Family Members

Family Members Eligible for Coverage

General Eligibility for Coverage

A Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. A Self and Family enrollment covers the enrollee and all eligible family members. Family members eligible for coverage are the enrollee’s:

• Spouse
• Child under age 26, including:
  •  Adopted child under age 26
  • Stepchild under age 26
  • Foster child under age 26
• Disabled child age 26 or older, who is incapable of self-support because of a physical or mental disability that existed before their 26th birthday

A grandchild is not an eligible family member unless the child qualifies as a foster child. Other examples of family members that are not eligible include an enrollee’s parents, former spouse, and domestic partner, even if they live with and are dependent upon the enrollee.

Special rules apply to family members if the enrollee is enrolled as a survivor annuitant or under the Spouse Equity Act or temporary continuation of coverage (TCC) provisions.

Tribal Employer Note: Individuals who retire from tribal employment are not eligible to continue FEHB Coverage; therefore, any reference to annuitants, survivor annuitants or Spouse Equity Act in this chapter does not apply to tribal enrollees or their family members.

Employing Office Responsibilities

The employing office is responsible for making final decisions about whether a family member is eligible for coverage. If a Carrier has any questions about whether someone is an eligible family member under a self and family enrollment, it may ask the enrollee or the employing office for more information. The Carrier must accept the employing office's decision on a family member's eligibility.

The employing office must require proof of a family member’s eligibility in two circumstances:

• during the initial opportunity to enroll (IOE);
• when an enrollee has any other QLE.

With a QLE, the employing office must require proof of family member eligibility for those that have not previously provided proof. At that time, it must reverify a:

• spouse not verified within the last year;
• foster child; and
• disabled child age 26 or older who is incapable of self-support.

Employing offices are not required to verify family member eligibility during the annual Federal Benefits Open Season due to the large volume of transactions; however, employing offices may verify family members at their discretion and at any time after enrollment.

FEHB Family Member Eligibility Documents

The following table lists documents that may establish family member eligibility for FEHB coverage. The enrollee may remove personal financial information and Social Security Numbers before submission.

Documents that are not in English must be accompanied by a certified or notarized translation.

Family Member	Acceptable Document(s) to Verify Eligibility
Spouse	Married less than 12 months: copy of government-issued marriage certificate. Married 12 months or more: copy of government-issued marriage certificate and one of the following sets of documents listing spouse: Front page of most recent tax year’s Federal or state tax return; or Proof of common residency (e.g., utility bill, other household bill, auto registration); and proof of financial interdependency (e.g., shared bank statement, credit card statement, life, or auto insurance policy). Common law marriage: see section below
Child under age 26	A copy of any one of the following documents listing child and enrollee: Government-issued birth certificate; or Certificate of live birth; or Front page of the most recent tax year’s Federal or state tax return; or Consular Report of Birth Abroad; or Official paternity test; or Voluntary affidavit of paternity or similar document; or Court or administrative order (e.g., National Medical Support Notice).
Adopted child under age 26	A copy of any one of the following documents listing child and enrollee: Final adoption certificate or decree; or Authorized letter from a placement agency for the purpose of adoption; or Front page of most recent tax year’s Federal or state tax return with child’s name; or Court or administrative order (e.g., National Medical Support Notice).
Stepchild under age 26	A copy of any one of the following documents: Birth certificate, or final adoption certificate/decree, listing current spouse as parent; or Front page of most recent tax year’s Federal or state tax return with child’s name; or Court or administrative order (e.g., National Medical Support Notice) The enrollee must also verify a spouse’s eligibility (see above for required documents), even if not enrolling the spouse in an FEHB plan.
Foster child under age 26	All the following documents: Certification of foster child status Government-issued birth certificate or other document verifying child’s date of birth Documentation of regular and substantial support for the child, such as: Evidence of eligibility as a dependent child for benefits under other state or Federal programs; Proof of inclusion of the child as a dependent on the enrollee’s front page of most recent tax year’s Federal or state tax returns; Canceled checks, money orders, or receipts for periodic payments from the enrollee for or on behalf of the child; Evidence of goods or services which show regular and substantial contributions of considerable value; Any other evidence which OPM, in guidance, deems to be sufficient proof of support. If applicable, include copy of court order naming employee or spouse as child’s legal guardian.
Disabled child age 26 or older who is incapable of self-support because of a physical or mental disability that existed before 26th birthday	Medical certificate stating the child is incapable of self-support because of a physical or mental disability that existed before he/she became age 26 and is expected to continue for more than one year. Additional information required to be included in the certification can be found here: www.opm.gov/healthcare-insurance/healthcare/reference-materials/reference/family-members/#medcert.

