(2) Except as provided in paragraph (b) of this section, the optional insurance acquired as an employee stops, with no 31-day extension or right of conversion, on the date reemployment terminates and any suspended optional life insurance is reinstated on the day following termination of the reemployment.

(b) Optional insurance acquired during reemployment may be continued after termination of the reemployment if the retired employee qualifies for a supplemental annuity or acquires a new retirement right, continues his regular insurance, and has had optional insurance in force for the full period (or periods) of service during which it was available to him. If the optional insurance acquired during reemployment is so continued, any suspended optional life insurance stops with no 31-day extension of coverage or right of conversion.

§ 890.101 Definitions; time computations. (a) In this part:

(1) Terms defined by section 8901 of title 5, United States Code, have the meanings there set forth.

(2) "Cancellation" means the act of filing a health benefits registration form terminating enrollment in a health benefits plan and electing not to be enrolled for the future by an enrolled employee or annuitant who is eligible to continue enrollment.

(3) "Change of enrollment" means the registration of an enrolled employee or annuitant to be enrolled for another plan or option, or for a different type of coverage (self alone or self and family), from that for which then enrolled.

(4) "Eligible" means eligible under the law and this part to be enrolled.

(5) "Employing office" means the office of an agency to which jurisdiction and responsibility for health benefits actions for the employee concerned have been delegated. For enrolled annuitants who are not also eligible employees, the office which has authority to approve payment of annuity or workmen's compensation for the annuitant concerned is the employing office.

(6) "Immediate annuity" means an annuity which begins to accrue not later than 1 month after the date enrollment under a health benefits plan would cease for an employee or member of family if he were not entitled to continue enrollment as an annuitant. Notwithstanding the foregoing, an annuity which commences on the birth of the posthumous child of an employee or annuitant is an immediate annuity.

(7) "Option" means a level of benefits. It does not include distinctions as to whether the members of the family are covered.

(8) "Pay period" means the biweekly pay period established pursuant to section 5504 of title 5, United States Code, for the employees to whom that section applies, the regular pay period for employees not covered by that section; and the period for which a single installment of annuity is customarily paid for annuitants.

(9) "Register" means to file with the employing office a properly completed health benefits registration form, either electing to be enrolled in a health benefits plan or electing not to be enrolled. "Register to be enrolled" means to register an election to be enrolled. "Enrolled" means to be enrolled in a health benefits plan approved by OPM under this part.

(10) "Regular tour of duty" means a work schedule, prescribed in advance to continue indefinitely or for at least 6 months, of a certain number of hours or other time units in a day, week, biweekly pay period, month, or year.

(b) Whenever, in this part, a period of time is slated as a number of days or a number of days from an event, the period is computed in calendar days, excluding the day of the event. Whenever, in this part, a period of

time is defined by beginning and ending dates, the period includes the beginning and ending dates.

§ 890.102 Coverage.

(a) Each employee, other than those excluded by paragraph (c) of this section, is eligible to be enrolled in a health benefits plan at the time and under the conditions prescribed in this part.

(b) An employee who serves in cooperation with non-Federal agencies and is paid in whole or in part from nonFederal funds may register to be enrolled within the period prescribed by OPM for the group of which the employee is a member following approval by OPM of arrangements providing that (1) the required withholdings and contributions will be made from Federally-controlled funds and timely deposited into the Employees Health Benefits Fund, or (2) the cooperating non-Federal agency will, by written agreement with the Federal agency, make the required withholdings and contributions from non-Federal funds and transmit them for timely deposit into the Employees Health Benefits Fund.

(c) The following employees are not eligible:

(1) An employee serving under an appointment limited to 1 year or less, except an acting postmaster, and a Presidential appointee appointed to fill an unexpired term.

(2) An employee whose employment is of uncertain or purely temporary duration, or who is employed for brief periods at intervals, and an employee who is expected to work less than 6 months in each year, except an employee who is employed under a cooperative work-study program of at least 1 year's duration which requires the employee to be in pay status during not less than one-third of the total time required for completion of the program.

(3) An intermittent employee-a non-full-time employee without a prearranged regular tour of duty.

(4) An employee whose pay on an annual basis is $350 a year or less.

(5) A beneficiary or patient employee in a Government hospital or home.

(6) An employee paid on a contract or fee basis, except an employee who is a citizen of the United States who is appointed by a contract between the employee and the Federal employing authority which requires his personal service and is paid on the basis of units of time.

(7) An employee paid on a piecework basis, except one whose work schedule provides for full-time service or parttime service with a regular tour of duty.

