BONNEVILLE POWER ADMINISTRATION

**HUMAN RESOURCES, DIVERSITY AND EEO**

**Portland, Oregon**

**PERSONNEL LETTER NO. 890-2 (Revised) DATE: May 13, 2002**

**SUBJECT:** Procedures for Temporary Continuation of Coverage (TCC)
Under the Federal Employees Health Benefits Program (FEHB) Coverage of
Eligible Individuals

# I. PURPOSE

To transmit notification and enrollment procedures for (1) employees who
lose their Federal Employees Health Benefits Program coverage because
they leave their Federal positions/jobs, (2) children who lose their
Federal Employees Health Benefits Program family member status because
they reach age 22 or marry, and (3) former spouses who lose their
Federal Employees Health Benefits Program family member status because
of divorce or annulment.

## II. PURPOSE OF REVISION {#ii.-purpose-of-revision .unnumbered}

### To update nomenclature, and procedures. This issuance supersedes Personnel Letter No. 890-2, Procedures for Temporary Continuation of Federal Employees Health Benefits Program (FEHB) Coverage of Eligible Individual, dated April 4, 1990.

## III. REFERENCES {#iii.-references .unnumbered}

A.  Title II of Public Law 100-654

B.  5 CFR, Part 890, Subpart K, Temporary Continuation of Coverage

## IV. REGULATION {#iv.-regulation .unnumbered}

Temporary Continuation of Coverage (TCC) is a provision of the FEHB law
that allows for temporarily continuation of FEHB coverage for Federal
employees who separate from Federal service and for family members who
lose eligibility.

TCC allows former employees to continue their Federal Health Benefits
Program coverage for up to 18 months, and former family members
(children and former spouses) to continue Federal Employees Health
Benefits Program coverage for up to 36 months.

## V. EXCEPTION {#v.-exception .unnumbered}

An employee is not eligible for TCC if a separation from Federal service
is due to "gross misconduct".

## VI. DEFINITIONS {#vi.-definitions .unnumbered}

##  {#section .unnumbered}

> **A. [Qualifying Event]{.underline}** under TCC means any of the
> following events that qualify an individual: (1) A separation from
> Government service; (2) A divorce or annulment; or (3) A change in
> circumstances that causes an individual to become ineligible to be
> considered an unmarried dependent child.

## B. [Gross Misconduct]{.underline} means a flagrant and extreme transgression of law or established rule of action for which an employee is separated and concerning which a judicial or administrative finding of gross misconduct had been made. {#b.-gross-misconduct-means-a-flagrant-and-extreme-transgression-of-law-or-established-rule-of-action-for-which-an-employee-is-separated-and-concerning-which-a-judicial-or-administrative-finding-of-gross-misconduct-had-been-made. .unnumbered}

## VII. ELIGIBILITY {#vii.-eligibility .unnumbered}

Federal employees and family members who lose their FEHB coverage
because of a qualifying event may be eligible for TCC.

# VIII. QUALIFYING EVENT

For **employees,** the qualifying events are:

1.  Separation from Federal service, voluntarily or involuntarily,
    unless separation is due to gross misconduct; or

2.  Separation for retirement and are not eligible to continue FEHB
    coverage as an annuitant.

For **children,** the qualifying events are:

a.  Marriage.

b.  Reaching age 22.

c.  Loss of status as stepchild, foster child, or recognized natural
    child.

d.  In the case of children whose coverage has continued beyond age 22
    because of their inability to support themselves due to a disability
    occurring before they reached age 22, recovering from the disability
    or becoming

> self-supporting.

e.  Death of the employee or annuitant if the child does not qualify for
    a survivor annuity, or

f.  Termination of a survivor annuity for any reason, including because
    he/she is no longer a full-time student.

For **former spouse** the qualifying events are:

1.  Divorce; or

2.  Annulment of the marriage.

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IX. **COVERAGE UNDER A TCC ENROLLMENT**

For a **former employee**, a TCC family enrollment covers the same
family members as were covered under the regular family enrollment.
Family members must continue to meet the same eligibility requirements
as under a regular family enrollment. A new family member, such as a new
spouse or a newborn child, who is added during the TCC enrollment period
is also covered as a family member.