Documents for Common Law Marriage

An employee may add a common law spouse to their FEHB enrollment only if the marriage was established in a state that recognizes such a marriage. The enrollee must provide the following information:

• A court order or judgment recognizing the marriage; or
• The employee’s declaration indicating:
  • The date on which and the state in which enrollee and spouse mutually agreed to become married;
  • The length of time enrollee and spouse have lived together;
  • The address or addresses at which enrollee and spouse have lived together;
  • Whether enrollee and spouse have been regarded among neighbors, friends, and relatives as being married spouses;
  • If the enrollee or spouse were previously married, the declaration must indicate date and place of each previous marriage as well as the date, place, and manner of termination (e., death, divorce, or annulment); and
  • Enrollee signature underneath the following statement:
    • WARNING: Any intentionally false statement or willful misrepresentation relative thereto 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).

In addition to the above, the enrollee must provide any one of the following documents listing the common law spouse:

• Front page of most recent tax year’s Federal or state tax return;
• Proof of common residency (g., utility bill, other household bill, auto registration); or
• Proof of financial interdependency (g., shared bank statement, credit card statement, life, or auto insurance policy).

Employing offices must add a copy of the common law marriage declaration (without the supporting documents) to the employee’s Official Personnel Folder or equivalent personnel file and send a copy to the FEHB Carrier.

Eligibility Verification Documents Approved

Once the employing office has verified family member eligibility, it will make a note on the Health Benefits Election Form (SF 2809) and place the form on the permanent side of the employee’s Official Personnel Folder or equivalent personnel file.

Insufficient Eligibility Verification Documents

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 determination; see Sample Letter “Information Provided Does Not Verify Family Member Eligibility” below. This letter must include an explanation of the employing office’s decision and the right to a reconsideration of its initial determination. The employing office must retain the letter in the employee’s records, along with any response and employing office reconsideration decision.

Sample Letter

Information Provided Does Not Verify Family Member Eligibility

For Employing Office/Tribal Employer Use

Family Member Eligibility Verification

[insert date]

[insert employee name and address]

We have reviewed the documents you submitted to verify Federal Employees Health Benefits (FEHB) eligibility for your family member(s). Based on our review, the documents are not sufficient to verify eligibility. Therefore, we have determined that the person(s) listed below are not eligible for coverage under your FEHB enrollment.

1. [Insert name of ineligible family member]
2. [Insert name of ineligible family member]

The documentation submitted was not approved due to:

[insert reason]

This is an initial decision. You have the right to request that we reconsider this decision. A request for reconsideration must be filed with the employing office listed below within 60 calendar days from the date of this letter. A request for reconsideration must be made in writing and must include your name, address, Social Security Number (or other personal identifier, e.g., plan member number), your family member’s name, the name of your FEHB plan, reason(s) for the request, and, if applicable, retirement claim number. Please also include a copy of this letter.

If the reconsideration decision reverses the family member’s denial, the FEHB Carrier will begin coverage retroactively to the date on which it would have been effective had the original request been approved.

Send your request for reconsideration to:

          [insert contact information]

The above office will issue a final decision to you within 30 calendar days of receipt of your request for reconsideration. If you need more time to submit your reconsideration request, please contact the employing office listed above in writing.

As a reminder, any intentionally false statement or willful misrepresentation, such as including ineligible family members on a 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.

