United States 

Office of 

Personnel Management 

The Federal Government’s Human Resources Agency

Benefits Administration Letter 

 

Number: 20-203 Date: November 5, 2020

SUBJECT: Federal Employees Health Benefits Program: Removal of Ineligible Family 

Members from Enrollments 

Background 

On January 23, 2018, the Office of Personnel Management (OPM) published a regulation at 83 

FR 3059 that provides a process for removing ineligible individuals from Federal Employees 

Health Benefits (FEHB) Program Self Plus One and Self and Family enrollments. The 

regulation outlines the steps employing offices need to take to request proof of family member 

eligibility and the process for enrollees to request reconsideration of a decision to remove an 

individual. 

The regulation allows the employing office, OPM or an FEHB Carrier to request proof of family 

member eligibility from an employee at any time for existing enrollments. An employing office 

should implement these procedures when there are questions or concerns about a family 

member’s eligibility. For the purposes of this BAL, the term “employee” also includes 

annuitants. Neither the regulation nor this BAL requires employing offices or carriers to perform 

a full-scale audit of FEHB enrollments. 

Purpose 

This BAL provides guidance to employing offices on (1) the process for requesting proof of 

family member eligibility for existing enrollments; (2) what documents may be used as proof; 

and (3) what employing office actions can be taken based on an employee’s or family member’s 

response to a request for verification of eligibility.

Carrier Letter 2020-16, Removal of Ineligible Family Members from Enrollments, provides 

similar guidance to FEHB Carriers on their procedures to request verification of family member 

eligibility. This Carrier Letter is attached for reference. In order to avoid duplicate requests for 

verification of family member eligibility, FEHB Carriers are instructed to copy the employing 

office on requests for verification of family member eligibility and on eligibility determinations, 

or when they receive a reconsideration request in error. The employing office must retain these 

letters as appropriate. 
2

In addition to this BAL, OPM is separately publishing a BAL that will direct employing offices 

to request proof of family member eligibility for new employees and for existing employees who 

change their enrollment due to a Qualifying Life Event (QLE) outside of the annual Federal 

Benefits Open Season. 

I. Requesting proof of family member eligibility for existing enrollments 

A. Request for verification of FEHB eligibility 

An employing office may request that an employee verify the eligibility of any or all family 

members covered under the employee’s FEHB enrollment at any time. 

To verify eligibility, the employing office shall send the employee a request for appropriate 

documentation of the family member or members’ relationship (see Attachment 1: Sample Letter

Request for Verification of Family Member Eligibility). The request must contain a written notice 

that the family member(s) will no longer be covered 60 calendar days after the date of the notice 

unless the employee provides appropriate documentation as listed in Attachment 5: FEHB 

Family Member Eligibility Documents.

B. Documents used as proof of family member eligibility 

Appropriate documentation includes, but is not limited to, copies of birth certificates, marriage 

certificates, and, if applicable, other proof of family member eligibility. See Attachment 5: 

FEHB Family Member Eligibility Documents for a list of acceptable documentation. 

Foster Child: The employing office must initially determine a foster child’s eligibility. Please 

note that concurrent with this guidance, OPM is updating the current Statement of Foster Child 

Status to a Certification of Foster Child Status that requires an employing office official’s signed 

approval. Employing offices must use the updated Certification of Foster Child Status for any 

new foster child determinations. See the FEHB Handbook at https://www.opm.gov/healthcareinsurance/healthcare/reference-materials/reference/family-members/ for more information on 

foster child eligibility. 

A Carrier may ask the employing office to provide a copy of an employee’s Statement of Foster 

Child Status or Certification of Foster Child Status to verify the employing office’s eligibility 

determination. 

Common law marriage: Only the employing office can approve eligibility of an individual as 

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

other documents. An employee can cover a common law spouse under the FEHB Program only 

if the marriage was initiated within a State that recognizes such a marriage. See Attachment 5: 

FEHB Family Member Eligibility Documents, Appendix 1 for the requirements. 
3

II. Employing Office actions

A. Eligibility verification documents approved 

If the employing office receives documentation and it determines that the documentation verifies 

eligibility of the family member(s), the employing office must notify the employee, the family 

member (see Attachment 2: Sample Letter Receipt of Eligibility Verification Documents), and 

the FEHB Carrier. The employing office must retain copies of the letters of request and the

determination letter in the employee’s official personnel folder and copy the FEHB Carrier to 

avoid a potential duplicative Carrier request to the same employee. In addition, the employing 

office must include a copy of family member verification letters received from the FEHB Carrier 

in the employee’s official personnel folder.

B. Information provided does not verify family member eligibility

If the employing office does not receive the requested documentation within 60 calendar days of 

the request or if it determines that the documentation provided is insufficient to verify eligibility 

of the family member(s), the employing office must notify the employee and the family member 

of this determination (see Attachment 3: Sample Letter Verification Documents Not Received or

Attachment 4: Sample Letter Information Provided Does Not Verify Family Member Eligibility). 

This written notice considered the “initial decision” must include an explanation of the

employing office’s decision, the effective date of the removal of the ineligible family member, 

and the right to a reconsideration of this initial determination. The employing office must

maintain a copy of this letter in the employee’s official personnel folder and should send a 

separate copy to the affected family member when a separate address is known. The employing 

office must also provide a copy of this letter to the FEHB Carrier to process removal of the 

ineligible family member(s) from the enrollment.

The removed family member may be eligible for a 31-day temporary extension of coverage, 

conversion, temporary continuation of coverage, or spouse equity coverage in certain limited 

circumstances; see 5 CFR 890.308(g). Any opportunity to enroll shall not extend beyond the date 

that opportunity would have ended if the individual had been removed on the date of loss of 

eligibility.