For a **child**, with a TCC family enrollment, his/her spouse and
children are covered family members.

For **former spouses**, family members are limited to children of both
the Federal employee and the former spouse. The new husband or wife of a
remarried former spouse is not covered as a family member.

**X. LENGTH OF TCC OF COVERAGE**

**Separating employees** can continue TCC for up to 18 months after the
date of separation.

**Children and former spouses** can continue TCC for up to 36 months
after:

1.  The date of the qualifying event, when the child or former spouse is
    covered as a family member of an employee or annuitant under a
    regular FEHB enrollment; or

2.  The date of the employee's separation, if the qualifying event
    occurs when the child or former spouse is covered under the TCC
    enrollment of a former employee.

If your child's or former spouse's qualifying event occurs while you are
enrolled for family coverage under TCC, the child or former spouse may
elect TCC in his or her own right. However, the TCC coverage may not
continue beyond 36 months after the date of your separation.

**XI. COST OF COVERAGE**

Enrollees pay the full enrollment premium (both the employee and
government shares), plus a 2 percent administrative fee to the National
Finance Center in New Orleans, Louisiana. Premiums begin on the day
after the free 31-day temporary extension ends and will be collected
monthly. However, individuals are billed the following months, with
payment due upon receipt. The first bill may be prorated depending on
effective date of paid coverage.

**XII. ELECTION OPTIONS**

An individual who elects continued coverage is not limited to the plan,
option or type of enrollment under which he/she is covered on the date
of loss of coverage. The individual may choose self-only or self and
family coverage, and may enroll in any plan or option for which he/she
is eligible.

a.  After the initial enrollment, the individual may change enrollment
    during open season or upon the occurrence of one of the following
    events:

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1.  Change in family status;

2.  Change to self only;

3.  Move from area served by comprehensive plan;

4.  Termination by an employee organization plan;

5.  Termination of plan in which enrolled;

6.  On becoming eligible for Medicare coverage; or

7.  Child's coverage under another enrollment ends.

b\. An individual may change from a self and family enrollment to self
only at any time.

c.  When a child enrolls for self and family, family members are his or
    her own spouse and children.

d.  When a former spouse enrolls for self and family, family members are
    limited to those individuals who are children of both the employee
    and the former spouse.

e.  Individuals who elect TCC have another 31-day extension of coverage
    at no cost to them and another opportunity to convert to nongroup
    coverage when the TCC ends, unless it ends because of cancellation
    by the individual or discontinuance of the plan.

**XIII. EFFECTIVE DATE**

For separating employees, children and former spouses, the effective
date of TCC is the day after the 31-day temporary extension of coverage
for conversion purposes.

NOTE: Coverage and premiums are retroactive to this date if the
individual submits the SF-2809, Health Benefits Registration Form, after
the 31-day temporary extension ends.

**XIV. PROCEDURES**

To ensure that those individuals eligible for temporary continuation of
health benefits coverage are properly notified of entitlement and
enrollment election process, the following separate steps for the three
groups of eligible individuals shall be followed.

1.  Employee gives notice of separation (other than retirement) or BPA
    separates employee:

> a\. If separating employee is enrolled for health benefits, the Human
> Resources Assistant in Personnel Services notifies the Employee
> Services Benefits Representative. A TCC coverage letter (Notice to a
> Separating Employee, Attachment 1) is mailed to the separated employee
> along with the Standard Form (SF) 2809, Health Benefits Election Form
> (Election Form) and R1-70-5, Guide to Federal Employees Health
> Benefits Plans for TCC and Former Spouse Enrollees, with a Business
> Reply envelope. The Employee Services Benefits Representative will
> monitor for receipt or nonreceipt of the signed acknowledgement and
> election form.
>
> b\. Upon receipt of the completed Election Form, eligibility is
> determined; the Agency portion is completed; copy 2 is sent to the
> National Finance Center for processing, and a copy is filed in the
> enrollee's health benefits file.
>
> c\. Enrollee is then mailed a letter (Notification of Receipt of
> Health Benefits Election Form, Attachment 4) notifying him/her of
> receipt of the SF-2809, Election Form, along with copy 5 of the
> processed election form.

