In April 2024, OPM released a Benefits Administration Letter directing agencies to confirm employees’ relationships to spouses and family members when an enrollment change is made during Open Season. Image: alexkich/Shutterstock.com
By: FEDweek StaffFollowing is the section of a statement before a House committee of acting OPM director Rob Shriver addressing trends in benefits in the FEHB program as well as the status of efforts to cull ineligible enrollees from the program.
The FEHBP is the largest employer-sponsored group health insurance program in the country, covering more than 8 million federal employees, retirees, their eligible family members, and other eligible persons. We are committed to providing strong employee benefits to recruit and retain federal employees. According to the 2023 Federal Employee Benefits Survey, 94 percent of FEHB enrollees report FEHB meets their needs to a great or moderate extent and 78 percent of employees say the availability of the FEHB program influences their decision to remain in a job with the federal government to a great or moderate extent. In the last two years, some key initiatives we have advanced include:
• Fertility Benefits: For the first time, OPM required FEHB carriers to cover artificial insemination. OPM also required plans cover a base level of the medicine needed for in vitro fertilization. Carriers are encouraged to offer benefits above the base level and offer more robust benefits. OPM will continue to work with carriers to expand these offerings.
• Coordination with Medicare: Carriers are encouraged to maximize value to individuals enrolled in FEHB and Medicare. In recent years, a growing number of Carriers have offered Employer Group Waiver Plan (EGWP) Medicare Part D (drug) benefits to enrollees who are eligible for Medicare. Continued coordination between FEHB plans and Part D EGWPs will enable FEHB annuitants to take advantage of the Inflation Reduction Act’s redesigned Medicare Part D Benefit, including a $35 cost-sharing cap for a month’s supply of insulin.
• Maternal Health Care: OPM has enhanced maternity care, including recommendations from the Administration’s Maternal Health Blueprint released in 2022.
• Obesity prevention and treatment: OPM has incorporated the latest professional society recommendations on the use of obesity-reducing drugs, including for youth, and supports the recommendations of the White House’s National Strategy for Hunger, Nutrition, and Health.
• Mental Health: OPM placed continued emphasis on benefits for mental health and substance use disorder, especially for youth, delivered in person and by telehealth.
In addition to these efforts, OPM remains committed to promoting the integrity of the FEHB program.
Current FEHB eligibility determination and enrollment is highly decentralized and requires nearly 100 employing offices across the federal government to determine eligibility when enrolling more than 8 million members. OPM has a modernization plan with a long-term goal of building a central enrollment capability for the FEHB program. Once implemented, this approach will both improve customer experience and address many of the root causes of ineligible enrollments with tools such as monitoring and eligibility determination mechanisms.
We have already begun this process by investing in a central enrollment system for the new PSHBP. The PSHBP accounts for more than 20 percent of current FEHB enrollees. However, we cannot scale this approach to the rest of the FEHB without Congress’s support. As part of our FY 2025 Congressional Budget Justification, OPM has included a legislative proposal that would allow OPM to access a total of $474 million over a ten-year period from the Employee Health Benefits Fund to develop and maintain eligibility and enrollment systems for the FEHBP and PSHBP. This would allow OPM access to consistent, stable funding to achieve this goal.
At the same time, OPM is working within the existing system and resources to outline new requirements for federal agencies and carriers to strengthen programmatic controls and monitoring of FEHB enrollments.
In April 2024, OPM released a Benefits Administration Letter directing agencies to confirm employees’ relationships to spouses and family members when an enrollment change is made during Open Season. Specifically, the guidance requires that agencies verify a meaningful sample of family members included in Open Season elections from the prior year to confirm that they are eligible to receive coverage and, if any ineligible individuals are identified during the sample, take steps to promptly remove them. The guidance also indicated that federal employees will be required to provide eligibility documentation for all new family member enrollments during Open Season in subsequent years. This directive builds on several other actions, rolled out in recent years, that collectively require agencies to verify eligibility documentation provided during each of the key periods when an employee might make a change to enrollments.
Additionally, OPM developed tools that will help crack down on possible bad actors. OPM worked with all carriers in the FEHBP and has recently completed development of a FEHB Master Enrollment Index (MEI). The MEI is a dataset of all FEHB enrolled federal employees, annuitants, and family members that functions as an authoritative source for enrollment information. The MEI will be increasingly important as we use it to conduct queries that can spot certain enrollment irregularities and flag for agencies to take further action as appropriate. OPM currently requires all agencies to notify enrollees of the consequences of improper enrollments, including fines and imprisonment.
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