United States Office of Personnel Management

The Federal Government’s Human Resources Agency

Tribal Benefits Administration Letter

Number: 21-602 Date: November 17, 2021

Subject: Family Member Eligibility Verification for 

Federal Employees Health Benefits (FEHB) Program 

Coverage 

Background 

On January 23, 2018, OPM published a final rule at 83 FR 3059, clarifying

that proof of family member eligibility must be provided upon request by an 

employing office

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, by an FEHB Carrier, or by OPM. This Tribal Benefits

Administration Letter (TBAL) directs employing offices to request proof of

family member eligibility during two circumstances outside of the annual

FEHB Open Season: the Initial Enrollment Opportunity (IEO), and all other

qualifying life events (QLEs). Employing offices are to verify the eligibility of

new family members for FEHB coverage as described below. 

1 Per 5 CFR 890.101, Employing office means the office of an agency to which jurisdiction 

and responsibility for health benefits actions for an employee, or an individual eligible for 

temporary continuation of coverage under subpart K of this part, have been delegated.

Purpose 

This TBAL provides guidance to employing offices on (1) the process for

requesting proof of family member eligibility (2) what documents may be

used as proof, and (3) what employing office actions must be taken based 

on an employee’s response to a request for verification of eligibility.

Carrier Letter 2021-06, Family Member Eligibility Verification for Federal

Employees Health Benefits (FEHB) Program Coverage, provides similar

guidance to FEHB Carriers on their responsibility to request eligibility

documents before adding a family member to an existing Self and Family

enrollment (Attachment #1). The FEHB Carrier must notify the enrollee and

employing office when the FEHB Carrier determines an individual is
Tribal Benefits Administration Letter 21-602

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ineligible. The FEHB Carrier must utilize the contact information provided 

quarterly by OPM to identify the employing office or Tribal employer. 

I. Employing office actions

A. Requesting proof of family member eligibility for IEO and

all QLEs

An employing office must require proof of family member eligibility for 

coverage through the FEHB Program for: 

• new employees during their initial enrollment opportunity (IEO)

• employees requesting FEHB changes due to all other QLEs

Due to the large volume of transactions during the annual FEHB Open 

Season, employing offices may, but are not required to, verify family 

member eligibility. 

When reviewing a new family member’s eligibility, employing offices may 

take this opportunity to verify the eligibility of family members currently 

enrolled who have not previously been verified. Please see TBAL No. 21-601

Removal of Ineligible Family Members from Enrollments, which sets forth a 

process for removing ineligible family members from coverage under the 

FEHB Program. 

B. Documents used as proof of family member eligibility

A list of documents, such as marriage and birth certificates, that employing 

offices may accept to verify family member eligibility is contained in 

Attachment #2 FEHB Family Member Eligibility Documents. 

Concurrent with this guidance, OPM is replacing the Statement of Foster 

Child Status with a Certification for Foster Children which requires an 

employing office official’s signed approval on the certification. Employing 

offices must use the updated Certification for Foster Children located in 

Attachment #2 FEHB Family Member Eligibility Documents for any new foster 

child determinations. See the Tribal Federal Employees Health Benefits 

Handbook for more information on foster child eligibility. 

Only the employing office may determine a foster child’s eligibility. In 

addition, only the employing office may approve eligibility of an individual as 

an employee’s common law spouse through examining a declaration of 

common law spouse and other documents. Carriers must refer employees to 

their employing offices for approval when they receive a request to add a 

common law spouse or foster child to an existing Self and Family enrollment. 
Tribal Benefits Administration Letter 21-602

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C. Eligibility verification documents approved

Once the employing office has verified family member eligibility, it must 

make a note in the Remarks section of the SF 2809 and place the form in 

the employee’s personnel folder (or its equivalent). At a minimum, the note 

must indicate the type of document(s) examined, the document’s issue date,

the date of the QLE (if applicable), and the name of the issuing authority. If 

the employing office is certifying a foster child or a declaration of common 

law marriage, the certification or declaration must be placed in the 

employee’s personnel folder (or its equivalent) in lieu of a SF 2809. 