For example, an enrollee and her spouse divorce on May 4, 2019. The enrollee does not remove 

the former spouse from the enrollee’s Self and Family enrollment, so the former spouse is 

receiving coverage but is not eligible. In this example, the former spouse is not eligible to receive 

a former spouse annuity and, thus, not eligible for spouse equity coverage. If the employing 

office later discovers the divorce, and removes the spouse from the enrollment on July 20, 2020, 

the former spouse is not eligible for a 31-day extension of coverage, conversion and/or 

temporary continuation of coverage because the regulatory window for election of 60 days 

outlined in 5 CFR 890.805(1) has passed. The sixty-day window began on the final date of the 

divorce, May 4, 2019 and ended on July 3, 2019.

Persons who are removed because they were never eligible as a family member do not have a 

right to conversion, temporary continuation of coverage, or a 31-day extension of coverage.
4

C. Employee or family member requests for an extension 

An employee or family member may request an extension to provide requested evidence because 

they are prevented by circumstances beyond their control from responding in a timely way (e.g., 

delay in receipt of verifying documents from a licensing entity). Employing offices may grant a 

reasonable extension to the deadline, especially in recognition of circumstances such as national 

or local emergencies that may impact licensing entities’ capabilities to provide documentation. 

D. Employee request to change enrollment type 

If the removal of the ineligible family member results in an enrollment decreasing from three or 

more persons to two persons or from two persons to one person, the employee is eligible to 

decrease the enrollment type to Self Plus One or Self Only, respectively, within 60 days. The 

employee must submit a Standard Form (SF) 2809 (Event Code 1C1) per the employing agency’s 

FEHB enrollment process to request the change in enrollment type. 

E. Effective date of removal of an ineligible family member 

The removal is effective on the date listed in the initial determination letter (Attachment 1: 

Sample Letter Request for Verification of Family Member Eligibility) and is prospective. If the 

employing office determines that the employee or the family member has made an intentional 

misrepresentation of material fact, the effective date of the removal may be made retroactive to 

the date of ineligibility. 

III. Reconsideration 

A. Reconsideration process after removal of an ineligible family member

The employing office must establish a reconsideration process for decisions on removal of 

ineligible family members, including decisions made by an FEHB Carrier. For a removal 

determination made by the employing office, the reconsideration review and decision must be 

conducted by an employing office representative (e.g., supervisor or manager) who is at least one 

level above the employing office representative that made the initial determination. For 

reconsiderations received from the FEHB Carrier, an employing office representative can 

conduct the review. 

The employee or affected family member must file a written request for reconsideration of the 

initial determination decision to the employing office within 60 calendar days from the date of 

the initial determination letter. See Attachment 3: Sample Letter Verification Documents Not 

Received and Attachment 4: Sample Letter Information Provided Does Not Verify Family 

Member Eligibility for information that must be included in the reconsideration request. The 

employing office must provide a copy of the reconsideration request to the FEHB Carrier. 

1 The use of 1C per this BAL for Removal of Ineligible Family Members is limited to decreasing the enrollment 

type only. 
5

B. Employee or family member request for extension 

The employing office may extend the time limit for requesting reconsideration when the 

employee or affected family member shows they were not notified of the time limit and were not 

otherwise aware of it, or that they were prevented by circumstances beyond their control from 

making the request within the time limit. 

C. Reconsideration decision 

The employing office must issue a written notice of its final decision to the employee and notify 

the FEHB Carrier of the decision within 30 calendar days of receipt of the request for 

reconsideration. The notice of its final decision must fully describe the findings and conclusions 

on which the decision is based. The employing office should send a separate copy to the affected 

family member when a separate address is known. 

If the reconsideration decision overturns the removal of the family member(s), the FEHB Carrier 

will reinstate coverage retroactively so there is no gap in coverage. 

IV. Fraud, waste and abuse

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

The employing office representative is the first line of defense against potential ineligible family 

member coverage. It is vital that agencies remind employees of the rules and their 

responsibilities pertaining to adding, changing or covering family members. Agencies 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. Coverage of 

ineligible family members increases costs for everyone in the Program. 

As a reminder, any intentionally false statement or willful misrepresentation, such as knowingly 

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 USC 1001) and may be subject to investigation. 

V. Reference information 

The OPM website lists the appropriate FEHB Carrier contacts at www.opm.gov/plancontacts. 

For more information on family member eligibility, please refer to the OPM website at 

https://www.opm.gov/healthcare-insurance/healthcare/eligibility/ and the FEHB Handbook at: 

https://www.opm.gov/healthcare-insurance/healthcare/reference-materials/fehb-handbook/.

OPM intends to issue additional educational material to assist employing offices in providing 

guidance to employees on family member eligibility. 

Due to the possibility of someone losing health insurance coverage, please ensure that all of the 

above timelines are met. For questions, contact the Agency’s Headquarters Benefits Officer. 
6

Please go to http://apps.opm.gov/abo/ for a list of agencies and their Headquarters Benefits 

Officers. 

 

Sincerely, 

Michael J. Rigas 

Acting Director 

Office of Personnel Management 

Attachments 

1. Sample Employing Office /Tribal Employer Letter – Request for Verification of Family 

Member Eligibility 

2. Sample Employing Office/Tribal Employer/Carrier Letter – Receipt of Eligibility 

Verification Documents 

3. Sample Employing Office/Tribal Employer/Carrier Letter – Verification Documents Not 

Received 

4. Sample Employing Office/Tribal Employer Letter – Information Provided Does Not 

Verify Family Member Eligibility 

5. FEHB Family Member Eligibility Documents 

6. Carrier Letter 2020-16 – Removal of Ineligible Family Members from Enrollments