 If you have questions about this letter, you may contact us at:

                             [insert employing office/tribal employer info]

 

                                                          [Signature]

cc: [FEHB Carrier]

Reconsideration Process

The employing office must establish a reconsideration process for its initial family member eligibility decision. The reconsideration review and decision-making process 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.

According to FEHB regulations and Carrier Letter 2021-06, the employing office is also responsible for performing all reconsiderations of FEHB Carrier determinations regarding the addition of a family member to an existing Self and Family enrollment.

Tribal Employer Note: Tribal employers must establish or identify an independent dispute resolution panel to adjudicate appeals of determinations made by a tribal employer regarding an individual’s status as a tribal employee eligible to enrollee in FEHB, eligibility of family members, and eligibility to change enrollment. This panel must be authorized to enforce eligibility decisions.

The employee must file a written request for reconsideration of the initial decision to the employing office within 60 calendar days from the date of the initial decision letter.

The employing office may extend the time limit for requesting reconsideration when the employee shows that 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.

The employing office 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 employing office 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 employing office’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 or make equivalent electronic changes.

If the employing office’s 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.

Children Placed for Adoption

To be considered eligible for coverage under an FEHB enrollment as an adopted child, the child must be placed for adoption with the enrollee. This means that the enrollee has assumed legal responsibility for total or partial support of the child in anticipation of adoption. This includes when a child is placed in the home of the enrollee by the state or a private agency for adoption. A final or interlocutory adoption decree is not necessary. The child is no longer an eligible family member when their placement with the enrollee ends, i.e., the enrollee’s legal responsibility for the child’s support ends. Each enrollee is responsible for informing their employing office when the enrollee is no longer financially responsible for the child.

Foster Children

Requirements

To be considered eligible for coverage under an FEHB enrollment as a foster child:

• the child must be under age 26 (if the child is over age 26 or over, he/she must be incapable of self-support);
• the child must currently live with the enrollee;
• the parent-child relationship must be with the enrollee, not the child's parent;
• the enrollee must currently be the primary source of financial support for the child; and
• the enrollee must expect to raise the child to adulthood.

The enrollee does not need to be related to the child nor do they need to legally adopt the child. As long as the above requirements are met, the enrollee may have a foster parent-child relationship even when:

• the child's parents are alive;
• the child's parent lives with the enrollee; or
• the child receives some support from sources other than the enrollee (for example, social security payments or support payments from a parent).

Below are some common examples of a foster parent-child relationship:

• A child whose parents have died is living with, and being supported by, a close relative who is an enrollee.
• A child who is living with, being raised by, and financially dependent on a grandparent who is an enrollee. (The parent of the child may also be a dependent.)
• A child living with an enrollee under a preadoption agreement.
• A child who is in the legal custody of an enrollee.

How to Get a Foster Child Covered

For a foster child to be covered as an eligible family member, the enrollee must provide documentation of their regular and substantial support of the child; and sign a Certification of Foster Child status stating that the foster child meets all the requirements

Certification of Foster Children Status

An employee must provide their employing office with the following foster child certification to establish a foster child’s eligibility for FEHB coverage. The employing office must file the original statement in the employee’s Official Personal Folder or equivalent personnel file and send a copy to the FEHB Carrier.  

CERTIFICATION OF FOSTER CHILD STATUS

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Effective Date

The effective date of a foster child's coverage as a family member is the first day of the pay period in which the employing office receives the Certification of Foster Child Status, above, including all of the evidence that establishes the eligibility of the child as a foster child.

When Coverage Ends

A foster child's coverage continues until they reach age 26 (unless they are incapable of self-support before reaching age 26) or are no longer living with the enrollee. If the foster child moves out of the enrollee’s home to live with a biological parent, the child cannot again be covered as the enrollee’s foster child unless:

• the parent dies;
• the parent is imprisoned;
• the parent becomes unable to care for the child due to a disability; or
• the enrollee obtains a court order for custody that takes parental responsibility from the parent and gives it to the enrollee.

