Office of Personnel Management

Retirement and Insurance Group

1920 1954 1959 1986 

 

Benefits Administration Letter

Number: 96-207 Date: October 16, 1996 

SUBJECT: Federal Employees Health Benefits Program: New Regulations for Payment

of Health Benefit Premiums for Periods of Nonpay Status or Insufficient Pay

 

I. OVERVIEW

 

A. Purpose This letter gives instructions on implementing an interim regulation

on the payment of Federal Employees Health Benefits (FEHB)

premiums during periods of leave without pay or insufficient pay

that was issued by the Office of Personnel Management on July 22,

1996. The regulation was transmitted to employing offices in

Benefits Administration Letter 96-601. Section 890.502(b) of the

regulation clarifies the responsibilities of both employing offices

and employees when employees enter nonpay status or their pay is

insufficient to cover their FEHB premium payments.

 

B. Problem addressed

 by the regulation

Current OPM guidance in Subchapter S20-2b(4) of the FEHB

Handbook for Personnel and Payroll Offices states that "All

employees entering nonpay status or whose salary is insufficient to

cover the health benefits premiums should be given a specific

notice informing them of the requirement for payment of health

benefits premiums for coverage which continues during periods of

nonpay status or insufficient salary." We became aware that many

Federal employees were not receiving this notice, and were being

billed for FEHB coverage that they were not aware they had.

 

C. Goals of the

 regulation

The new regulation has three goals. The first goal is to ensure that

all employees who enter nonpay status, or whose pay is

insufficient, receive notice of their options to continue or terminate

their FEHB coverage. The second goal is to ensure that agencies

have the necessary documentation so they can collect premiums
2

from employees who elect to continue their FEHB coverage. The

third goal is to not penalize employees who decide to terminate

their FEHB coverage during a period of nonpay status or

insufficient pay.

 

D. General notice to

 all employees

Because of the importance of the changes made by this regulation

for employees, agencies must distribute Attachment 1 to all

employees at the earliest possible date. Distribution may be made

through hard copy, newsletters, computer bulletin boards, and other

available methods.

 

II. EFFECTIVE DATE AND APPLICABILITY

 

A. Effective date The regulation became effective on August 21, 1996. Therefore,

it will generally apply to pay periods of nonpay status or

insufficient pay that begin on or after August 21, 1996. The

regulation does not apply to periods of nonpay status or insufficient

pay that began before August 21, 1996.

 

B. Applicability The regulation establishes general rules which usually apply to

periods of nonpay status or insufficient pay. However, additional

or special rules apply when employees enter nonpay status to

perform uniformed service; to serve as an officer or employee of an

employee organization; to work under the Intergovernmental

Personnel Act; or, who are in a leave without pay status in excess

of 365 days under the Family and Medical Leave Act.

 

III. EMPLOYING OFFICES MUST NOTIFY EMPLOYEES

A. Employing office Employing offices must have a procedure which identifies all

 must identify employees whose FEHB premium payments cannot be withheld

 employees from their salary because they are in nonpay status or their pay is

insufficient to cover the premiums. In order to do this, there

needs to be maximum cooperation between personnel, payroll,

and employees' supervisors.

Rather than relying on Standard Form (SF) 50's, agencies must rely

on time keeping/payroll data. Employing offices cannot rely on SF

50's for this information because they are not issued for employees

entering leave without pay for less than 30 days or
3

when employees have insufficient pay. In addition, in many of the

cases we have examined where a SF 50 was required, the SF 50

was never issued, or it was issued after the period of nonpay status

ended.

 

B. Employing office

 must notify

 employees

Employing offices must give a written notice to employees as soon

as possible after the employing office becomes aware that FEHB

premium payments cannot be withheld from their salary because

they are in nonpay status or their pay is insufficient to cover the

premiums. The notice must contain all the necessary information

on the options to continue or terminate the enrollment. Attachment

2 is a sample notice that contains all the necessary information.

 

C. How to notify

 employees

If the employing office cannot give the written notice directly to the

employee in person, it must send the notice by first class mail.