2.  Employee's child loses coverage because of marriage and/or attaining
    age 22:

> a\. Employee and/or child advises the Employee Services Benefits
> Representative in Personnel Services (either personally or by
> telephone) of the change in the child's status.
>
> b\. If advised in person by the child, the Benefits Representative
> provides a letter (Notice of a Marriage or Reaching Age 22, Attachment
> 2) for the child's signature and date, and completion of any other
> requested information. The Agency retains the original signed letter
> and provides a copy to the child.
>
> c\. If advised by either the employee or child by telephone or e-mail,
> the Employee Services Benefits Representative issues a letter (Notice
> of a Marriage or Reaching Age 22, Attachment 2) along with SF-2809,
> Health Benefits Election Form and R1, Guide to Federal Employees
> Health Benefits Plans for TCC and Former Spouse Enrollees, with a
> Business Reply envelope. The Employee Services Benefits Representative
> will monitor for receipt or nonrecipt of the signed acknowledgement
> and election form.

d\. Upon receipt of the completed election form, eligibility is
determined, the Agency portion is completed, a copy is filed in the
enrollee's health benefits folder, and copy 2 is sent to the National
Finance Center for processing.

> e\. Child is then mailed a letter (Notification of Receipt of Health
> Benefits Election Form, Attachment 4) notifying him/her of receipt of
> the SF-2809 Election along with copy 5 of the processed election form.

3.  Former spouse loses coverage or marriage is annulled:

> a\. When the Employee Services Benefits Representative is advised by
> the former spouse of divorce or annulment, a TCC coverage letter
> (Notice to a Former Spouse or Marriage Annulled, Attachment 3) is sent
> to the former spouse or annulled person along with the Standard Form
> (SF) 2809, Health Benefits Election Form and R1-70-5, Guide to Federal
> Employees Health Benefits Plans for TCC and Former Spouse Enrollees,
> with a Business Reply envelope. The Employee Services Benefits
> Representative will monitor for receipt or nonreceipt of the signed
> acknowledgement and election form.
>
> b\. Upon receipt of the completed election form, eligibility is
> determined; the Agency portion is completed, a copy is filed in the
> enrollee health benefits file, and the original form is sent to the
> National Finance Center for processing.
>
> c\. The former spouse or annulled person is then mailed a letter
> (Notification of Receipt of Health Benefits Election Form, Attachment
> 4) notifying him/her of receipt of SF-2809, along with copy 5 of the
> processed election form.

**XV. NATIONAL FINANCE CENTER RESPONSIBILITIES**

The National Finance Center (NFC) provides billing and collection
services after initial eligibility determinations and processing by
Employee Services Benefits Representatives. Specifically, NFC provides
the following services:

a.  Payment instructions and coupons to enrollees;

b.  Collection of premiums, including cancellation of enrollments for
    failure to pay premiums, making determinations on reinstatement
    requests, and advising enrollees of review rights;

c.  Cancellation of enrollments at the expiration of the eligibility
    period;

d.  Conducts open seasons and distributes open season materials;

e.  Processes open season enrollment changes, address, and name changes;

f.  Makes subsequent eligibility determinations;

g.  Processes all changes in enrollments occurring during continuation
    period; and

h.  Maintains a health benefits file for each enrollee.

