prior to the taxable year in which the child turns 27.
Example: enrollees can not be reimbursed for expenses incurred by child who turns 27 anytime in 2011.
Other Benefit Programs Changes to Eligibility Due to Health Reform
Other Benefit Programs Not Affected
The ACA makes no changes to the:
- Federal Employees Dental and Vision Insurance Program (FEDVIP)
- Federal Employees’ Group Life Insurance Program (FEGLI) or the
- Federal Long Term Care insurance Program (FLTCIP)
ACA does not extend coverage to age 26 or provide coverage for married children under these Programs