 

D. Use of electronic mail Employing offices cannot use electronic mail at this time to give

the written notice to employees. While we are strongly in favor of

automating repetitive actions required under the FEHB Program,

we are also committed to ensuring that employees receive the

written notice. Especially important in this case is the fact that an

employee's failure to timely respond results in termination of FEHB

coverage. However, we are willing to work with employing offices

who want to automate the written notification requirement on a

pilot basis. We are convinced that such pilots will result in

guidance that can be used by all employing offices.

 

E. Contents of the

 notice

The main purpose of the attached notice is to inform employees of

their options in regard to their FEHB coverage so they can make an

educated decision. The notice informs employees of their options

to continue or terminate their FEHB enrollment. The notice

explains the effect of a termination. The notice states that by

deciding to continue coverage, the employee agrees to either pay

the premium directly or incur a debt. The notice provides a space

for employees to continue or terminate their enrollment. The notice

also informs employees that if they do not return the notice within

31 days of receiving the notice, (45 days for employees residing

overseas), their enrollment will automatically terminate.

 
4

F. Tracking receipt and

 return of notice

When tracking whether the employee signed and returned the

notice within the required time frame note that:

 A notice that is mailed is deemed to be received by the

 employee 5 days after the date of the notice.

 When the employee mails the signed form, the date of the

 postmark is deemed to be the date the notice is returned to

 the employing office.

 

IV. WHAT HAPPENS IF THE ENROLLMENT TERMINATES?

A. Two ways enrollment

 may terminate

Employees' FEHB enrollments will terminate if (1) they fail to sign

and return the written notice within 31 days of receiving the notice,

(45 days for employees residing overseas), or (2) they return the

signed notice, electing to terminate their enrollment.

 

B. When the employee

 elects to terminate

 the enrollment

When an employee elects to terminate the enrollment the

employing office must prepare an SF 2810 terminating the

enrollment. In the remark section include the statement,

"Employee elected to terminate the enrollment during a period

of...." Conclude the remark with the applicable statement i.e.,

"nonpay status" or "insufficient pay." Attach the signed notice to

the SF 2810 and file in the permanent side of the Official Personnel

Folder (OPF). Follow standard procedures for distributing the

copies of the SF 2810.

 

C. When the employee

 does not return the

 notice within time

 frame

When an employee does not return the written notice within 31

days of receiving the notice, (45 days for employees residing

overseas), the employing office must prepare an SF 2810

terminating the enrollment. In the remark section include the

statement, "Employee did not timely return written notice during a

period of...." Conclude the remark with the applicable statement

i.e., "nonpay status" or "insufficient pay." Attached the file copy

of the notice to the SF 2810 and file in the permanent side of the

Official Personnel Folder (OPF). Follow standard procedures for

distributing the copies of the SF 2810.

 

D. Effective date of

 termination

The effective date of a termination under IV.B or IV.C is

retroactive to the end of the last pay period in which the premium

was withheld from pay.
5

 

V. WHAT IS THE EFFECT OF A TERMINATION?

 

A. Terminations are

 different from

 cancellations

Previously, employees who decided not to continue their coverage

during nonpay status or insufficient pay had to cancel their

enrollment. Now, employees terminate their enrollment if they

decide not to continue their coverage. The three major differences

between cancellations and terminations are explained below.

 

B. Temporary extension

 of coverage and

 conversion

When an enrollment is terminated, FEHB coverage continues

temporarily for 31 days, and the employee and any covered family

members may convert to nongroup coverage. Temporary

extension of coverage and conversion are not available when the

enrollment is cancelled.

 

C. Opportunity to

 reenroll

As explained below in section VII, when an enrollment is

terminated, the employee does not have to wait until the next open

season to reenroll. When employees cancel their FEHB

enrollment, they must usually wait until the next open season to

enroll.

 

D. Satisfying 5-year rule

 for continuing

 coverage during

 retirement

A termination is not considered a break in the continuous coverage

necessary for continuing FEHB coverage during retirement. The

period during which the termination is in effect does not count

toward satisfying the required 5 years of continuous coverage. A

cancellation is considered a break in the continuous coverage

necessary for continuing FEHB coverage during retirement.