Godfrey C. Beckett

Manager, Human Resources, Diversity and EEO

+---+-----------+----------------------------+----------+-----------+---+
| ! |           | ## Depa                    |          |           |   |
| [ |           | rtment of Energy {#departm |          |           |   |
| ] |           | ent-of-energy .unnumbered} |          |           |   |
| ( |           |                            |          |           |   |
| m |           | Bonneville Power           |          |           |   |
| e |           | Administration\            |          |           |   |
| d |           | P.O. Box 3621              |          |           |   |
| i |           |                            |          |           |   |
| a |           | Portland, Oregon           |          |           |   |
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|   | A         |                            |          |           |   |
|   | ttachment |                            |          |           |   |
|   | 1         |                            |          |           |   |
|   |           |                            |          |           |   |
|   | In reply  |                            |          |           |   |
|   | refer to: |                            |          |           |   |
|   | Notice to |                            |          |           |   |
|   | a         |                            |          |           |   |
|   | S         |                            |          |           |   |
|   | eparating |                            |          |           |   |
|   | Employee  |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+

Dear:

Your health insurance coverage in the Federal Employees Health Benefits
Program (FEHB) terminates the last day of the pay period in which you
separate from Federal service, subject to a 31-day temporary, no-cost
extension of coverage for conversion to a non-group contract.

You have the right to temporarily continue your FEHB coverage for up to
18 months after your separation instead of converting to a non-group
contract at this time. You may select any FEHB plan for which you are
eligible. To continue your coverage, you must pay the full amount of the
premium (both the employee and Government shares) plus a 2 percent
administrative fee. The first 31 days of coverage would be the extension
described above. Your enrollment charges would begin on the day after
the 31 days of free coverage ends. At the end of the 18-month period,
you would have another 31-day temporary extension of coverage for
conversion to a

non-group contract.

If you want to continue your coverage, your election form must be
received at the Bonneville Power Administration, P.O. Box 3621,
Portland, OR 97208-3621, within 60 days after the date of your
separation.

The election form and detailed information about your opportunity to
continue your coverage are enclosed. We have also provided a copy of the
letter for you to sign, acknowledging receipt, and a business reply
envelope for returning it. Please send the signed copy to
[Name]{.underline}, [Address]{.underline}, [City]{.underline},
[State]{.underline}, as soon as possible. You may get additional
information by calling me at ([area code]{.underline}), ([phone
number]{.underline}).

Sincerely,

I acknowledge receipt of this notice.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature Date

+---+-----------+----------------------------+----------+-----------+---+
| ! |           | ## Depart                  |          |           |   |
| [ |           | ment of Energy {#departmen |          |           |   |
| ] |           | t-of-energy-1 .unnumbered} |          |           |   |
| ( |           |                            |          |           |   |
| m |           | Bonneville Power           |          |           |   |
| e |           | Administration\            |          |           |   |
| d |           | P.O. Box 3621              |          |           |   |
| i |           |                            |          |           |   |
| a |           | Portland, Oregon           |          |           |   |
| / |           | 97208-3621                 |          |           |   |
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|   |           |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+
|   | A         |                            |          |           |   |
|   | ttachment |                            |          |           |   |
|   | 2         |                            |          |           |   |
|   |           |                            |          |           |   |
|   | In reply  |                            |          |           |   |
|   | refer to: |                            |          |           |   |
|   | Notice of |                            |          |           |   |
|   | a         |                            |          |           |   |
|   | Marriage  |                            |          |           |   |
|   | or        |                            |          |           |   |
|   | Reaching  |                            |          |           |   |
|   | Age 22    |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+

Dear:

Your health insurance coverage as a family member of an employee in the
Federal Employees Health Benefits Program (FEHB) ended when you
([married, reached age 22]{.underline}), subject to a 31-day temporary,
no cost extension of coverage for conversion to a non-group contract.

You have the right to temporarily continue your FEHB coverage for up to
36 months after the date of your marriage or your reaching age 22,
instead of converting to a non-group contract at this time. You may
select any FEHB plan for which you are eligible. If you choose family
coverage, your spouse and your children will also be covered. To
continue your coverage, you must pay the full amount of the premium
(both the employee and Government Shares) plus a 2 percent
administrative fee. The first 31 days of coverage would be the extension
described above. Your enrollment charges would begin on the day after
the 31 days of free coverage ends. At the end of the 36-month period,
you have another 31-day temporary extension of conversion to a non-group
contract.

If you are interested in continuing coverage, your election form must be
received at the Bonneville Power Administration, P.O. Box 3621,
Portland, OR 97208-3621, within 60 days after the date of your marriage
or your reaching age 22.