D. If eligibility verification document(s) are insufficient

If the employing office determines that an eligibility document for any family 

member is insufficient, it must provide the employee with a written notice of 

its initial decision, see Attachment #3: Sample Letter Information Provided 

Does Not Verify Family Member Eligibility. This letter must include an 

explanation of the employing office’s decision, require the employee to 

submit a new SF 2809 listing only verified family members, and provide 

notice of the right to a reconsideration of the employing office’s initial 

decision. The employing office must enroll the employee and/or verified 

family members pending any reconsideration request. The employing office 

must retain the decision letter in the employee’s personnel folder (or its 

equivalent), along with any response and employing office reconsideration.

II. Reconsideration process

The employing office must establish or identify an independent dispute 

resolution panel to reconsider an initial decision on the family member’s 

eligibility. For additional guidance see the Tribal Federal Employees Health 

Benefits Handbook. 

In addition, the dispute resolution panel is responsible for performing all 

reconsiderations of FEHB Carrier determinations regarding the addition of a 

family member to an existing Self and Family enrollment. 

If the dispute resolution panel determines that the family member is 

ineligible, the employee may request that OPM reconsider the denial. Such a 

request must be made in writing and any decision by OPM will be binding on 

the employing office.

The employee must file a written request for reconsideration of the initial 

decision to the dispute resolution panel within 60 calendar days from the 

date of the initial decision letter. See Attachment #3 Sample Letter 

Information Provided Does Not Verify Family Member Eligibility for 

information that must be included in the reconsideration request. 
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The dispute resolution panel may extend the time limit for requesting 

reconsideration when the employee shows that they were not notified of the 

time limit and was not otherwise aware of it, or that they were prevented by 

circumstances beyond their control from making the request within the time 

limit. 

The dispute resolution panel must issue a written notice explaining its final 

decision to the employee within 30 calendar days of receipt of the request 

for reconsideration. If the dispute resolution panel reverses its initial 

determination, the action must be made retroactive to the date when it 

would have been effective had the employing office not made its initial 

determination. If the dispute resolution panel’s reversal changes an 

employee’s enrollment type to Self Plus One or Self and Family, then the 

employing office must request that the employee submit a new SF 2809 

listing all eligible family members and make the corresponding changes in 

the enrollment portal.

If the final decision overturns an FEHB Carrier’s initial decision on the family 

member’s eligibility, the employing office must send a copy of the written 

notice to the FEHB Carrier. The OPM website lists the appropriate FEHB 

Carrier contacts at www.opm.gov/plancontacts. The Carrier must add the 

family member to the employee’s existing Self and Family enrollment 

retroactive to the date when it would have been effective had the FEHB 

Carrier not made its initial decision.

III. Fraud, waste and abuse

Employing offices play a critical role in ensuring the integrity of the FEHB 

enrollment process. The human resource or tribal personnel representative is 

the first line of defense against potential ineligible enrollments. It is essential 

that employing offices remind employees of the rules and their 

responsibilities pertaining to adding, changing, or enrolling family members. 

Employing offices should also take reasonable measures to verify and 

confirm eligibility, recognizing that ineligible family members can result in 

the FEHB paying erroneous or even fraudulent claims. Enrollment of 

ineligible family members increases costs for everyone in the Program.

As a reminder, any intentionally false statement or willful misrepresentation, 

such as including ineligible family members on an FEHB health insurance 

plan, is a violation of the law, punishable by a fine of not more than $10,000 

or imprisonment of not more than 5 years, or both (18 U.S.C. 1001) and 

may be subject to investigation. 
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IV. Reference information

Visit our Tribal Programs website for more information on family member 

eligibility and the Tribal Federal Employees Health Benefits FEHB Handbook. 

OPM intends to issue additional educational material to assist employing 

offices in providing guidance to employees on family member eligibility. 

V. Timeline

Within 90 calendar days of the issuance of this TBAL, employing offices must 

implement the updated verification procedures. If you have questions, 

please contact the Tribal Desk at TribalPrograms@opm.gov. 

Sincerely,

Laurie E. Bodenheimer

Associate Director

Healthcare and Insurance 

Encl.: 

1. Carrier Letter No. 2021-06 Family Member Eligibility Verification for

Federal Employees Health Benefits (FEHB) Program Coverage

2. FEHB Family Member Eligibility Documents

3. Sample Agency/Tribal Employer Letter – Information Provided Does Not

Verify Family Member Eligibility