A. Employee or spouse

If an individual files for deemed insured HI and indicates he is a Federal employee (or the spouse of a Federal employee) covered under FEHBA, his claim should be disallowed. If a Federal employee or the spouse of one states he (she) is not covered, he (she) should be questioned regarding the nature of his or his spouse's employment. If it can be determined from the claimant that he is not a “Federal employee” as defined in HI 00801.076 no further development is required. However, have the claimant sign a statement regarding the nature of his employment.

If there is a question as to his FEHBA eligibility and the claimant (or the claimant's spouse) is currently employed by a Federal agency, contact the agency (through the parallel DO). Ask the agency whether the employee is or could be covered under the Federal Employees Health Benefits Act of 1959. Be sure to identify the employee properly. Providing all other requirements are met. HI entitlement may be established for the claimant if the agency's reply indicates that the claimant (or his spouse) could not be enrolled under FEHBA. If the reply indicates the claimant (or his spouse) is or could have been covered, the application for HI must be denied. Be sure the file contains an RC or other report of the information received from the Federal agency.

B. Annuitant or spouse

Ordinarily, we will accept an annuitant's statement regarding his status under FEHBA. However, where the employment on which the annuity is based ended after 2/15/65, verify any statement that the annuitant could not be covered under the 1959 Act if:

1. There was more than 12 years employment or the retirement was for disability; and

2. the employment was not one of the types listed in HI 00801.076A. or B. which is excluded from FEHBA coverage; and

3. there was an annuity immediately payable upon termination of the employment which was sufficient to cover the cost of the premium.

If the above conditions exist, have the individual contact the agency (in most cases this will be the U.S. Civil Service Commission, Washington, D.C. 20415, or the Bureau of EmployeesCompensation, Washington, D.C. 20211) from which he receives his annuity. He should request a letter from them showing whether or not he could have been covered under FEHBA had he or his spouse enrolled. Advise him to include his annuity number in any correspondence. A copy of the agency's letter should be included in file.