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Who Can and Can’t Get Coverage Under Your Health Insurance

OPM doesn’t know how many people with FEHB coverage are actually ineligible for the program.

Earlier this week, Republicans on the House Oversight and Accountability Committee demanded answers from the Office of Personnel Management about a recent Government Accountability Office report that concluded the agency isn’t doing enough to minimize the risk of fraud in the Federal Employees Health Benefits program.

Since FEHB’s inception in 1960, OPM has delegated responsibility to agency employing offices to make eligibility determinations for enrollees and family members. OPM did not require employing offices to review supporting documentation to verify family member eligibility during new hire enrollment or certain qualifying life events until 2021. That, GAO concluded, left FEHB vulnerable to making improper payments.

FEHB covers about 8 million people, but OPM doesn’t have a precise estimate of how many of those are actually ineligible members, and at what cost. OPM projected that cost savings from an audit of the program could save $360 million to $1 billion in future claims avoided.

It may surprise you to learn that in the following situations, your family members are not eligible for FEHB coverage:

  • If you have a court order requiring you to provide health insurance for your ex-spouse.
  • If you’re a surviving spouse who has remarried and would like to cover your new spouse on your federal health insurance that you receive based on your late spouse’s federal service.
  • If your elderly parents have moved in with you and need health coverage.

Family members who are eligible for coverage are:

  • Your spouse, including a common law spouse, but only if the marriage was initiated in a state that recognizes such marriages.
  • Children under 26, including biological children, stepchildren, adopted children or foster children.
  • Children 26 and older who are incapable of self-support, assuming their disabling condition began before age 26. 

Other relatives, such as parents or grandchildren (unless a grandchild qualifies as a foster child), are not eligible for coverage as family members even if they live with you and are dependent on you.

If you have a child who is disabled but have not yet established that fact, contact your agency’s human resources office if you are a federal employee or your retirement system (generally OPM) if you are an annuitant. You will need to obtain a form which you and the child’s doctor must complete. A child temporarily living with you is not a foster child; neither is one placed in your home by a welfare or social service agency that retains control of the child and pays for maintenance. 

If you are a survivor annuitant, remember that self and family enrollment provides coverage for you and all eligible family members of the deceased employee or retiree. If you remarry before age 55, your coverage will end. If your survivor annuity continues because you were married to the deceased for 30 years or more or if you remarry after age 55, your coverage will continue, but it will not cover your new spouse and his or her dependents. If you also receive an annuity as a retiree based on your own federal career, you may be eligible to transfer the enrollment to your retirement annuity to cover your new spouse and his or her eligible children.

Your spouse loses eligibility for coverage under your self and family enrollment on the effective date of a divorce or annulment of a marriage. A former spouse can continue coverage for up to 36 months after that date, but must pay the full premium (plus a 2% administrative charge), with no government contribution.

The FEHB program is vulnerable to improper payments caused by inadvertent errors or fraud and abuse. Remember that if you deliberately cover ineligible family members, you could face criminal charges. Here are a few examples GAO found of employees who were prosecuted for violations of FEHB coverage provisions:

  • The FEHB program paid more than $150,000 in claims on behalf of an ex-spouse over 14 years of ineligible coverage from 1993 to 2017 due to the employee misrepresenting the date of their divorce. The enrollee pleaded guilty to making false statements. 
  • An employee fraudulently covered two individuals who were ineligible and remained on FEHB health insurance from January 2005 to January 2017. The FEHB program paid claims totaling more than $100,000 on behalf of the ineligible individuals. The employee pleaded guilty and was sentenced to 24 months of supervised release. 
  • The FEHB program paid more than $12,000 for services provided to multiple ineligible family members of an employee. In July 2018, the employee pleaded guilty to making false statements relating to health care matters, and was sentenced to three years probation and ordered to pay more than $12,000 in restitution. 

GAO has recommended that OPM implement a monitoring mechanism to identify and remove ineligible family members from the FEHB program. Enrollment of such people increases costs for everyone in the program.