The election form and detailed information about your opportunity to
continue coverage are enclosed. We have also provided a copy of the
letter for you to sign, acknowledging receipt, and a business reply
envelope for returning it to BPA. Please send us the signed copy as soon
as possible. You may get additional information by calling
[name]{.underline} at ([area code]{.underline}), ([phone
number]{.underline}).

Sincerely,

I acknowledge receipt of this notice.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature Date

+---+-----------+----------------------------+----------+-----------+---+
| ! |           | ## Depart                  |          |           |   |
| [ |           | ment of Energy {#departmen |          |           |   |
| ] |           | t-of-energy-2 .unnumbered} |          |           |   |
| ( |           |                            |          |           |   |
| m |           | Bonneville Power           |          |           |   |
| e |           | Administration\            |          |           |   |
| d |           | P.O. Box 3621              |          |           |   |
| i |           |                            |          |           |   |
| a |           | Portland, Oregon           |          |           |   |
| / |           | 97208-3621                 |          |           |   |
| i |           |                            |          |           |   |
| m |           |                            |          |           |   |
| a |           |                            |          |           |   |
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| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
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| n |           |                            |          |           |   |
| " |           |                            |          |           |   |
| h |           |                            |          |           |   |
| e |           |                            |          |           |   |
| i |           |                            |          |           |   |
| g |           |                            |          |           |   |
| h |           |                            |          |           |   |
| t |           |                            |          |           |   |
| = |           |                            |          |           |   |
| " |           |                            |          |           |   |
| 1 |           |                            |          |           |   |
| . |           |                            |          |           |   |
| 1 |           |                            |          |           |   |
| 6 |           |                            |          |           |   |
| 5 |           |                            |          |           |   |
| 9 |           |                            |          |           |   |
| 7 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| i |           |                            |          |           |   |
| n |           |                            |          |           |   |
| " |           |                            |          |           |   |
| } |           |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+
|   |           |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+
|   | A         |                            |          |           |   |
|   | ttachment |                            |          |           |   |
|   | 3         |                            |          |           |   |
|   |           |                            |          |           |   |
|   | In reply  |                            |          |           |   |
|   | refer to: |                            |          |           |   |
|   | Notice to |                            |          |           |   |
|   | a Former  |                            |          |           |   |
|   | Spouse or |                            |          |           |   |
|   | Marriage  |                            |          |           |   |
|   | Annulled  |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+

Dear:

Your health insurance coverage as a family member of an employee in the
Federal Employees Health Benefits Program (FEHB) ended when ([you were
divorced or your marriage was annulled]{.underline}), subject to a
31-day temporary, no cost extension of coverage for conversion to a

non-group contract.

You have the right to temporarily continue your FEHB coverage for up to
36 months after the date of your ([divorce or annulment]{.underline})
instead of converting to a non-group contract at this time. You may
select any FEHB plan for which you are eligible. If you choose family
coverage, your children will also be covered, if they are children of
both you and the Federal employee. To continue your coverage, you must
pay the full amount of the premium (both the employee and Government
Shares) plus a 2 percent administrative fee. The first 31 days of
coverage would be the extension described above. Your enrollment charges
would begin on the day after the 31 days of free coverage ends. At the
end of the 36-month period, you have another 31-day temporary extension
of conversion to a non-group contract.

Enclosed is an election form and detailed information about your
opportunity to continue your coverage. You can get additional
information by calling (n[ame]{.underline}) at ([area
code]{.underline}), ([phone number]{.underline}).

