A final rule from the Office of Personnel Management (OPM) published to the Federal Register on Tuesday will require federal employees and retirees to prove the eligibility of any family member added to their Federal Employees Health Benefits (FEHB) or Postal Service Health Benefits (PSHB) Program coverage.
The rule will be effective July 2, and will require all FEHB and PSHB enrollees to provide documentation — such as marriage certificates, federal or state tax returns or birth certificates — verifying that family members added to their health plans are eligible for benefits.
“This regulation is necessary to address the presence of ineligible family members covered by the FEHB program,” OPM’s rule states. “There are ineligible family members participating in the program and more can be done to identify and remove them from coverage.”
Out of the estimated 4 million family members enrolled in the FEHB and PSHB programs in 2025, approximately 3 percent of enrolled family members are ineligible for benefits, according to OPM.
“For a newly added family member, the employing office must obtain proof of a family member’s eligibility in two circumstances: during the initial opportunity to enroll and when an enrollee has any other qualifying life event,” the rules states. “This regulation is necessary to address the presence of ineligible family members covered by the FEHB program. There are ineligible family members participating in the program and more can be done to identify and remove them from coverage.”
For a qualifying life event, or QLE, the employing office must require proof of family member eligibility for those that have not previously provided proof including a:
- spouse not verified within the last year;
- foster child; and
- disabled child age 26 or older who is incapable of self-support.
The employing office, OPM, or the health care insurance carrier may disenroll or remove an individual from an enrollment if the enrollee fails to provide adequate documentation of the eligibility. An enrollee or removed individual may request reconsideration of the decision to remove the individual from enrollment from the employing office or OPM within 60 days of the initial decision. That reconsideration is final.
This final rule implements Section 90101 of the FEHB Protection Act of 2025 (FPA) and builds on the 2018 rule-making, which strengthened verification and removal processes. A 2022 Government Accountability Office report outlined that OPM had no monitoring mechanism in place to identify and remove ineligible family members who were receiving FEHB benefits. OPM has estimated these related improper payments could cost the program up to approximately $1 billion per year. OPM performs an annual fraud risk assessment of the FEHB program but has not included ineligible members as a fraud risk to the program.