When a Child is Not Considered a Foster Child

A child who has been placed in an enrollee’s home by a welfare or social service agency under an agreement where the agency retains control of the child or pays for maintenance is not eligible for coverage under an FEHB enrollment as a foster child because there is no regular parent-child relationship with the enrollee. A child living temporarily with an enrollee as a matter of convenience is not eligible for coverage as a foster child. For example, a child who lives with an enrollee only while attending school normally is not eligible for coverage as a foster child because this is considered an arrangement of convenience.

Since it is impossible to cover every family situation, the Benefits Officer may contact OPM for assistance in making difficult determinations.

A Child's Temporary Absences

If an enrollee’s foster child temporarily lives elsewhere while attending school or for other reasons, the child is still considered to be an eligible family member if they are otherwise living with the enrollee in a regular parent-child relationship. An enrollee’s foster child who lives with the enrollee at least 6 months of a year under a court order directing shared custody may be considered living with the enrollee in a regular parent-child relationship.

Parent-Child Relationship

A "regular parent-child relationship" means that the enrollee is exercising parental authority, responsibility, and control over the child by caring for, supporting, disciplining, and guiding the child, including making decisions about the child's education and health care.

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Change in Family Status

Election Opportunities

When the enrollee has a change in family status, including a change in marital status, they may enroll, increase enrollment, decrease enrollment, or change from one plan or option to another. The enrollment change must be submitted between 31 days before to 60 days after the change in family status.

Certain restrictions apply if the enrollee is enrolled as a survivor annuitant or as a former spouse under the Spouse Equity Act.

Tribal Employer Note: Spouse Equity Act does not apply to tribal enrollees or their family members.

Events Considered to be Changes in Family Status

Generally, a change in family status is an event that adds to or decreases the number of eligible family members. The following are some events that are considered a change in family status for health benefits purposes:

• an enrollee’s marriage, including a valid common law marriage (in accordance with applicable state law);
• birth of an enrollee’s child;
• an enrollee’s legal adoption of a child under age 26 or the acquisition of a foster child under age 26;
• an enrollee’s spouse or child under age 26 enters into or is discharged from military service;
• issuance or termination of a court order granting an enrollee or an enrollee’s spouse a final divorce, interlocutory divorce, or limited divorce;
• issuance of a court decree of annulment, or in the case of a marriage void from its beginning (ab initio) also a declaratory judgment, or conviction of an enrollee’s spouse of bigamy;
• issuance of a court order specifically requiring an enrollee to enroll their children or provide health insurance benefits for them;
• the death of an enrollee’s spouse, including a declaration by a court that a missing spouse is presumed dead.

Removal of an ineligible family member provides an opportunity to decrease enrollment type to Self Only or Self Plus One.

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Court Orders Requiring an Enrollee to Provide Coverage for Children (Children's Equity)

If an employee is subject to a court or administrative order requiring them to provide health benefits for their children, they must enroll in Self Plus One or Self and Family coverage in a plan that provides full benefits to their children in the area where they live or provide documentation that the employee has other health coverage for the children.

If an employee is eligible for FEHB coverage and does not comply with the court order to enroll in an appropriate health plan or does not provide documentation of other coverage for their children, the Federal Employees Health Benefits Children's Equity Act of 2000 (Public Law 106-394) requires the employing office to enroll the employee in Self Plus One or Self and Family coverage in the lowest coverage option of the Blue Cross and Blue Shield Service Benefit Plan.

Court or Administrative Orders

The court or administrative order can be submitted by anyone, including the custodial parent, an attorney for the custodial parent, and the state administrative agency that issues the order.

If the court order deals only with health insurance benefits, it does not have to be certified. If the court order also deals with life insurance or retirement benefits, then it must be certified for those purposes. Administrative orders, which come from state child support agencies, will not be certified.

For the court or administrative order to be considered valid under the law, the employing office must have received it on or after October 30, 2000.

Employing Office Review

The employing office must review the employee records to determine whether the child (children) are eligible for FEHB and, if so, whether they are enrolled in a Self Plus One or a Self and Family plan that provides full benefits for their children in the location where they live. If the employee has such coverage, the employing office will notify the issuer of the court or administrative order. It will send a copy of the employee’s SF 2809 to the Carrier, along with a copy of the court or administrative order to notify the Carrier of the additional family member or members being covered under the Self Plus One or Self and Family enrollment.