If you want to continue your coverage, your election form must be
received at the address shown below within 60 days after the date of
your ([divorce or annulment]{.underline}) or the date you receive this
notice, whichever is later. Bring or mail your election to
([name]{.underline}), ([address]{.underline}), [(city, state and zip
code)]{.underline}

Sincerely,

I acknowledge receipt of this notice.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature Date

+---+-----------+----------------------------+----------+-----------+---+
| ! |           | ## Depart                  |          |           |   |
| [ |           | ment of Energy {#departmen |          |           |   |
| ] |           | t-of-energy-3 .unnumbered} |          |           |   |
| ( |           |                            |          |           |   |
| m |           | Bonneville Power           |          |           |   |
| e |           | Administration\            |          |           |   |
| d |           | P.O. Box 3621              |          |           |   |
| i |           |                            |          |           |   |
| a |           | Portland, Oregon           |          |           |   |
| / |           | 97208-3621                 |          |           |   |
| i |           |                            |          |           |   |
| m |           |                            |          |           |   |
| a |           |                            |          |           |   |
| g |           |                            |          |           |   |
| e |           |                            |          |           |   |
| 1 |           |                            |          |           |   |
| . |           |                            |          |           |   |
| w |           |                            |          |           |   |
| m |           |                            |          |           |   |
| f |           |                            |          |           |   |
| ) |           |                            |          |           |   |
| { |           |                            |          |           |   |
| w |           |                            |          |           |   |
| i |           |                            |          |           |   |
| d |           |                            |          |           |   |
| t |           |                            |          |           |   |
| h |           |                            |          |           |   |
| = |           |                            |          |           |   |
| " |           |                            |          |           |   |
| 1 |           |                            |          |           |   |
| . |           |                            |          |           |   |
| 1 |           |                            |          |           |   |
| 6 |           |                            |          |           |   |
| 4 |           |                            |          |           |   |
| 5 |           |                            |          |           |   |
| 8 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| 3 |           |                            |          |           |   |
| i |           |                            |          |           |   |
| n |           |                            |          |           |   |
| " |           |                            |          |           |   |
| h |           |                            |          |           |   |
| e |           |                            |          |           |   |
| i |           |                            |          |           |   |
| g |           |                            |          |           |   |
| h |           |                            |          |           |   |
| t |           |                            |          |           |   |
| = |           |                            |          |           |   |
| " |           |                            |          |           |   |
| 1 |           |                            |          |           |   |
| . |           |                            |          |           |   |
| 1 |           |                            |          |           |   |
| 6 |           |                            |          |           |   |
| 5 |           |                            |          |           |   |
| 9 |           |                            |          |           |   |
| 7 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| 2 |           |                            |          |           |   |
| i |           |                            |          |           |   |
| n |           |                            |          |           |   |
| " |           |                            |          |           |   |
| } |           |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+
|   |           |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+
|   | A         |                            |          |           |   |
|   | ttachment |                            |          |           |   |
|   | 4         |                            |          |           |   |
|   |           |                            |          |           |   |
|   | In reply  |                            |          |           |   |
|   | refer to: |                            |          |           |   |
|   | Not       |                            |          |           |   |
|   | ification |                            |          |           |   |
|   | of        |                            |          |           |   |
|   | Receipt   |                            |          |           |   |
|   | of Health |                            |          |           |   |
|   | Benefits  |                            |          |           |   |
|   | Election  |                            |          |           |   |
|   | Form      |                            |          |           |   |
|   |           |                            |          |           |   |
|   | Dear:     |                            |          |           |   |
|   |           |                            |          |           |   |
|   | Your      |                            |          |           |   |
|   | request   |                            |          |           |   |
|   | for       |                            |          |           |   |
|   | Temporary |                            |          |           |   |
|   | Con       |                            |          |           |   |
|   | tinuation |                            |          |           |   |
|   | of        |                            |          |           |   |
|   | Coverage  |                            |          |           |   |
|   | (TCC) of  |                            |          |           |   |
|   | Health    |                            |          |           |   |
|   | Benefits  |                            |          |           |   |
|   | has been  |                            |          |           |   |
|   | received  |                            |          |           |   |
|   | and       |                            |          |           |   |