 

E. Not eligible for TCC Temporary Continuation of Coverage (TCC) is not available to

employees whose FEHB coverage terminates during nonpay status

or insufficient pay. TCC is only available to employees whose

FEHB coverage terminates because of separation from

employment.

 
6

VI. RETROACTIVE REINSTATEMENT OF TERMINATED FEHB COVERAGE

 

A. Circumstances

 beyond control

When employees' enrollments are terminated because

circumstances beyond their control, (such as a serious injury or

similar circumstances), prevented them from timely returning the

notice, they may request reinstatement of their FEHB coverage by

writing to their employing office. Employees must file the request

within 30 calendar days from the date the employing office gave

them notification of the termination. Employees must include with

the request a description of the circumstances beyond their control

that prevented timely return of the notice.

When making a reinstatement request, employees must also include

the signed written notice electing to continue FEHB coverage and

agreeing to either pay the premium directly or incur a debt.

 

B. Employing office

 procedures when

 request is granted

When the employing office decides reinstatement of the enrollment

is appropriate, it must take the following action. Complete parts A,

D, and H of the SF 2810; note in the remarks section "Employee

reinstated"; and, follow standard procedures for distributing the

copies of the SF 2810.

 

C. Employing office

 procedures when

 request is denied

When the employing office decides reinstatement of the enrollment

is not appropriate it must notify employees of their right to request

a review of the decision from the employing agency. The

reconsideration process must follow the requirements of

5 CFR 890.104, which include the condition that the

reconsideration review must be an independent review designated

at or above the level at which the initial decision was rendered.

 

VII. WHEN CAN EMPLOYEES REENROLL FOR FEHB COVERAGE?

A. Determining factor The triggering event that allows employees who terminated their

FEHB enrollment to reenroll is determined by whether the

termination occurred during a period of nonpay status or

insufficient pay.

 

B. Nonpay status Employees who terminated their enrollment while they were in

nonpay status may reenroll within 31 days of returning to pay and

duty status.
7

 

C. Insufficient pay Employees who terminated their enrollment while their pay was

insufficient may reenroll within 31 days after the end of the first

pay period their pay becomes sufficient to cover their FEHB

premium.

 

D. Effective date Reenrollments under VII.B and VII.C take effect the first day of the

first pay period that begins after the date the employing office

receives an appropriate request to reenroll and that follows a pay

period during any part of which the employee is in pay status.

 

E. Can choose any plan

 or option

Employees can reenroll into any plan or option available to them

under the FEHB Program. They are not restricted to enrolling into

the same plan and option they had when their coverage was

terminated.

 

F. Effect of failure to

 reenroll

Employees who fail to reenroll during the 31-day time period must

wait for an open season until they can enroll for FEHB coverage,

unless another qualifying event, such as a change in marital status,

occurs before the next open season. The break in coverage which

results from the failure to reenroll is taken into account when

determining whether the employee has satisfied the continuous

coverage requirement for continuing FEHB coverage during

retirement.

 

G. Future change in

 time period to

 reenroll

On July 9, 1996, OPM published in the Federal Register a

proposed regulation entitled, "Federal Employees Health Benefits

Program: Opportunities to Enroll and Change Enrollment"

(61 FR 35973). This regulation will most likely be finalized in the

near future. When the regulation does take effect, one of the

changes it will make is to expand the time frame for employees to

reenroll under VII.B and VII.C from 31 to 60 days.

 

VIII. WHAT HAPPENS IF THE ENROLLMENT CONTINUES?

A. Two options Employees who elect to continue coverage during nonpay status or

insufficient pay can choose between paying the premiums directly

or incurring a debt.

 
8

B. Filing election in

 OPF

When employees return the written notice electing to continue

FEHB coverage, the employing office must add a copy of the

signed notice to the permanent side of the Official Personnel

Folder.

