5 CFR § 892.101 - Definitions.
Days mean calendar days.
Dependent means a family member who is both eligible for coverage under the FEHB Program and either a dependent as defined in section 152 of the Internal Revenue Code or a child as defined in section 152(f)(1) of the Internal Revenue Code who is under age 27 as of the end of the employee's taxable year.
FEHB Program means the Federal Employees Health Benefits Program described in 5 U.S.C. 8901.
Open Season means the period of time each year as described in § 890.301(f) of this chapter when all individuals eligible for FEHB coverage have the opportunity to enroll or change their enrollment. These changes become effective with the first pay period that begins in the following year. For additional open seasons authorized by OPM, the effective date is specified.
OPM means the Office of Personnel Management.
Qualifying life (QLE) event means an event that may permit changes to your FEHB enrollment as well as changes to your premium conversion election as described in Treasury regulations at 26 CFR 1.125–4. Such events include the following:
(1) Change in family status that results in an increase or decrease in the number of eligible family members as follows:
(i) Marriage, divorce, annulment, legal separation;
(ii) Birth, adoption, acquiring a foster child that meets the definition in § 890.101(a) or a stepchild, issuance of a court order requiring an employee to provide coverage for a child;
(iii) Last dependent child loses coverage, for example, the child reaches age 26, disabled child becomes capable of self support, child acquires other coverage by court order; and
(iv) Death of a spouse or dependent.
(2) Any change in employment status that could result in entitlement to coverage; for example:
(i) Reemployment after a break in service of more than 3 days;
(ii) Return to pay status from non-pay status if employee previously elected to terminate coverage (if employee did not elect to terminate see § 892.101 (5);
(iii) Return to receiving pay sufficient to cover premium withholdings if coverage terminated;
(iv) Your spouse or dependent changes hours from either full-time to part-time status, or the reverse, which significantly affects their eligibility for coverage;
(v) Start or end of a period of unpaid leave of absence (leave without pay [LWOP], or other non-pay status) by you or your spouse. A period of unpaid leave is a continuous unpaid leave of absence of more than one pay period; and
(vi) Start or end of your spouse's employment that affects you or your spouse's eligibility for coverage.
(3) Any change in employment status that could affect the cost of insurance, including:
(i) Change from temporary appointment with eligibility for coverage under 5 U.S.C. 8906a to an appointment that permits receipt of government contribution; and
(ii) Change from full-time to part-time status or the reverse.
(4) An employee is restored to a civilian position after serving in uniformed services as described in § 890.304 (a)(vi)(vii).
(5) Start of non-pay status and end of non-pay status if employee did not terminate coverage (if coverage terminated see § 892.101 (2)(ii)).
(6) An employee enrolled in a health maintenance organization (HMO) or a covered family member moves or becomes employed outside the geographic area from which the carrier accepts enrollments, or if already lives or works outside the area, moves further from this area.
(7) Transfer from a post of duty within the United States to a post of duty outside the United States, or the reverse.
(8) Separation from Federal employment when the employee or employee's spouse is pregnant.
(9) An employee becomes entitled to Medicare. (For change to self only, self plus one, cancellation, or change in premium conversion status see paragraph (11) of this definition.)
(10) An employee or eligible family member loses coverage under FEHB or another group insurance coverage including the following:
(i) Loss of coverage due to termination of membership in an employee organization sponsoring the FEHB plan;
(ii) Loss of coverage of employee or eligible family member due to discontinuance in whole or part of FEHB plan;
(iii) Loss of coverage under another Federally-sponsored health benefits program, including, TRICARE, Medicare, or Indian Health Service;
(iv) Loss of coverage under Medicaid or similar State-sponsored program of medical assistance for the needy; and
(v) Loss of coverage under a non-Federal health plan, including foreign, State or local government, or private sector group health plan as described in § 890.301 (i)(6).
(11) An employee or eligible family member gains coverage under FEHB or another group insurance plan, including the following:
(i) Another Federally-sponsored health benefits program, including, TRICARE, Medicare, or Indian Health Service;
(ii) Medicaid or similar State-sponsored program of medical assistance for the needy; and
(iii) A non-Federal health plan, including foreign, State or local government, or private sector group plan.
(12) A change in an employee's spouse or dependent's coverage options, for example:
(i) Employer starts offering a different type of coverage;
(ii) Employer stops offering the type of coverage that the employee's spouse or dependent has (if no other coverage is available);
(iii) A health maintenance organization (HMO) adds a geographic service area that now makes the employee's spouse eligible to enroll in that HMO;
(iv) Employee's spouse is enrolled in an HMO that removes a geographic area that makes the spouse ineligible for coverage under that HMO, but other health plans or options are available (if no other coverage is available see § 892.101 (10); and
(v) Change in the cost of coverage.
(13) An employee or eligible family member becomes eligible for premium assistance under Medicaid or a State Children's Health Insurance Program (CHIP). An eligible employee may enroll and an enrolled employee may decrease or increase enrollment type, change from one plan or option to another, or make any combination of these changes when the employee or an eligible family member of the employee becomes eligible for premium assistance under a Medicaid plan or a State Children's Health Insurance Program. An employee must enroll or change his or her enrollment within 60 days after the date the employee or family member is determined to be eligible for assistance.