|   | p         |                            |          |           |   |
|   | rocessed. |                            |          |           |   |
|   | Please    |                            |          |           |   |
|   | find      |                            |          |           |   |
|   | enclosed  |                            |          |           |   |
|   | your copy |                            |          |           |   |
|   | of the    |                            |          |           |   |
|   | Health    |                            |          |           |   |
|   | Benefits  |                            |          |           |   |
|   | Election  |                            |          |           |   |
|   | Form. We  |                            |          |           |   |
|   | have      |                            |          |           |   |
|   | completed |                            |          |           |   |
|   | part H    |                            |          |           |   |
|   | and       |                            |          |           |   |
|   | forwarded |                            |          |           |   |
|   | the       |                            |          |           |   |
|   | remaining |                            |          |           |   |
|   | copies to |                            |          |           |   |
|   | the       |                            |          |           |   |
|   | National  |                            |          |           |   |
|   | Finance   |                            |          |           |   |
|   | Center    |                            |          |           |   |
|   | (NFC),    |                            |          |           |   |
|   | for their |                            |          |           |   |
|   | pr        |                            |          |           |   |
|   | ocessing. |                            |          |           |   |
|   |           |                            |          |           |   |
|   | The NFC   |                            |          |           |   |
|   | will send |                            |          |           |   |
|   | you a     |                            |          |           |   |
|   | notice of |                            |          |           |   |
|   | e         |                            |          |           |   |
|   | nrollment |                            |          |           |   |
|   | letter    |                            |          |           |   |
|   | and set   |                            |          |           |   |
|   | of        |                            |          |           |   |
|   | payment   |                            |          |           |   |
|   | coupons   |                            |          |           |   |
|   | appr      |                            |          |           |   |
|   | oximately |                            |          |           |   |
|   | one to    |                            |          |           |   |
|   | two       |                            |          |           |   |
|   | months    |                            |          |           |   |
|   | after the |                            |          |           |   |
|   | NFC       |                            |          |           |   |
|   | receives  |                            |          |           |   |
|   | your      |                            |          |           |   |
|   | election  |                            |          |           |   |
|   | form. The |                            |          |           |   |
|   | effective |                            |          |           |   |
|   | date of   |                            |          |           |   |
|   | your new  |                            |          |           |   |
|   | e         |                            |          |           |   |
|   | nrollment |                            |          |           |   |
|   | will be   |                            |          |           |   |
|   | re        |                            |          |           |   |
|   | troactive |                            |          |           |   |
|   | to the    |                            |          |           |   |
|   | 31^st^    |                            |          |           |   |
|   | day after |                            |          |           |   |
|   | your      |                            |          |           |   |
|   | q         |                            |          |           |   |
|   | ualifying |                            |          |           |   |
|   | event     |                            |          |           |   |
|   | (see Part |                            |          |           |   |
|   | H, item 3 |                            |          |           |   |
|   | on your   |                            |          |           |   |
|   | Health    |                            |          |           |   |
|   | Benefits  |                            |          |           |   |
|   | Election  |                            |          |           |   |
|   | Form).    |                            |          |           |   |
|   | You will  |                            |          |           |   |
|   | pay the   |                            |          |           |   |
|   | full cost |                            |          |           |   |
|   | of this   |                            |          |           |   |
|   | insurance |                            |          |           |   |
|   | plus a 2  |                            |          |           |   |
|   | percent   |                            |          |           |   |
|   | admin     |                            |          |           |   |
|   | istrative |                            |          |           |   |
|   | fee, on a |                            |          |           |   |
|   | monthly   |                            |          |           |   |
|   | basis, as |                            |          |           |   |
|   | described |                            |          |           |   |
|   | in the    |                            |          |           |   |
|   | plan      |                            |          |           |   |
|   | c         |                            |          |           |   |
|   | omparison |                            |          |           |   |
|   | brochure  |                            |          |           |   |
|   | that you  |                            |          |           |   |
|   | p         |                            |          |           |   |
|   | reviously |                            |          |           |   |
|   | received. |                            |          |           |   |
|   |           |                            |          |           |   |
|   | The NFC   |                            |          |           |   |
|   | sends the |                            |          |           |   |
|   | e         |                            |          |           |   |
|   | nrollment |                            |          |           |   |
|   | in        |                            |          |           |   |