The employing office will file the order in the employee’s Official Personnel Folder (OPF) or equivalent personnel file and flag the OPF or other file in some manner to indicate that the file contains a court or administrative order relating to health insurance benefits.

Coverage that Does Not Provide Full Benefits in the Area Where the Children Live

If an employee is eligible for FEHB but does not have coverage that provides full benefits in the location in which the children reside, the employing office will notify the employee that it has received a court order requiring them to provide health insurance benefits for their children. The employing office will give the employee until the end of the pay period following the one in which they received the notice to enroll in an appropriate health insurance plan or provide documentation that they have other health insurance benefits for the children.

The employing office may use the following sample notification.

Sample Notice

Dear [Employee's name]:

We have received a [court/administrative] order stating that you must provide health insurance benefits for your child[ren]. You are not currently enrolled in Self Plus One or Self and Family coverage under the Federal Employees Health Benefits (FEHB) Program with a Carrier that provides full benefits in the area where your child[ren] live[s].

The Federal Employees Health Benefits Children's Equity Act of 2000 (Public Law 106-394) requires Federal agencies to ensure that employees comply with the terms of such court and administrative orders. You must enroll in Self Plus One or Self and Family coverage in a plan that provides full benefits where your child[ren] live[s] or provide documentation that you have other health insurance benefits for your child[ren] by [insert date that is the last day of the pay period following the one in which this notice is issued].

If you do not enroll or provide documentation of other coverage for your child[ren] by [repeat date from paragraph above], we will enroll you in [Self Plus One/Self and Family (choose option as appropriate)] coverage under the lowest option of the Blue Cross and Blue Shield Service Benefit Plan. As long as the [court/administrative] order remains in effect and your child[ren] [is/are] eligible under the FEHB Program, you must continue Self Plus One or Self and Family coverage in a health insurance plan that provides full benefits where your child[ren] live[s], unless you provide documentation that you have obtained other coverage.

Sincerely,

[Signature, name, and title of appropriate official]

[In addition to sending a copy to the employee, keep a copy in the employee's OPF or other record.]

Failure to Enroll or Provide Documentation of Other Coverage by the Due Date

Without enrollment in an appropriate plan or documentation of other coverage for the children, the employing office will process enrollments as described below.

If there is No Enrollment at All

If the employee compelled by the court or administrative order is not enrolled for any FEHB coverage, the employing office will enroll them in a Self Plus One or a Self and Family enrollment in the lowest option of the Blue Cross and Blue Shield Service Benefit Plan.

If the Enrollee Has Self Only Coverage

If the employee has a Self Only enrollment in a fee-for-service plan, the employing office will change the enrollment to a Self Plus One or a Self and Family in the same option of the same plan.

If the employee has a Self Only enrollment in an HMO, and the HMO serves the area where the child or children live, the employing office will change the enrollment to a Self Plus One or a Self and Family in the same option of the same plan.

If the employee has a Self Only enrollment in an HMO, and the HMO does not serve the area where the child or children live, the employing office will change the enrollment to a Self Plus One or a Self and Family in the lowest option of the Blue Cross and Blue Shield Service Benefit Plan.

If the Employee Has a Self Plus One or a Self and Family Coverage in an HMO That Doesn't Serve the Area Where the Children Live

If the employee has a Self Plus One or a Self and Family enrollment, but it's in an HMO that doesn't serve the area where the child or children live, the employing office will change the enrollment to a Self Plus One or a Self and Family in the lowest option of the Blue Cross and Blue Shield Service Benefit Plan.

Involuntary Enrollment by an Employing Office

If an employing office needs to enroll an employee involuntarily, it will complete a Health Benefits Election form (SF 2809) with the employee’s identifying information. It will use event code 1C (Change in family status). In the signature block in Part G, it will write "See Remarks." In the remarks block in Part I, it will write "Being enrolled for [Self Plus One or Self and Family] coverage involuntarily under Pub. L. 106-394."

