OPM has issued guidance on removing ineligible family members from coverage under the FEHB program, stressing that under its rules, either an employing agency, OPM or an FEHB carrier may “request proof of family member eligibility from an employee at any time for existing enrollments.”
In a pair of similar messages to agencies and to carriers, OPM set the process for requesting proof of family member’s eligibility for existing enrollments, what documents may be used as proof, what actions can be taken based on the response, and the process for reconsidering a decision to remove someone from coverage. Carriers are to inform employing offices in order to avoid duplicate requests for verification, it added, and carriers are to be “judicious in exercising this authority.”
Those who once were eligible but no longer are eligible may have rights to conversion, temporary continuation of coverage, or a 31-day extension of coverage. Persons who are removed because they were never eligible as a family member do not have those rights. The enrollee meanwhile would be eligible to downgrade from family to self plus one coverage if the result is that only two eligible persons remain covered, or to self-only if only the enrollee remains covered.
Issues of eligibility commonly arise in cases of common law marriage, adoption or foster placement, addition of stepchildren after marriage, or children aging out of eligibility after reaching age 26.
In issuing the rules in early 2018, OPM estimated that 1-3 percent of persons covered as spouses and 4-12 percent of those covered as children in FEHB are ineligible. The inspector general’s office there also has raised concerns several times about ineligible persons in both the FEHB and the FEDVIP dental-vision insurance program, noting the added costs of claims by such persons that are reflected in the premiums.
OPM added that neither the rules nor the new guidance require agencies or FEHB carriers to perform a full audit of covered persons.