OPM issued rules in 2018 allowing employing offices and FEHB carriers to request proof of family member eligibility at any time. Image: Valeri Potapova/Shutterstock.com
By: FEDweek StaffThe FEHB program remains at risk of fraud from enrollments of ineligible persons, the GAO has said, at an estimated cost of up to $1 billion a year in claims which in turn add to the cost of premiums.
Its report echoes several issued in recent years by the inspector general’s office at OPM about the $59 billion a year program in which the 4.1 million enrollees — about an equal number of family members also are covered — pay about 30 percent of the total premium cost and the government 70 percent.
GAO credited OPM with issuing rules in 2018 allowing – but not requiring – employing offices and FEHB carriers to request proof of family member eligibility at any time for existing participants, and rules in 2021 requiring employing offices and carriers to verify family member eligibility for certain types of new enrollments. But it said that OPM still “cannot reasonably ensure ineligible family members are not covered in FEHB enrollments.”
It said that while OPM performs an annual risk assessment of the FEHB, it has not specified ineligible members as a fraud risk and “does not plan to establish a monitoring mechanism to identify and remove ineligible family members who already have FEHB coverage. Without such a monitoring mechanism, ineligible family members may remain covered and related improper payments may continue to accrue over time.”
Officials of five employing offices GAO interviewed said that “they do not regularly perform any ongoing monitoring or eligibility verification for currently participating family members. Instead, these officials noted that they might discover ineligible family members when employees make coverage changes . . . Similarly, officials from each of the five FEHB insurance carriers we spoke with told us they perform limited activities to identify and remove ineligible family members from the FEHB program.”
OPM does not have an estimate of how many ineligible members exist and at what cost to the program, GAO said. The report cited as an example an IG finding that a federal employee had enrolled in his family coverage for a dozen years two ineligible individuals, purported to be his wife and stepchild, at a cost in additional claims related to them of more than $100,000.
OPM management agreed to monitor whether employing offices and carriers are verifying family member eligibility but said it already is doing so through training and tracking compliance with the 2021 rules. OPM also said it is seeking funding to set up a government-wide enrollment portal that would allow for further scrutiny of family enrollees.
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See also,
Decisions to Make about FEGLI after Retirement
Oversight of Federal Employment, Retirement Issues Ahead
The TSP 2022 Website and Unresolved Issues
The Process of Retiring: Check Your Agency’s Work