(d) Paragraph (c) of this section does not deny coverage to an individual appointed to perform "part-time career employment," as defined in section 3401(2) of title 5, United States Code, and 5 CFR Part 340, Subpart B.

(e) The Office of Personnel Management makes the final determination of the applicability of this section to specific employees or groups of employ

ees.

(5 U.S.C. 1104; Pub. L. 95-454; 92 Stat. 1120 and sec. 3(5) of the Civil Service Reform Act of 1978; Pub. L. 95-454; 92 Stat. 1112)

[33 FR 12510, Sept. 4, 1968, as amended at 33 FR 20002, Dec. 31, 1968; 35 FR 753, Jan. 20, 1970; 44 FR 57382, Oct. 5, 1979]

§ 890.103 Correction of errors.

(a) The employing office can make prospective correction of administrative errors as to enrollment at any time.

(b) OPM may order correction of an error, mistake, or omission upon a showing satisfactory to OPM that it would be against equity and good conscience not to do so.

(c) OPM may order the termination of an employee's or annuitant's enrollment in a group practice plan and permit his enrollment in another plan upon a showing satisfactory to OPM that the furnishing of adequate medical care is jeopardized by a seriously impaired relationship between a patient and the plan's medical staff. [44 FR 37895, June 29, 1979]

§ 890.104 Initial decision and reconsideration.

(a) Who may file. An employee or annuitant may request OPM to reconsider a decision of an employing office or an initial decision of OPM refusing

to permit registration for or change of enrollment or refusing to permit enrollment of an individual as a family member.

(0) Agency decision. A request for reconsideration of an agency decision must be filed within 30 calendar days from the date of the written decision stating the right to reconsideration by OPM. The time limit may be extended as provided in paragraph (e) of this section. OPM may, in its discretion, issue a final decision under paragraph (f) of this section in lieu of a reconsideration decision.

(c) Initial decision. A decision shall not be considered an initial decision as used in § 890.104(a) of this part unless rendered by OPM in writing and unless such decision states the right to reconsideration.

(d) Reconsideration. A request for reconsideration must be made in writing, must include the claimant's name, address, date of birth, claim number (if appropriate), name of carrier and reasons for the request.

(e) Time limit. A request for reconsideration of an initial OPM decision must be filed within 30 calendar days from the date of OPM's initial decision. OPM may extend the time limit on filing when the individual shows that he/she was not notified of the time limit and was not otherwise aware of it, or that he/she was prevented by circumstances beyond his/ her control from making the request within the time limit.

(f) Final decision. After reconsideration; OPM shall issue a final decision which shall be in writing, and shall fully set forth the findings and conclusions of OPM.

[44 FR 37895, June 29,1979]

§ 890.105 Reopening.

(a) Time limit. An agency or an employee may, within 30 calendar days after receipt of the reconsideration decision, request the Associate Director for Compensation to reopen any previous decision by his/her representative for reconsideration. The Associate Director may reopen the decison on his/ her own motion or when the party requesting reopening submits written argument or evidence which tends to establish that:

(1) New and material evidence is available that was not readily available when the reconsideration decision was made;

(2) The reconsideration decision involves an erroneous interpretation of law or regulation, or a misapplication of established policy; or

(3) The reconsideration decision is of a precedential nature involving new or unreviewed policy considerations that may have effect beyond the case at hand.

(b) How to file. A request to reopen a reconsideration decision must be in writing, must include the individual's name, address, date of birth and claim number and must state the basis for the request.

(c) Associate Director for Compensation decison. When the Associate Director has reopened a reconsideration decision, he/she shall review the record or the proceedings and all written representations. He/she shall issue a written decision and send copies thereof to the parties and to the employee's representative. The decision of the Associate Director shall be final.

[44 FR 37895, June 29, 1979]

§ 890.106 Review of claim for payment or service.

(a) OPM does not adjudicate individual claims for payment or service under health benefits plans. Individual claims for payment or service are adjudicated by the health benefits plan in which the employee or annuitant is enrolled.

(b) If a claim (or portion of a claim) or a service is initially denied by a health benefits plan, the plan will reconsider its denial upon receipt within one year of the denial of written request for reconsideration from the employee or annuitant. Such written request should set forth the reasons why the employee or annuitant believes that the denied claim or service should have been paid or provided. The plan must affirm the denial in writing to the employee or annuitant, setting out in detail the reasons therefor, within 30 days after receipt of the request for reconsideration, or pay or provide the claim or service within such time, unless it requests additional informa

tion reasonably necessary to a determination. Such requests by the plan must specifically identify the additional information required and the reason or reasons therefor. If the information requested is not supplied within 60 days of the request therefor, the plan shall make its determination and notify the employee or annuitant as provided elsewhere in this section.

