OPM has issued guidance on verifying that family members are eligible for coverage under the FEHB program, including the process to be used and the documentation to be required.
The “benefits administration letter” is the latest in a series of steps to tighten scrutiny of those covered, in light of inspector general reports warning that ineligible persons are being insured under the program, raising premium costs to the government and to other FEHB enrollees.
The directive applies to agency responsibilities to verify eligibility of family members during initial enrollment of newly hired employees and when family members are being added to an existing enrollment due to a “qualifying life event” such as marriage. OPM at the same time issued similar but separate instructions to FEHB carriers regarding a situation in which they are responsible for verifying eligibility for situations in which premiums do not change such as adding a family member to an existing family enrollment.
The employing office or the FEHB carrier, as pertinent, may require documents such as a marriage license and proof of common residency for a marriage; a government-issued birth certificate for a child; an adoption certificate or decree for an adopted child; and a medical certificate of disability for a child age 26 or older who is incapable of self-support because of a condition arising before that age.
OPM added that in the case of adding a foster child to coverage, determination of eligibility is up to the employing office. “In addition, only the employing office may approve eligibility of an individual as an employee’s common law spouse through examining a declaration of common law spouse and other documents,” it said.
The policies require both employing offices and carriers to contact the enrollee for further information if the documentation is not considered sufficient, and also provide for a reconsideration procedure in the case of a decision of ineligibility.