 

C. Employing office's

 responsibilities

The new regulations, like the previous regulations on this subject,

require agencies to establish a method for accepting direct payment

of FEHB premiums from an employee in nonpay status or

insufficient pay. Employing offices must tell employees who elect

to pay premiums directly how to make the payments. Employees

who do not pay all the premiums that become due incur a debt for

past-due FEHB premiums. Employing offices are responsible for

determining the debt incurred by employees during nonpay status

or insufficient pay, and collecting and forwarding to OPM the

appropriate past-due health benefits premiums.

 

IX. COLLECTING PAST-DUE FEHB PREMIUMS FOR PAY PERIODS BEGINNING

 BEFORE SEPTEMBER 30, 1996

 

A. Withholding debt

 from salary

Employing offices must give a written notice to employees

indebted for past-due FEHB premiums while on nonpay status

when they return to pay and duty status, (and to employees who

incurred the debt because their salary was insufficient when their

salary becomes sufficient to pay FEHB premiums). The notice

much state that the amount due will be withheld by deducting the

regular premium and an additional premium per pay period until

the debt is paid. The notice must include the employing office's

contact person for employees who have questions about the notice.

Attachment 3 is a sample notice that contains all the necessary

information.

 

B. Final payment of

 salary and accrued

 annual leave

If employees separate from service before repaying the debt, the

full amount of any final payment of salary or accrued annual leave

is available for offset.

 

C. Notice to separating

 employees

Employing offices must give a written notice to employees who

separate from the employing office before collection of any

past-due FEHB premiums are completed. Because the debt should

generally be recovered promptly when employees return to duty,

and because the full amount of any final checks to employees may

be offset to settle the debt, it is expected that this notice will be
9

used primarily in the case of employees who do not return to duty

after a period of nonpay status or insufficient pay. Attachment 4 is

a suggested notice to be used for this purpose.

 

D. Refund of retirement

 deductions and

 annuity payments

If separated employees apply for withdrawal of their accumulated

retirement deductions or receive annuity payments, the refunds or

annuity payments are available for offset. An employee's SF 2806,

"Individual Retirement Record" for the Civil Service Retirement

System (CSRS), (or SF 3100 for the Federal Employees Retirement

System (FERS)), must be noted when forwarded to OPM to show

that the employee is indebted. In the remarks column enter,

"Indebted in Amt of $ for FEHB, OPM 1522 (Will be Fwd)(is

Attached)." In this way, the amount necessary to settle the debt

may be offset from any refund of retirement deductions or annuity

payments.

Employing offices must use OPM Form 1522, "Request for Offset

for Past-Due Health Benefits Premiums From Monies Payable

Under the Civil Service Retirement System (in Lieu of SF 2805)",

to request the offset of any outstanding past-due FEHB premiums

from any amounts to be paid to the former employee from the

CSRS or FERS. The employing office must submit the OPM Form

1522 to OPM after giving the separated employee the notice

required by IX.C.

If the debt is settled before an offset is processed by OPM and sent

to the employing office, the employing office must notify OPM to

prevent a duplicate recovery of the debt and the consequent need

for a refund to the former employee.

 

E. Subsequent federal

 employment

When an indebted employee separates, the employing office must

document the Official Personnel Folder (right hand side) to alert

the next employing office, if any, that the amount of the debt must

be withheld from pay and forwarded to the former employing

office which is still responsible for forwarding the amount due to

OPM on an SF 2812. Such documentation may consist of the file

copy of the notice required by IX.A or IX.C, appropriately noted.

In such a case, the new employing office must contact the former

employing office to verify the debt and to make the necessary

arrangements for forwarding any amounts collected.

 

F. Any other source In addition to the above methods to collecting past-due FEHB

premiums, this debt can also be collected from any other source
10

normally available for the recovery of a debt due the United

States. Therefore, employing offices should also utilize other

available methods to collect past-due health benefits premiums.

 

G. Remitting

 payments to OPM

The procedures for remitting premiums to OPM are unchanged.

The amounts forwarded for coverage during nonpay status or

insufficient pay, including amounts collected for past-due FEHB

premiums, must be incorporated in the employing office's regular

SF 2812. OPM will not accept individual payment and/or separate

documents concerning payments of this type.

