[Federal Register Volume 72, Number 50 (Thursday, March 15, 2007)]
[Rules and Regulations]
[Pages 12037-12038]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E7-4695]
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OFFICE OF PERSONNEL MANAGEMENT
5 CFR Part 875
RIN 3206-AK99
Federal Long Term Care Insurance Program: Miscellaneous Changes,
Corrections, and Clarifications
AGENCY: Office of Personnel Management.
ACTION: Final regulation.
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SUMMARY: The Office of Personnel Management (OPM) is issuing a final
rule to make miscellaneous changes, corrections, and clarifications to
the Federal Long Term Care Insurance Program (FLTCIP) regulations.
DATES: Effective Date: April 16, 2007.
FOR FURTHER INFORMATION CONTACT: Edward M. DeHarde, Center for Employee
and Family Support Policy, Strategic Human Resources Policy Division,
Office of Personnel Management, 1900 E Street, NW., Washington, DC
20415; or call him at 202-606-0004.
SUPPLEMENTARY INFORMATION: The current FLTCIP regulations were
published in the Federal Register at 70 FR 30605, May 27, 2005. In
those regulations OPM replaced references to ``Federal civilian and
Postal employees and members of the uniformed services'' with ``active
workforce member'' in several places. We are making a similar change in
two additional places: Sec. 875.405 and Sec. 875.410. We are also
correcting a section reference in Sec. 875.209 of the previously
published regulations.
In addition, Sec. 875.408 of the FLTCIP regulations discusses
incontestability, a provision that allows coverage based on an
erroneous application to continue under certain circumstances. The
FLTCIP contractor often doesn't learn that coverage is based on an
erroneous application until someone files a claim, and the contractor
becomes aware that the information on the individual's application
differed from what is shown in the individual's medical records. If the
erroneous coverage has been in effect less than two years, or if the
application contained knowingly false or misleading information, the
contractor may rescind (void) the coverage and refund the individual's
premiums. Section 875.104 of the FLTCIP regulations contains procedures
for resolving disputes concerning eligibility for benefits and payment
of claims. These final regulations clarify that the claims dispute
procedures apply only to persons who have valid coverage under the
Program. They do not apply to individuals whose erroneous coverage is
rescinded.
A proposed rule was published to amend 5 CFR part 875 in the
Federal Register at 71 FR 19459, April 14, 2006. OPM requested comments
by June 13, 2006. We received one comment by that date, from an FLTCIP
enrollee. The issues raised by this commenter are discussed below.
The commenter did not address the miscellaneous changes,
corrections, and clarifications that were contained in the proposed
regulation. Instead, the commenter suggested that OPM should
specifically list in the regulations which injuries qualify for
coverage under FLTCIP to ensure that enrollees with similar injuries
receive similar coverage. The comment received is beyond the scope of
the proposed change to FLTCIP regulations. In addition, coverage under
FLTCIP is not based on an enrollee's injury or medical diagnosis; it is
based on an enrollee's established inability to perform defined
activities of daily living or an enrollee's severe cognitive
impairment. Therefore, for the reasons supplied in the proposed rule,
the proposed rule amending 5 CFR part 875 which was published in the
Federal Register at 71 FR 19459, April 14, 2006, is adopted as a final
rule without change.
Executive Order 12866, Regulatory Review
This rule has been reviewed by the Office of Management and Budget
in accordance with Executive Order 12866.
Regulatory Flexibility Act
I certify that these regulations will not have a significant
economic impact on a substantial number of small entities because they
affect only enrollees in the Federal Long Term Care Insurance Program.
List of Subjects in 5 CFR Part 875
Administrative practices and procedures, Employee benefit plans,
Government contracts, Government employees, Health insurance, Military
personnel, Retirement.
Office of Personnel Management.
Linda M. Springer,
Director.
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Accordingly, OPM is amending 5 CFR part 875, as follows:
PART 875--FEDERAL LONG TERM CARE INSURANCE PROGRAM
0
1. The authority citation for 5 CFR part 875 continues to read as
follows:
Authority: Authority: 5 U.S.C. 9008.
0
2. In Sec. 875.104 add paragraph (f) to read as follows:
Sec. 875.104 What are the steps required to resolve a dispute
involving benefit eligibility or payment of a claim?
* * * * *
(f) The procedures described in paragraphs (a), (b), (c), (d), and
(e) of this section apply only if you have valid coverage under the
FLTCIP. If the Carrier determines that your coverage was based on an
erroneous application and voids the coverage as described in Sec.
875.408 of this part, these provisions do not apply. The Carrier will
provide you with information on your review rights in its rescission
letter (letter voiding your coverage).
0
3. In Sec. 875.209 revise the last sentence of paragraph (b) to read
as follows:
Sec. 875.209 How do I demonstrate that I am eligible to apply for
coverage?
* * * * *
(b) * * * The incontestability provisions in Sec. 875.408 do not
apply to this section.
0
4. In Sec. 875.405 revise the first sentence of paragraph (a)(1) to
read as follows:
Sec. 875.405 If I marry, may my new spouse apply for coverage?
(a)(1) If you are an active workforce member and you have married,
your spouse is eligible to submit an application for coverage under
this section within 60 days from the date of your marriage and will be
subject to the underwriting requirements in force for the spouses of
active workforce members during the most recent open season. * * *
* * * * *
0
5. In Sec. 875.408 revise paragraph (a) to read as follows:
[[Page 12038]]
Sec. 875.408 What is the significance of incontestability?
(a) Incontestability means coverage issued based on an erroneous
application may remain in effect. Such coverage will not remain in
effect under any of the following conditions:
(1) If your coverage has been in force for less than 6 months, the
Carrier may void your coverage upon a showing that information on your
signed application that was material to your approval for coverage is
different from what is shown in your medical records.
(2) If your coverage has been in force for at least 6 months but
less than 2 years, the Carrier may void your coverage upon a showing
that information on your signed application that was material to your
approval for coverage is different from what is shown in your medical
records and pertains to the condition for which benefits are sought.
(3) After your coverage has been in effect for 2 years, the Carrier
may void your coverage only upon a showing that you knowingly and
intentionally made a false or misleading statement or omitted
information in your signed application for coverage regarding your
health status that was material to your approval for coverage.
(4) If your coverage is voided, as described in paragraph (a)(1),
(a)(2), or (a)(3) of this section, no claims will be paid. In addition,
the provisions of Sec. 875.104 relating to the procedures for
resolving a dispute involving benefits eligibility or claims denials do
not apply to your situation. You may request a review by the Carrier if
you believe that your coverage was voided in error. You must submit
your request in writing to the Carrier within 30 days of the date of
the rescission letter (letter voiding your coverage).
* * * * *
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6. In Sec. 875.410 revise the first sentence to read as follows:
Sec. 875.410 May I continue my coverage when I leave Federal or
military service?
If you are an active workforce member, your coverage will
automatically continue when you leave active service, as long as the
Carrier continues to receive the required premium when due. * * *
[FR Doc. E7-4695 Filed 3-14-07; 8:45 am]
BILLING CODE 6325-39-P