CFR Subpart A

CFR Subpart A
in effect

5 C.F.R. § 875.101 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. In this part, the terms annuitant, employee, member of the uniformed services, retired member of the uniformed services, and qualified relative have the meanings set forth in section 9001 of title 5, United States Code, and supplement the following definitions: Abbreviated underwriting is a type of underwriting that asks fewer questions about your health status than with full underwriting to enable the Carrier to determine whether your application for coverage will be approved. The Carrier may also require review of your medical records, a phone interview, or an in-home interview. Actively at work means: (1) That as an active workforce member other than a member of the uniformed services you meet all of the following conditions: (i) You are reporting for work at an approved work location and you work at least one-half of your regularly scheduled hours for that day; and (ii) You are able to perform all the usual and customary duties of your employment on your regular work schedule. (2) For a member of the uniformed services, that you are on active duty and are physically able to perform the duties of your position. Carrier means a “qualified carrier” as defined in section 9001 of title 5, United States Code, with which OPM has contracted to provide long term care insurance coverage under this section. A Carrier may designate one or more administrators to perform some of its obligations. Domestic partner is defined as a person in a domestic partnership with an employee, annuitant, member of the uniformed services, or retired member of the uniformed services. Domestic partnership means: (1) A committed relationship between two adults, of the opposite sex or same sex, in which the partners— (i) Are each other's sole domestic partner and intend to remain so indefinitely; (ii) Maintain a common residence, and intend to continue to do so (or would maintain a common residence but for an assignment abroad or other employment-related, financial, or similar obstacle); (iii) Are at least 18 years of age and mentally competent to consent to a contract; (iv) Share responsibility for a significant measure of each other's financial obligations; (v) Are not married or joined in a civil union to anyone else; (vi) Are not a domestic partner of anyone else; (vii) Are not related in a way that would prohibit legal marriage in the U.S. jurisdiction in which the domestic partnership was formed; (viii) Provide documentation demonstrating fulfillment of the requirements of paragraphs (1)(i) through (vii) of this definition as prescribed by OPM; and (ix) Certify that they understand that willful falsification of the documentation described in paragraph (1)(viii) of this definition may lead to disciplinary action and the recovery of the cost of benefits received related to such falsification and may constitute a criminal violation under 18 U.S.C. 1001. (2) You or your domestic partner must notify the employing office if at any time between the time of application and the time coverage is scheduled to go into effect, any of the conditions listed in paragraphs (1)(i) through (vii) of this definition are no longer met, in which case a domestic partnership is deemed terminated. Such notification must be made as soon as possible, but in no event later than thirty calendar days after such conditions are no longer met. Eligible individual means an employee, annuitant, member of the uniformed services, retired member of the uniformed services or qualified relative, as defined in section 9001 of title 5, United States Code. Enrollee means an eligible individual whose application for coverage the Carrier has approved and whose coverage is in effect. FLTCIP means the Federal Long Term Care Insurance Program. Free look means that within 30 days after you are approved for coverage and receive the Benefit Booklet, you may cancel that coverage if you are not satisfied with it and receive a refund of any premium you paid for that coverage. It will be as if the coverage was never issued. Full underwriting is the more comprehensive type of underwriting under the FLTCIP, which requires that you answer many questions about your health status to enable the Carrier to determine whether your application for coverage will be approved. The Carrier may also require review of your medical records, a phone interview, or an in-home interview. Special application period is a period in which active workforce members and their spouses may apply based on abbreviated underwriting. Such application periods will be provided for pursuant to OPM's authority in section 9008 of title 5, United States Code. Stepchild(ren), as set forth in section 9001 of title 5, United States Code, means the child(ren) of the spouse or domestic partner of an employee, annuitant, member of the uniformed services, or retired member of the uniformed services. Stepparent means any person, other than your mother or father, who is currently married to one of your parents, or, if one of your parents is dead, a person who was married to that parent at the time of that parent's death. Underwriting requirements means the information about your current health status and history and other information that you must provide to the Carrier with your application for coverage to enable the Carrier to determine your insurability. Workforce member means a Federal civilian or Postal employee, member of the uniformed services, Federal annuitant, retired member of the uniformed services, or member of any other eligible group, as defined in section 9001 of title 5, United States Code. An active workforce member is one who is currently employed or is on active duty.

5 C.F.R. § 875.102 Where do I send benefit claims?

You must submit your benefit claims to the FLTCIP Carrier.

5 C.F.R. § 875.103 Do I need to authorize release of my medical records when I file a claim?

Yes, if you file a claim for benefits, the Carrier needs to have a valid authorization from you to release your medical records.