 

X. SPECIAL CIRCUMSTANCES

 

A. Employees who pay

 their FEHB

 premiums over less

 than 12 months

Some employees normally pay their total health benefits premiums

for the year over a period of less than 12 months, such as teachers

on a 10-month contract. Accordingly, when the employee is in

nonpay status during the expected nonpay period (for which the

premiums taken during pay status have been adjusted), such as the

teacher's summer break, the employee does not pay any additional

premiums. However, if the employee enters a nonpay status during

the normal working period so that the health benefits withholding

is not made for a pay period in which it otherwise would have been

made, the employee is responsible for the premiums for that period

of nonpay status in the same way as employees on a regular yearround withholding system.

 

B. Part-time employees Career part-time employees who receive a prorated Government

share are responsible, for periods of nonpay status, for the same

health benefits premiums which would be withheld from pay if

they were in pay status with their regularly scheduled tour of duty.

 

C. Temporary

 employees

Temporary employees with one year of current continuous

employment can enroll for FEHB coverage and must pay both the

employee and Government contribution. For periods of nonpay

status, temporary employees remain responsible for both

contributions.

 

D. Discharges in

 bankruptcy

An individual is no longer required to repay any past-due FEHB

premiums if the debt is discharged in bankruptcy. When an

employing office is notified of a discharge in bankruptcy they must

inform OPM of the discharge so OPM does not make an offset
11

from an individual's refund of retirement contributions or annuity

payment.

 

XI. PAYMENT OF THE GOVERNMENT CONTRIBUTION

 

 Rule Employing offices must in any and all circumstances, on a current

basis, pay their share of the cost of an enrollment under the FEHB

Program for every pay period during which an employee's

enrollment continues whether the employee is in a pay or nonpay

status. The employing office must submit the Government

contribution as soon as it becomes due, that is, with the other

deductions and contributions forwarded on the SF 2812, Report of

Withholdings and Contributions, for the same pay period in which

the coverage continued.

 

XII. COORDINATION WITH RETIREMENT OR WORKERS' COMPENSATION CASES

 

A. Purpose The purpose of this section is to inform employing offices when

and how to coordinate the collection of past-due FEHB premiums

with deductions from Federal retirement and workers'

compensation benefit payments.

 

B. General Information When an individual applies for disability retirement or workers'

compensation benefits, the annuity or compensation is generally

payable from the day following the last day of pay. If the enrollee

is eligible to continue coverage during receipt of annuity or

compensation, the appropriate premium is withheld from the

benefits retroactive to the beginning date of the payments.

Therefore, if an employee's application for annuity or

compensation is approved, the amounts due for health benefits are

withheld from these benefits.

 

C. When premium is

 not paid

If the FEHB premium has not been paid, either directly by the

employee or through collection of the debt, for the same period for

which FEHB withholdings are made from annuity or compensation

no action is necessary by the former employing office.

 

D. When premium is

 paid

If the FEHB premium has been paid, either directly by the

employee or through collection of the debt, for the same period for

which FEHB withholdings are made from annuity or compensation
12

these amounts must be refunded to the employee by the

employing office, to avoid double payments by the employee.

 

E. Coordination with

 retirement cases

In retirement cases except for the case noted below, the employing

office must refund the amounts received directly from the

employee for periods after the last day of pay because these periods

will be covered by withholdings from annuity. When the employee

does not meet the requirements for an annuity on the day after the

last day of pay, such as when the employee has not completed 5

years of civilian service until a later date, the annuity will not begin

until a later date. In such cases, the employing office must only

make a refund for periods of nonpay status after the annuity began.

 

F. Coordination with

 disability retirement

 cases

The employing office must refund amounts received directly from

an employee when it receives OPM's approval form for disability

retirement applications, unless the employing office does not have

sufficient information on file to determine that all periods of

nonpay status after the last day of pay will be covered by

withholdings from annuity. If the employing office is unable to

determine the period to be covered by a refund of premiums, a

request for verification of the correct period for which annuity

withholdings will be made must be requested by letter attached to

the documents transferring the employee's health benefits to OPM.

