The inspector general’s office has again urged attention to the issue of ineligible enrollees in the FEHB program, following a similar earlier call regarding the FEDVIP program.
In both cases, the IG said that it appears that many family members are being covered when they don’t meet eligibility requirements, resulting in claims that result in higher costs to those who are legitimately enrolled.
Said the latest report, “Unentitled family members or other persons enrolled in an FEHB plan often go undetected due to the difficulty in identifying these ineligible dependents, an area that has always been a high risk for the program. OPM has not published an estimate of how many ineligible dependents receive benefits from the FEHB or the total cost to the program, despite it being known as an area of substantial fraud.”
The report noted, though, that in 2014 OPM cited estimates that up to 10 percent of family enrollees in private sector plans are ineligible for coverage.
The IG added that over the last five years it “has identified several audit findings related to ineligible dependents age 26 and older whose eligibility to participate in the FEHB was unsupported. In addition, investigations of ineligible dependent cases found that enrollees are able to change, update, and add dependents directly with health plans, which accept the changes without verification. Recent audit work shows that enrollees are allowed to self-certify dependent eligibility because there are no requirements in place to verify family relationships by federal agency benefit officers or FEHB insurance carriers.”
It recommended that agency benefit officers verify the FEHB eligibility of dependents at the time of initial enrollment and when a family member is added to coverage by collecting and maintaining documentation such as proof of birth and marriage certificates. OPM would “need to work with its partners (agencies, payroll offices, carriers) to develop and implement a system to verify and maintain supporting eligibility documentation to reduce the aforementioned issues related to unentitled FEHB enrollments,” it said.
The earlier report on FEDVIP raised similar issues and made similar recommendations regarding FEDVIP, citing instances such as a man claiming grandchildren as his own children and multiple people covered as a spouse at the same time.