**Important Information for HUMAN RESOUCES MANAGEMENT (HRM) STAFF **

## FLYER

Benefits 04-3

February 18, 2004

### TO: Chief, HRMS

######## SUBJ: Issuing Denials of Enrollment for the Federal Employees Health Benefits (FEHB) Program and Premium Conversion

The role of the HR specialist is to assist employees in understanding
the eligibility criteria of the FEHB program, what the program offers,
the cost of enrollment and the types of FEHB plans available. It is the
responsibility of HR offices to provide accurate information in a timely
manner in order for the employee to make an informed FEHB enrollment
decision.

There are times when the HR specialist determines that the employee is
not eligible to enroll or change his or her FEHB enrollment and a denial
of FEHB enrollment must be made. HR specialists must review these types
of requests on a case-by-case basis, keeping in mind that decisions made
regarding employees FEHB eligibility (either to accept or deny FEHB
enrollment) will set precedence for future requests. In order to
establish consistency in how HR offices handle FEHB and Premium
Conversion denials, the Worklife and Benefits Division is providing
guidance and sample letters (sample letters are found at the end of this
flyer).

Guidance on reconsidering initial decisions, denying enrollment and
changes in FEHB enrollment is set forth in 5 CFR 890.104. In addition,
OPM had issued BAL 95-204 that provided guidance to HR offices in
setting up the administrative review procedures for reconsideration of
initial decisions for both FEHB and FEGLI. You may view this BAL by
going to <http://www.opm.gov/asd/pdf/95-204.pdf>. When a HR office
receives an employee's SF-2809, Employee Health Benefits Registration
form (or when an employee requests a change in FEHB enrollment), a
decision must be made whether or not to accept the employee's health
benefit election.

The same procedures apply in reconsidering initial decisions affecting
an employee's participation in **premium conversion**, which is set
forth in 5 CFR 892.103 and 5 CFR 890.104. When a HR office receives an
employee's request to participate or waive participation in premium
conversion, a decision whether or not to accept the employee's request
must be made. The events that allow employees to participate or waive
participation, and the timeframes that allow these changes can be found
in

5 CFR 892.

Once the HR office determines that a denial or change in FEHB enrollment
and or change in premium conversion is appropriate, it must give the
employee a written decision denying the employee's election to enroll or
to change enrollment. This decision, which is the initial decision,
should be issued on VA letterhead with a telephone number for the HR
point of contact. It should contain the following information:

-   An explanation of the reason(s) for the denial of coverage or
    opportunity to change

-   The right to request reconsideration

-   The procedures for requesting reconsideration

-   The time limit for requesting reconsideration

-   The address of the office making reconsideration decisions

**[A request for reconsideration must]{.underline}:**

-   Be made in writing

-   Include the employee's name, address, date of birth, social security
    number, and reasons(s) for request

-   Include a copy of the initial denial decision

**[Time Limit]{.underline}:**

A request for reconsideration of an initial decision must be filed
within 30 calendar days from the date of the written decision stating
the right to reconsideration. For this purpose, filing means date of
postmark. This time limit may be extended if the employee shows that
he/she was not notified of the time limit and was not otherwise aware of
it or that he/she was unable, due to reason beyond his/her control, to
make the request within the time limit. A facsimile will be accepted for
meeting the time limit but the original request must be received before
final action on the request will be taken. Employees should be directed
to mail their reconsideration request to their servicing HR office.
**Important Note: Reconsiderations must take place at or above the level
at which the initial decision was made.**

The Worklife and Benefits Division hopes this guidance, along with the
sample letters, will assist HR offices in dealing with these types of
situations. Questions regarding this flyer should be directed via email
to Therese M. Kilgore or Bruce Ducharme in Outlook.

Office of Human Resources Management

HRM Programs and Policies Service (051)

#### Worklife and Benefits Division

# VA Headquarters -- Washington, DC

Office of Human Resources Management

HRM Programs and Policies Service (051)

#### Worklife and Benefits Division

# VA Headquarters -- Washington, DC