 

G. Coordination with

 workers'

 compensation cases

In workers' compensation cases, the employing office must receive

verification from the Office of Workers' Compensation Programs

of the dates for which health benefit premiums have been withheld

from benefits before refunding any amounts paid directly to the

agency.

 

XIII. RECENTLY ENACTED LEGISLATION

A. Summary Section 422 of the Treasury, Postal Service and General

Government Appropriations, 1997, as incorporated in Section

101(f) of the Omnibus Consolidated Appropriation Act of 1997,

Public Law 104-208, requires that agencies advance salary to

employees in nonpay status in the amount of the employee

contribution for their FEHB coverage. Agencies are also required

to forward the full FEHB premium (both Government and

employee contributions) for employees in nonpay status on a

current basis for each pay period FEHB coverage continues. The

Act was enacted on September 30, 1996, and became effective for
13

pay periods beginning on or after September 30, 1996.

 

B. Further guidance Once we fully evaluate this provision we will provide further

guidance, including instructions on how to collect the debt resulting

from the advancement of salary.

 

Abby L. Block, Chief

Insurance Policy and

 Information Division

4 Attachments
Attachment 1

14

IMPORTANT CHANGES 

IN THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

This notice provides information about revised rules effective August 21, 1996, for employees who ar e

enrolled in the Federal Employees Health Benefits (FEHB) Program and who enter nonpay statu s

(including leave without pay), or whose pay otherwise becomes insufficient to cover premiums.

Employees who are enrolled in the FEHB Program are responsible for payment of their regular premium

for each pay period they are enrolled. When an em ployee enters nonpay status, or when pay is insufficient

to cover the cost of the premium, the employing office must provide the employee written notification of

the following options:

• continuing the enrollment and agreeing to pay the premium or incur a debt; or

• terminating the enrollment.

If an employee chooses to continue the enrollment, payment of the premiums may be made either on a

current basis, or when the employee returns to work. If an employee chooses to terminate the enrollment

and avoid the indebtedness for the premium, the revised rules provide that:

• the termination is subject to the 31-day temporary extension of coverage;

• the employee and any covered family members may convert to a nongroup contract;

and

• the employee may re-enroll in any FEHB plan upon returning to pay and duty status,

without having to wait for an open season or other enrollment event.

Also, under the revised rules, if an employee fails to make an election within the 31-day time frame, (45

days for employees residing overseas), the FEHB enrollment will automatically terminate.

A termination under the revised rules is not considered a break in the continuous coverage necessary for

continuing health insurance into retiremen t. However, the period during which the termination is in effect

does not count toward satisfying the required 5 years of continuous coverage.

Additional or special rules apply when employees enter nonpay status to perform uniformed service; t o

serve as an officer or employee of an employee organization; to work under the Intergovernmenta l

Personnel Act; or, who are in leave without pay st atus in excess of 365 days under the Family and Medical

Leave Act.

For full details, contact your employing organization. (Please try to give a specific person or office, and

a phone number.)
Attachment 2

15

FEDERAL EMPLOYEE HEALTH BENEFITS (FEHB) OPTIONS WHILE IN NONPAY STATUS

Name of Employee: Date: 

You must respond within 31 days, (45 days for employees residing overseas), of this notice or your FEHB

enrollment will automatically terminate.

Each pay period you are enrolled in the FEHB Program, you are responsible for payment of the employee share

of the premium. When you enter nonpay status, or your pay is insufficient to cover the premium, you must:

• terminate the enrollment; or

• continue the enrollment and agree to pay the premium or incur a debt.

TERMINATING THE ENROLLMENT

If you elect to terminate your enrollment (or the enrollment automatically terminates), the termination will take

effect at the end of the last pay period in which premiums were withheld from pay. FEHB coverage will continue

at no cost to you for an additional 31 days. During the 31 days, you and your covered family members may

convert to a nongroup contract. The termination is not considered a break in the continuous coverage necessary

for continuing FEHB coverage into retirement. However, the period during which the termination is in effect

does not count toward satisfying the required 5 years of continuous coverage. When you return to pay and duty

status, or at the end of the first pay period your pay becomes sufficient to cover your premium, you must reenroll

within 31 days if you want FEHB coverage.

