§ 890.302 Coverage of family members

5 CFR 890.302(a)(1)(a)(1) Enrollment. An enrollment for self plus one includes the enrollee and one eligible family member. An enrollment for self and family includes all family members who are eligible to be covered by the enrollment except as provided in § 890.308(h). Except as provided in paragraph (a)(2) of this section, no employee, former employee, annuitant, child or former spouse may enroll or be covered as a family member if he or she is already covered under another person's self plus one or self and family enrollment in the FEHB Program.

5 CFR 890.302(a)(1)(i)(i) Verifying family member eligibility. The enrollee must provide proof of family member eligibility to the employing office, the carrier, or OPM, as specified by OPM, at the time a family member is added to an enrollment, including during an initial opportunity to enroll, any open season, due to a qualifying life event, or at any other time a family member is added. Proof of family member eligibility must also be provided upon request to the carrier, the employing office, or OPM as provided in §§ 890.308(e) or (f) and 890.1608.

5 CFR 890.302(a)(1)(ii)(ii) Verifying a qualifying life event. When an enrollee seeks to add a family member based on a qualifying life event, the enrollee must provide proper documentation to the employing office, the carrier, or OPM, as specified by OPM, to verify the veracity of any qualifying life event before a covered family member may be added to the enrollment. Qualifying life events are described in § 892.101 of this chapter or § 890.301.

5 CFR 890.302(a)(2)(2) Dual enrollment.—(i) Prohibition on dual enrollment. A dual enrollment exists when an individual is covered under more than one enrollment under this part. Dual enrollments are prohibited except when an eligible individual would otherwise not have access to coverage and the dual enrollment has been authorized by the employing office.

5 CFR 890.302(a)(2)(ii)(ii) Exception. An individual described in paragraph (a)(2)(i) of this section may enroll if he or she or his or her eligible family members would otherwise not have access to coverage, in which case the individual may enroll in his or her own right for self only, self plus one, or self and family coverage, as appropriate. However, an eligible individual is entitled to receive benefits under only one enrollment regardless of whether he or she qualifies as a family member under a spouse's or parent's enrollment. To ensure that no person receives benefits under more than one enrollment, each enrollee must promptly notify the insurance carrier as to which person(s) will be covered under his or her enrollment. These individuals are not covered under the other enrollment. Examples include but are not limited to:

5 CFR 890.302(a)(2)(ii)(A)(A) To protect the interests of married or legally separated Federal employees, annuitants, and their children, an employee or annuitant may enroll in his or her own right in a self only, self plus one, or self and family enrollment, as appropriate, even though his or her spouse also has a self plus one or self and family enrollment if the employee, annuitant, or his or her children live apart from the spouse and would otherwise not have access to coverage due to a service area restriction and the spouse refuses to change health plans.

5 CFR 890.302(a)(2)(ii)(B)(B) When an employee who is under age 26 and covered under a parent's self plus one or self and family enrollment acquires an eligible family member, the employee may elect to enroll for self plus one or self and family coverage.

5 CFR 890.302(a)(2)(iii)(iii) Children are entitled to receive benefits under only one enrollment regardless of whether the children qualify as family members under the enrollment of both parents or of a parent and a stepparent and regardless of whether the parents are married, unmarried, divorced, or legally separated. To ensure that no person receives benefits under more than one enrollment, each enrollee must promptly notify the insurance carrier as to which family members will be covered under his or her enrollment. These individuals are not covered under the other enrollment.

5 CFR 890.302(b)(1)(b)(1) A child under the age of 26, or a child of any age who is incapable of self-support because of a mental or physical disability which existed before age 26, is considered to be a family member eligible to be covered by the enrollment of an enrolled employee or annuitant or a former employee or child enrolled under § 890.1103 of this part if he or she is—

5 CFR 890.302(b)(1)(i)(i) A child born within marriage;

5 CFR 890.302(b)(1)(ii)(ii) A recognized natural child;

5 CFR 890.302(b)(1)(iii)(iii) An adopted child;

5 CFR 890.302(b)(1)(iv)(iv) A stepchild; or

5 CFR 890.302(b)(1)(v)(v) A foster child.

5 CFR 890.302(b)(2)(2) For purposes of this part, the term “stepchild” refers to the child of an enrollee's spouse and shall continue to refer to such child after the enrollee's divorce from the spouse or death of the spouse, so long as the child continues to live with the enrollee in a regular parent-child relationship.

5 CFR 890.302(c)(c) Child incapable of self-support. When an individual's enrollment for self plus one or self and family includes a child who has become 26 years of age and is incapable of self-support, the employing office must require such enrollee to submit a physician's certificate verifying the child's disability. The certificate must—

5 CFR 890.302(c)(1)(1) State that the child is incapable of self-support because of a physical or mental disability that existed before the child became 26 years of age and that can be expected to continue for more than 1 year;

5 CFR 890.302(c)(2)(2) Include a statement of the name of the child, the nature of the disability, the period of time it has existed, and its probable future course and duration; and,

5 CFR 890.302(c)(3)(3) Be signed by the physician and show the physician's office address. The employing office must require the enrollee to submit the certificate on or before the date the child becomes 26 years of age. However, the employing office may accept otherwise satisfactory evidence of incapacity that is not timely filed.

5 CFR 890.302(d)(d) Renewal of certificates of incapacity. The employing office must require an enrollee who has submitted a certificate of incapacity to renew that certificate on the expiration of the minimum period of disability certified.

5 CFR 890.302(e)(e) Determination of incapacity.

5 CFR 890.302(e)(1)(1) Except as provided in paragraph (e)(2) of this section, the employing office shall make determinations of incapacity.

5 CFR 890.302(e)(2)(2) Either the employing office or the carrier may make a determination of incapacity if a medical condition, as specified by OPM, exists that would cause a child to be incapable of self-support during adulthood.

5 CFR 890.302(f)(f) Switching a covered family member.

5 CFR 890.302(f)(1)(1) An enrollee with a self plus one enrollment may switch his or her covered family member during the annual Open Season, upon a change in family status, upon a change in coverage, or upon a change in eligibility, so long as switching a covered family member is consistent with the event that has taken place.

5 CFR 890.302(f)(2)(2) Switching a covered family member under a self plus one enrollment will be effective on the first day of the first pay period that begins after the date the employing office receives an appropriate request to switch the covered family member.