(c) If a plan either affirms its denial of a claim, or fails to respond to a written request for reconsideration within 30 days of the request, the employee or annuitant may make a written request to OPM's Associate Director for Compensation for a review to determine whether the plan's denial is in accord with the terms of OPM's contract with the carrier of the plan. The plan shall provide written notice to the employee or annuitant of the right to request such a review when it affirms a denial after reconsideration. A request for review will not be honored if received by OPM more than 90 days from the date of the plan's affirmation of the denial. Nor will a request for review be honored if, upon request by the Associate Director, the employee or annuitant does not furnish authorization signed by the patient (or person capable of acting for the patient) for the release of medical evidence to the Associate Director.

(d) In reviewing a claim denied by a plan, the Associate Director will review copies of all original evidence and findings upon which the plan denied the claim and any additional evidence submitted to the Associate Director or otherwise obtained by the plan or Associate Director. Plans will release such evidence and findings to the Associate Director within 30 days of request therefor. Any evidence obtained by the Associate Director in connection with a review of the denied claim will be held privileged and confidential and will be reviewed only by persons having official need to see it.

(e) In reviewing a claim denied by a plan, the Associate Director may request the employee or annuitant to obtain and submit additional medical or hospital records. The Associate Director may also request a confidential advisory opinion from an independent physician, or such other information

or evidence as may in the Associate Director's judgment, be required to evaluate the claim denial. An Associate Director's request for an advisory opinion shall not disclose the identity of the claimant or patient, the plan, or any medical institutions or physicians involved in the claim.

(f) Within 30 days after all evidence requested by the Associate Director has been received, it shall notify the employee and the plan of its findings on review.

[40 FR 25433, June 16, 1975. Redesignated at 44 FR 37895, June 29, 1979]

§ 890.107 Delegation of authority for resolving certain contract disputes.

For the purpose of making findings of fact and to the extent that conclusions of law may be required under any proceeding conducted in accordance with the provisions of the disputes clause included in health benefits contracts, OPM delegates this function to the Armed Services Board of Contract Appeals.

[40 FR 50023, Oct. 28, 1975; 40 FR 55829, Dec. 2, 1975. Redesignated at 44 FR 37895, June 29, 1979]

§ 890.108 Legal actions.

An action to compel enrollment of an employee or annuitant not excluded by § 890.102(c) should be brought against the employing office. An action to recover on a claim for health benefits should be brought against the carrier of the health benefits plan. An action to review the legality of OPM's regulations or a decision made by OPM should be brought against the Office of Personnel Management, Washington, D.C. 20415.

[33 FR 12510, Sept. 4, 1968. Redesignated at 44 FR 37895, June 29, 1979]

regard to age, race, sex, health status, or hazardous nature of employment, of each eligible employee and annuitant except that a plan which is sponsored or underwritten by an employee organization may not accept the enrollment of a person who is not a member of the organization, but it may not limit membership in the organization on account of these prohibited factors. The carrier may terminate the enrollment of an employee or of an annuitant, other than a survivor annuitant, in a health benefits plan sponsored or underwritten by an employee organization on account of termination of membership in the organization. A comprehensive medical plan need not enroll an employee or annuitant residing outside geographic areas specified by the plan. A carrier who wishes to terminate the enrollment of an employee or annuitant under this paragraph may do so by notifying the employing office in writing, with a copy of the notice to the employee. The termination is effective at the end of the pay period in which the employing office receives the notice.

(3) Provide health benefits for each enrolled employee and annuitant and covered member of their families wherever they may be.

(4) Provide for conversion to a contract for health benefits regularly offered by the carrier, or an appropriate affiliate, for group conversion purposes, which shall be guaranteed renewable, subject to such amendments as apply to all contracts of this class, except that it may be canceled for fraud, overinsurance or nonpayment of periodic charges. A carrier shall permit conversion within the time allowed by the temporary extensions of coverage provided under § 890.401 for each employee, annuitant, and member of family entitled to convert. When an employing office gives an employee written notice of his privilege of conversion, the carrier shall permit conversion at any time before (i) 15 days after the date of notice or (ii) 75 days after his enrollment is terminated, whichever is earlier. When OPM requests an extension of time for conversion because of delayed determination of ineligibility for immediate annuity, the carrier shall permit con