5 C.F.R. § 875.104 What are the steps required to resolve a dispute involving benefit eligibility or payment of a claim?

(a) If you dispute the Carrier's denial of your eligibility for benefits or your claim for payment of benefits, you must first send a written request for reconsideration to the Carrier no later than 60 days from the date of its decision. (b) The Carrier must provide you with written notice of its review decision no later than 60 days after the date it receives your reconsideration request. (c) If the Carrier upholds its denial (or does not respond within 60 days), you have the right to appeal its reconsideration decision directly to the Carrier. You must make this appeal in writing within 60 days from the date of the Carrier's notice upholding its decision. You will be notified of the decision on your appeal in writing no later than 60 days from receipt of your appeal request. (d) If a denial of your eligibility for benefits or a denial of your claim is upheld upon appeal due to the evaluation of your medical condition/functional capacity, the Carrier will inform you that you may request that an independent third party, mutually agreed to by OPM and the Carrier, review the decision. You must make this request in writing within 60 days from the date of the notice informing you of the appeal decision. The independent third party must notify you in writing of its decision no later than 60 days from the Carrier's or its designee's receipt of your request for appeal to the third party. This is the final administrative remedy available to you. The decision of the independent third party is final and binding on the Carrier. (e) You may seek judicial review of the final administrative denial of a claim. Such action may not be brought prior to exhaustion of the administrative process provided in this section. To pursue such judicial review, you must bring legal action against the Carrier in an appropriate United States district court within 2 years from the date of the final decision. You may not sue OPM, the independent reviewer, or any other entity. If you prevail in court, your recovery is limited to the amount of benefits payable under your benefit booklet and schedule of benefits. (f) The procedures described in paragraphs (a), (b), (c), (d), and (e) of this section apply only if you have valid coverage under the FLTCIP. If the Carrier determines that your coverage was based on an erroneous application and voids the coverage as described in § 875.408 of this part, these provisions do not apply. The Carrier will provide you with information on your review rights in its rescission letter (letter voiding your coverage).

5 C.F.R. § 875.105 May OPM correct errors?

OPM may order correction of administrative errors after reviewing evidence and finding that it would be against equity and good conscience not to do so.

5 C.F.R. § 875.106 What responsibilities do agencies have under this Program?

Federal agencies and uniformed services establishments are responsible for: (a) Providing access to information about the FLTCIP to eligible individuals; (b) Responding to questions from the Carrier, including questions on the employment status of an applicant or enrollee; (c) Providing reports as OPM requires; (d) Complying with Benefits Administration Letters and other OPM issuances/instructions; and (e) Deducting premiums as authorized by a workforce member and as requested by the Carrier, when possible.

5 C.F.R. § 875.107 What are OPM's responsibilities as regulator under this Program?

Consistent with the authority and discretion given to OPM by the FLTCIP law, OPM's responsibilities include those functions typically associated with, and preemptive of, State insurance regulatory authorities such as: (a) Reviewing and approving the content and format of materials associated with the FLTCIP pursuant to section 9008(d) of title 5, United States Code; (b) Reviewing and approving rates, forms, and marketing materials; (c) Determining the qualifications of enrollment personnel and the Program administrator(s); (d) Suspending applications for FLTCIP coverage, including coverage increases as specified in § 875.110; and (e) Holding special application periods as specified in § 875.402.

5 C.F.R. § 875.108 If the Carrier approves my application, will I get a certificate of insurance?

If the Carrier approves your application for coverage, OPM and/or the Carrier will make available to you a benefit booklet and schedule of benefits with complete coverage information, which will serve as your proof of insurance. You will also get a copy of your approved application for coverage.

5 C.F.R. § 875.109 Which board of contract appeals has jurisdiction for resolving contract disputes between OPM and the Carrier?

For purposes of applying chapter 71 of title 41 to disputes arising between OPM and the Carrier, the Civilian Board of Contract Appeals has jurisdiction to decide an appeal relative to such a dispute.

5 C.F.R. § 875.110 May OPM suspend applications for FLTCIP coverage?

(a) OPM may suspend applications for FLTCIP coverage, including coverage increases, when OPM determines that a suspension is in the best interest of the Program. (b) OPM will issue a document in the Federal Register with the effective date of the suspension period, during which no applications for FLTCIP coverage will be accepted. The effective date will be determined at the discretion of the Director and will be at least 30 days after the publication date of the document. (c) The duration of the suspension period, as determined at the discretion of the Director and not to exceed 24 months unless subsequently extended, will be announced in a document published in the Federal Register. (d) At least 30 days before the end of the suspension period, OPM may issue a document in the Federal Register announcing an extension of the suspension period when OPM determines that such extension is in the best interest of the Program. The duration of any extension to the suspension period will not exceed 24 months, unless subsequently extended by additional periods of suspension, each not to exceed 24 months.