When the employing office sends the SF 2809 to the employee’s Carrier, it will attach a copy of the court or administrative order. It will send the employee’s copy of the SF 2809 to the custodial parent, along with a plan brochure, and make a copy of both documents for the employee.

Effective Date of Involuntary Enrollment

In most cases, the effective date will be the first day of the pay period following the one in which the employing office completes the SF 2809.

Example

Chester's employing office receives an administrative order on November 14, 2019, saying that he must provide health benefits for his two children. Chester doesn't have any FEHB coverage. His employing office notifies him that he has until December 7, 2019 (the end of the following pay period) to enroll or provide documentation that he has other coverage for them. He doesn't respond. On December 9, 2019, Chester's employing office completes an SF 2809 enrolling him for Self and Family coverage in the lowest option of the Blue Cross and Blue Shield Service Benefit Plan. The effective date would be December 22, 2019 (the first day of the next pay period).

Exception: If the court or administrative order specifies an effective date, the enrollment would be retroactive. In such a case, the employing office must make the enrollment retroactive to the beginning of the pay period that includes that effective date, but no further back than 2 years.

Employing Office Identification of Eligible Family Members

Usually, the court or administrative order will have the names and birthdates of the children.

Nonpay or Insufficient Pay Status

When the employee is in nonpay or insufficient pay status, the provisions of 5 CFR 890.502(b) apply (see "Leave Without Pay Status and Insufficient Pay"). However, in this case, the employee does not have the option of terminating coverage. The employee must continue the coverage and either make direct premium payments or incur a debt to the Government.

Enrollment Changes after Involuntary Enrollment

If the employee was involuntarily enrolled and the employing office finds that circumstances beyond their control prevented the enrollee from making their own enrollment election, the employee may change the enrollment prospectively within 60 days after the employing office advises them of its finding. Otherwise, during Open Season or when the employee has a qualifying life event, the employee can change to a different nationwide fee-for-service plan or to an HMO that provides full health insurance benefits for the children who are covered under the court or administrative order in the area where they live.

However, the employee cannot (even during Open Season):

• cancel their enrollment,
• change to Self Only,
• change to Self Plus One when more than one child must be covered, or
• change to an HMO that doesn't provide coverage in the area where their children live,

as long as the court or administrative order is still in effect and the children are eligible under the FEHB Program (unless the employee provides documentation that they have other coverage for the children). This applies whether the enrollment was voluntary or involuntary. If the employee submits an SF 2809 making such an enrollment change, the employing office will not process it. If it gets processed by mistake, the employing office will void it. The employing office will notify the employee the change cannot be made and that the existing Self Plus One or Self and Family enrollment will remain in effect.

Invalid Enrollment Changes

The employee’s payroll office should flag the records for all employees subject to a court or administrative order for health insurance benefits to ensure the employee will not be able to make an enrollment change through the employing office’s electronic enrollment system or on the SF 2809.  

Duration of Enrollment

If the court or administrative order doesn't specify a time limit on the coverage, the employee must keep the Self Plus One or Self and Family enrollment until the last child reaches age 26.

If the court or administrative order states that coverage must continue until a specific age, and that age is over age 26, the coverage must continue until the last child reaches age 26. Unless they meet the requirements for a disabled child age 26 or older who is incapable of self-support, children cannot continue FEHB coverage beyond age 26, regardless of what the court or administrative order says. If the child is incapable of self-support as determined by the employing office, coverage must continue until the age specified in the court or administrative order.

For most employees, if the court or administrative order states that the coverage must continue until a specific age, and that age is below age 26, the employee may cancel the coverage or change to Self Only in the Open Season following when the child reaches the age stated in the court or administrative order. If an employee has waived premium conversion, the employee may cancel or decrease enrollment at any time after the last child reaches the age stated in the court or administrative order.

Upon Retirement for Federal Employees 

If the employee is eligible to carry FEHB coverage into retirement, they must continue the Self Plus One or Self and Family coverage after retirement to provide coverage for the children under the court or administrative order. As long as the court or administrative order remains in effect, the annuitant cannot:

• cancel or suspend coverage,
• change to Self Only,
• change to Self Plus One when more than one child must be covered, or
• change to an HMO that doesn't provide full benefits where the children live.

