HI 00801: Hospital Insurance Entitlement
A. Employees—General
Except as indicated below, a “Federal employee” could be covered under FEHBA. The term “Federal employee” for FEHBA purposes means: an appointive or elective officer or employee in or under the executive, judicial, or legislative branch of the United States Government (including a Government-owned or controlled corporation) or of the municipal government of the District of Columbia; an Official Reporter of the Debates of the Senate and persons employed by the Official Reporters of Debates of the Senate in connection with the performance of their official duties; and an employee of Gallaudet College.
If the employee could be covered, his spouse could also be covered, and will be precluded from HI under the deemed insured provision.
Excluded from the definition of “Federal employee” under FEHBA and thus not precluded from entitlement to deemed insured HI are those engaged in:
1. TVA
Employment with the Tennessee Valley Authority.
2. Uniformed service
Employment as a member of the uniformed service (i.e., members of the Armed Forces, Coast Guard, and Commissioned Officers of the Public Health Service, and Coast and Geodetic Survey).
3. Noncitizen employee
Employment as a noncitizen employee whose permanent-duty station is located outside the United States.
4. FCA
Employment with a corporation which is under the supervision of the Farm Credit Administration and has one or more of the members of its Board of Directors elected or appointed by private interests.
5. CSC exclusion
Employment which is excluded from coverage under FEHBA by U.S. Civil Service Commission regulations: temporary employment, intermittent part-time employment, employment for which the salary on an annual basis is $350 a year or less, employment of a patient in a Government hospital or home, and employment on a contract or fee basis. In addition, Federally-appointed cooperative employees serving with State agencies may, as described in B. below, be excluded from FEHBA coverage.
If the claimant alleges he has (or had) coverage under FEHBA based upon employment which appears to be excluded from such coverage under the guides in 1.-5. above, review the fuller discussion of these exclusions under Civil Service Commission regulations provided in the Federal Personnel Manual Supplement, 890-1, subchapter S4. If this review does not resolve the question of eligibility for FEHBA coverage, develop under HI 00801.081.
B. Federally-appointed cooperative employees serving with state agencies
Under Civil Service Commission regulations, Federally-appointed cooperative employees serving with non-Federal agencies and paid in whole or part from non-Federal funds (e.g., county agricultural agents) may enroll under FEHBA if the non-Federal agency arranges with the Commission for the payment of premiums. In the absence of such arrangements, these employees and their spouses would not be considered to have had an opportunity to enroll in a FEHBA plan. They would not, therefore, be precluded from entitlement to HI under the deemed insured provision. Those who retired before an arrangement was made would also not be precluded from HI entitlement.
Most of these arrangements under the Civil Service Commission regulations have been made through the Department of Agriculture and only with State Extension Services in the following States:
| State | Effective Date of Agreement |
|---|---|
| Alaska | May 31, 1968 |
| Arizona | October 30, 1960 |
| Arkansas | June 1, 1961 |
| Colorado | November 30, 1964 |
| Delaware | May 30, 1970 |
| Hawaii | August 31, 1960 |
| Kansas | June 1, 1960 |
| Kentucky | June 1, 1960 |
| Maine | February 14, 1961 |
| Minnesota | September 14, 1960 |
| Mississippi | October 30, 1967 |
| Montana | August 31, 1960 |
| Nebraska | August 1, 1960 |
| Nevada | January 29, 1962 |
| New Hampshire | May 1, 1963 |
| New Mexico | August 31, 1960 |
| North Dakota | August 1, 1960 |
| Oklahoma | June 1, 1960 |
| Oregon | May 30, 1972 |
| South Carolina | May 31, 1968 |
| Utah | June 6, 1961 |
| Vermont | November 30, 1967 |
| Virgin Islands | November 6, 1966 |
| Washington | December 30, 1967 |
| West Virginia | July 1, 1962 |
If consistent with the above information, accept the statement of a Federally-appointed cooperative employee (or a civil service annuitant who formerly was such an employee) that he had no opportunity to enroll under FEHBA. If, on the other hand, such employee served in one of the listed States after the date of the arrangement with the Civil Service Commission, apply the rules in HI 00801.081.
C. Annuitant or his spouse
A former Federal employee or the spouse of a former Federal employee can be covered under FEHBA if he (or his spouse) is an “annuitant” and meets certain other conditions. Under the 1959 Act, an “annuitant” includes an individual who:
Retired on an immediate retirement annuity after 12 or more years of service; or
Retired on a disability annuity; or
Receives an annuity as the widow or widower of a Federal employee; or
Receives monthly compensation under the Federal Employees Compensation Act and is, as determined by the Secretary of Labor, unable to work; or
Receives monthly compensation as a surviving spouse of an individual who qualified to receive compensation under 4, above.
To be covered under FEHBA, an individual's annuity must be sufficient to cover the cost of the premium. An individual who started receiving an annuity before 7/60 but had no Federal employment after 6/60, could not be covered before 7/74.