|   | formation |                            |          |           |   |
|   | to the    |                            |          |           |   |
|   | health    |                            |          |           |   |
|   | insurance |                            |          |           |   |
|   | carrier   |                            |          |           |   |
|   | the first |                            |          |           |   |
|   | and       |                            |          |           |   |
|   | fifteenth |                            |          |           |   |
|   | of each   |                            |          |           |   |
|   | month.    |                            |          |           |   |
|   | T         |                            |          |           |   |
|   | herefore, |                            |          |           |   |
|   | it could  |                            |          |           |   |
|   | take up   |                            |          |           |   |
|   | to three  |                            |          |           |   |
|   | months or |                            |          |           |   |
|   | more      |                            |          |           |   |
|   | before    |                            |          |           |   |
|   | you       |                            |          |           |   |
|   | receive   |                            |          |           |   |
|   | an        |                            |          |           |   |
|   | ident     |                            |          |           |   |
|   | ification |                            |          |           |   |
|   | card from |                            |          |           |   |
|   | your      |                            |          |           |   |
|   | carrier.  |                            |          |           |   |
|   | In the    |                            |          |           |   |
|   | meantime, |                            |          |           |   |
|   | the       |                            |          |           |   |
|   | enclosed  |                            |          |           |   |
|   | election  |                            |          |           |   |
|   | form will |                            |          |           |   |
|   | serve as  |                            |          |           |   |
|   | proof of  |                            |          |           |   |
|   | your      |                            |          |           |   |
|   | insurance |                            |          |           |   |
|   | coverage  |                            |          |           |   |
|   | should    |                            |          |           |   |
|   | you       |                            |          |           |   |
|   | require   |                            |          |           |   |
|   | medical   |                            |          |           |   |
|   | t         |                            |          |           |   |
|   | reatment. |                            |          |           |   |
|   | Tell the  |                            |          |           |   |
|   | medical   |                            |          |           |   |
|   | facility  |                            |          |           |   |
|   | to make a |                            |          |           |   |
|   | copy of   |                            |          |           |   |
|   | this form |                            |          |           |   |
|   | to submit |                            |          |           |   |
|   | with any  |                            |          |           |   |
|   | claim.    |                            |          |           |   |
|   | (Do not   |                            |          |           |   |
|   | let them  |                            |          |           |   |
|   | keep your |                            |          |           |   |
|   | copy of   |                            |          |           |   |
|   | the       |                            |          |           |   |
|   | form.)    |                            |          |           |   |
|   |           |                            |          |           |   |
|   | If you    |                            |          |           |   |
|   | have any  |                            |          |           |   |
|   | problems  |                            |          |           |   |
|   | obtaining |                            |          |           |   |
|   | service,  |                            |          |           |   |
|   | please    |                            |          |           |   |
|   | contact   |                            |          |           |   |
|   | the NFC   |                            |          |           |   |
|   | at        |                            |          |           |   |
|   | 1-800     |                            |          |           |   |
|   | -242-9630 |                            |          |           |   |
|   | or the    |                            |          |           |   |
|   | phone     |                            |          |           |   |
|   | number in |                            |          |           |   |
|   | Part H,   |                            |          |           |   |
|   | item 8,   |                            |          |           |   |
|   | on you    |                            |          |           |   |
|   | Health    |                            |          |           |   |
|   | Benefits  |                            |          |           |   |
|   | Election  |                            |          |           |   |
|   | Form, if  |                            |          |           |   |
|   | the NFC   |                            |          |           |   |
|   | number    |                            |          |           |   |
|   | does not  |                            |          |           |   |
|   | respond   |                            |          |           |   |
|   | satisf    |                            |          |           |   |
|   | actorily. |                            |          |           |   |
|   |           |                            |          |           |   |
|   | S         |                            |          |           |   |
|   | incerely, |                            |          |           |   |
|   |           |                            |          |           |   |
|   | Human     |                            |          |           |   |
|   | Resources |                            |          |           |   |
|   | S         |                            |          |           |   |
|   | pecialist |                            |          |           |   |
|   | (         |                            |          |           |   |
|   | Benefits) |                            |          |           |   |
|   |           |                            |          |           |   |
|   | Enclosure |                            |          |           |   |
+---+-----------+----------------------------+----------+-----------+---+