If the annuity becomes insufficient to make the premium withholdings, the annuitant may not terminate the enrollment. Instead, the annuitant must continue the coverage and make direct premium payments, or incur a debt to the Government, for as long as the order remains in effect and the child or children continue to be eligible.

Tribal Employer Note: Individuals who retire from tribal employment are not eligible for FEHB Coverage.

Multiple Court or Administrative Orders Received by the Employing Office 

A Self and Family enrollment covers all eligible family members. If an enrollee is subject to a court or administrative order and another court or administrative order is filed relating to a different child (or children), a change in enrollment may not be needed because that child is also covered under the enrollee’s existing Self and Family enrollment.

However, if the enrollee is enrolled in an HMO and the children covered under the subsequent court or administrative order live in an area that the HMO doesn't serve, the employing office will notify the enrollee and give them a chance to choose a different Carrier that will cover all children covered under a court or administrative order. If the enrollee doesn’t change plans, the employing office will change the enrollment to the lowest option of the Blue Cross and Blue Shield Service Benefit Plan.  When the employing office sends the SF 2809 to the employee’s Carrier, it will attach a copy of the court or administrative order.  It will send the employee’s copy of the SF 2809 to the custodial parent, along with a plan brochure, and make a copy for the employee.

If the enrollee has a Self Plus One enrollment the employing office will follow the process listed above to ensure a Self and Family enrollment that covers the additional child(ren).

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Changes that Do Not Affect Enrollment

Family Members

If an increase or decrease in the number of family members does not lead to a change in the enrollment type, then the enrollee doesn’t need to report the change in the number of family members to their employing office. However, the enrollee must report the change to the Carrier. The Carrier will request evidence of family relationship to add a new family member per Carrier Letter 2021-16, Family Member Eligibility Verification for Federal Employees Health Benefits (FEHB) Program Coverage.

The enrollment is not affected when:

• a child is born and the enrollee already has a Self and Family enrollment;
• the enrollee’s spouse dies, or they divorce, and the enrollee has children still covered under their Self and Family enrollment;
• the enrollee’s child reaches age 26, and the enrollee has other children or a spouse still covered under their Self and Family enrollment; the Carrier will automatically end coverage for any child who reaches age 26.  (If the enrollee wants temporary continuation of coverage (TCC) or a conversion contract for the child who reaches age 26, the enrollee must inform their employing office of the child's loss of FEHB eligibility within 60 days.)

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Loss of Family Member Status

When a family member loses coverage because they are no longer an eligible family member, they will be entitled either to a  31- day temporary extension of coverage, temporary continuation of coverage (TCC), or to convert to an individual policy with the enrollee’s Carrier. If the enrollee and their spouse are divorcing, the former spouse may be eligible for coverage under the Spouse Equity Act provisions.

The Carrier, not the employing office, will provide the eligible family member with a 31-day temporary extension of coverage from the termination effective date. For more information visit the Termination, Conversion, and TCC section.

Tribal Employer Note: Spouse Equity Act does not apply to tribal enrollees or their family members.

When a Family Member is no Longer Eligible

A family member immediately loses eligibility for coverage when:

• a divorce decree is final (according to state law), regardless of any requirement in the decree to provide health insurance coverage (see Former Spouses and TCC for options to provide coverage);
• a child reaches age 26, unless they are incapable of self-support;
• a foster child marries or stops living with the enrollee in a regular parent-child relationship; or
• a stepchild no longer meets requirements for coverage.

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Legal Separation

If an enrollee’s spouse is covered under the enrollee’s Self and Family or Self Plus One enrollment and the enrollee and their spouse legally separate or are in the process of getting a divorce or an annulment, the enrollee’s spouse is eligible to continue coverage under the enrollment during that time. This may be a qualifying life event if the coverage is with an HMO and the enrollee or spouse moves outside the HMO’s service area.