CONTINUING THE ENROLLMENT AND AGREEING TO PAY THE PREMIUM

If you elect to continue your coverage, you must elect to pay the premiums directly or to incur a debt in the

amount of the unpaid premiums. If you elect to pay directly, mail a check or money order payable to 

. Include on the check your name, social security number, a note that the payment is for "FEHB premium", and

the pay period for which the payment is being made. Mail to: (address) .

If you elect to incur a debt, or if you elect to pay directly but fail to pay the entire amount due, you will receive

a notice stating the total amount due. The notice will be sent when you return to pay status, your pay becomes

sufficient, or you separate from employment. By electing to continue coverage you agree that the amount due

will be withheld from salary by deducting the regular premium and an additional premium per pay period until

the debt is paid. If the amount due cannot be withheld in full from salary, it will be recovered from a lump sum

payment of accrued leave, income tax refunds, amounts payable under the Civil Service Retirement System or

Federal Employees Retirement System, or any other source normally available for the recovery of a debt due the

United States.

Please check the appropriate space(s) below, sign, and return this notice to your employing office at: (address)

 .

After reading and understanding the above, I elect to:

Continue the enrollment (Check one): Submit direct payments Incur a debt

(Signature) (Date) 

Terminate the enrollment. (Signature) (Date) 

Refer questions to: (Name) (Telephone) 
Attachment 3

16

Notice of Intent to Recover Past-Due Health Benefits Premiums From Salary

Name of Employee: Date:

 Employees enrolled in the Federal Employees Health Benefits (FEHB) Program are responsible for payment

of the employee share of the cost of their enrollment for every pay period during which their enrollment

continues. When you entered nonpay status, or your pay became insufficient to cover the FEHB premium, you

signed a notice electing to continue your FEHB enrollment and agreed that any unpaid premiums for this period

of coverage would be withheld from salary. The amount due will be withheld by deducting your regular premium

and an additional premium per pay period until the debt is paid.

 Our records show that you are indebted as described below. Please note that a recovery action from your salary

will start soon. If you believe the amount of the indebtedness is incorrect, or if you have any questions regarding

this notice, please contact the person mentioned below as soon as possible. Unless you pay the amount due in

full, these withholdings will begin automatically as shown. If you should separate from service before the full

amount due is recovered, your final salary payment will be used to complete recovery of the indebtedness. The

remaining amount due, if any, will be recovered from a lump sum payment of accrued leave, income tax refunds,

amounts payable under the Civil Service Retirement System or Federal Employees Retirement System, or any

other source normally available for the recovery of a debt due the United States.

Name of FEHB plan and enrollment code: 

Pay periods not covered by withholdings: 

Total premiums required for these pay periods: 

Amounts you paid directly to agency: 

Total amount due to date: 

Recovery from salary begins on: 

Amount of each installment: 

Number of installments: 

Name, address and telephone number of contact person: 

 
Attachment 4

17

Notice of Intent to Recover Past-Due Health Benefits Premiums

Name of Employee: Date:

 Employees enrolled in the Federal Employees Health Benefits (FEHB) Program are responsible for payment

of the employee share of the cost of their enrollment for every pay period during which their enrollment

continues. When you entered nonpay status, or your pay became insufficient to cover the FEHB premium, you

signed a notice electing to continue your FEHB enrollment and agreed that any unpaid premiums for this period

of coverage would be recovered from any source normally available for the recovery of a debt due the United

States.

 Our records show that you are indebted as described below. You may pay the full amount due by check or

money order made payable to . However, if you believe that the amount due is

incorrect, or if you have any questions about this indebtedness please contact the person mentioned below within

15 days. If we do not hear from you, we will take action to recover the amount due from a lump sum payment

of accrued leave, income tax refunds, amounts payable under the Civil Service Retirement System or Federal

Employees Retirement System, or any other source normally available for the recovery of a debt due the United

States.

Name of FEHB plan and enrollment code: 

Pay periods not covered by withholdings: 

Total premiums required for these pay periods: 

Amounts you have already paid: 

Total amount due: 

Name, address and telephone number of contact person: