United States Office of Personnel Management

The Federal Government’s Human Resources Agency

Tribal Benefits Administration Letter 

Number: 21-601 Date: November 17, 2021

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 FEHB 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 employees to request reconsideration 

of a decision to remove an individual from the enrollment. The regulation 

allows an 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. Neither 

the regulation nor this TBAL requires employing offices or carriers to perform 

a full-scale audit of FEHB enrollments. 

Note: 5 CFR 890.308(f) is applicable to Tribal/subpart N as Tribal Employers 

must comply with FEHB Law (Chapter 89 of title 5, United States Code), 

FEHB regulations and FEHB Program policies and procedures. 

Purpose

This TBAL 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. 
Tribal Benefits Administration Letter 21-601

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FEHB Program 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. In order to 

avoid duplicate requests for verification of family member eligibility, FEHB 

Carriers are instructed to copy the employing office when it sends a request 

for verification of family member eligibility and its eligibility determination, 

or when it receives a reconsideration request in error. The employing office 

must retain these letters and/or act, as appropriate. 

In addition to this TBAL, OPM is separately publishing TBAL 20-602 FEHB 

Family Member Eligibility Verification that directs 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 FEHB 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 a request for appropriate 

documentation of the family member’s 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 on the 

certification. Employing offices must use the updated Certification of Foster 

Child Status (attached) for any new foster child determinations. 

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. 
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Common law marriage: Only the employing office can approve a 

declaration of common law marriage. 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. 

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. Carrier contact information is available at 

www.opm.gov/plancontacts. 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, please 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 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 request 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 so the Carrier can 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, and temporary continuation of 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.

Persons who were removed because they were never eligible as a family 

member are not eligible for a 31day temporary extension of coverage, and 
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do not have a right to conversion or temporary continuation of coverage. 

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. 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 § 890.1105 (d) has passed. The sixty-day window begun on 

the final date of the divorce, May 4, 2019 and ended on July 3, 2019.

 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 

contact the employing office and submit a Standard Form (SF) 2809 (Event 

Code 1C1) to request the change in enrollment type. The employing office 

must enter any enrollment changes into Tribal Insurance Processing System 

(TIPS). 

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, except if the employing office determines 

that the employee or the family member has made an intentional 

misrepresentation of material fact, in which case the effective date of the 

removal may be made retroactive to the date of ineligibility.

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

type only.
Tribal Benefits Administration Letter 21-601

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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 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. 

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 was 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 Tribal Benefit Officer (TBO) is the first line of 
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defense against potential ineligible enrollments. It is vital that tribes remind 

employees of the rules and their responsibilities pertaining to adding, 

changing or enrolling family members. Tribes 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 knowingly including ineligible family members on an FEHB 

enrollment is a violation of the law, punishable by a fine of not more than 

$10,000 or imprisonment of 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. Due to the 

possibility of someone losing health benefits coverage, please ensure that 

you meet all the above timelines. 

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

website at www.opm.gov/healthcare-insurance/healthcare/eligibility/ and 

the Tribal Handbook. 

If you have questions, please contact the OPM Tribal Desk at 

tribalprograms@opm.gov . 

Sincerely,

Laurie Bodenheimer

Associate Director

Healthcare and Insurance

Encl.:

1- Sample Employing Office Letter – Request for Verification of Family 

Member Eligibility

2- Sample Employing Office /Carrier Letter – Receipt of Eligibility 

Verification Documents
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3- Sample Employing Office /Carrier Letter – Verification Documents Not 

Received

4- Sample Employing Office 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