Divorce or Annulment

After a divorce or annulment is final, the enrollee’s former spouse cannot remain covered as a family member under their Self Plus One or Self and Family enrollment (even if a court order requires it). It is the enrollee’s responsibility to inform their Carrier (if maintaining current enrollment) and/or their employing office (if decreasing enrollment type) that the divorce or annulment is final, and the former spouse should no longer be covered. If a court order requires the enrollee to provide coverage for their former spouse, the former spouse is still not eligible to continue coverage as a family member under the enrollee’s FEHB enrollment. Therefore, the enrollee may need to purchase separate insurance coverage for their former spouse to comply with the court order. Once the divorce or annulment is final, the enrollee’s former spouse loses coverage at midnight on the day the divorce or annulment is final, subject to a 31-day extension of coverage.

The enrollee’s former spouse may be eligible for their own enrollment under the Spouse Equity Act, temporary continuation of coverage (TCC), or to convert to an individual policy with the enrollee’s Carrier. Under a Spouse Equity Act Self Plus One or Self and Family enrollment, the enrollment is limited to the former spouse and the natural and adopted children of both the enrollee and the former spouse. Under a Spouse Equity Act enrollment, a foster child or stepchild of the former spouse is not considered a covered family member. Please visit the Former Spouses and TCC sections for more information.

Tribal Employer Note: Spouse Equity Act does not apply to tribal enrollees or their family members.

Divorce is a Qualifying Life Event (QLE). When an enrollee has a Self Plus One or a Self and Family enrollment and the enrollee has no other eligible family members other than a spouse, the enrollee may change to a Self Only enrollment and may change plans or options within 60 days of the date of the divorce or annulment. 

Divorce is a QLE that allows the enrollee to designate a different covered family member if the enrollee’s spouse was designated as a covered family member under their Self Plus One enrollment and the enrollee has another eligible family member. The enrollee must complete an SF 2809 (or electronic equivalent) designating a new eligible family member and submit it to their employing office.

Divorce is a QLE that allows an enrollee to decrease their Self and Family enrollment to a Self Plus One enrollment if the enrollee only has one eligible family member remaining after the divorce.

If the enrollee has other eligible family members covered under the Self and Family enrollment, they must inform the Carrier of the date of divorce or annulment and have the Carrier remove the former spouse. The enrollee does not need to complete an SF 2809 (or electronic equivalent) or obtain any agency verification in these situations. However, the Carrier will ask for a copy of the divorce decree as proof of divorce. If the enrollee’s divorce results in a court order requiring them to provide health insurance coverage for eligible children, they may be required to maintain a Self Plus One or a Self and Family enrollment.  See the section on Children’s Equity for more information.

Coverage of Stepchildren after Divorce, Annulment, or Death

An enrollee’s stepchild loses coverage after the enrollee’s divorce or annulment from, or the death of, the parent.

An enrollee’s stepchild remains an eligible family member after the enrollee’s divorce or annulment from, or the death of, the parent only when the stepchild continues to live with the enrollee in a regular parent-child relationship.

If an enrollee’s stepchild stops living with the enrollee in a regular parent-child relationship, the child may enroll under temporary continuation of coverage (TCC) provisions because they no longer meet the definition of an eligible child.

Tribal Employer Note: Spouse Equity Act does not apply to tribal enrollees or their family members.

Adult Child Incapable of Self-Support

Coverage

A Self Plus One or Self and Family enrollment covers a child age 26 or over who is incapable of self-support because of a physical or mental disability that existed before the child reached age 26.

Requirements

The child age 26 or over may be considered incapable of self-support only if their physical or mental disability is expected to continue for at least one year and, because of the disability, they are not capable of working at a self-supporting job.

A disability does not itself qualify a child over the age of 26 for continued coverage because a disability doesn't preclude employment in all occupations or necessarily make them incapable of self-support. A child does not qualify for continued coverage as a family member if the onset of their disability before age 26 doesn't result in incapability of self-support until age 26 or after.

Determination of Incapacity for Self-Support

When Employing Office Must Make Determination

The employing office is responsible for determining whether an enrollee’s dependent child age 26 or over is incapable of self-support because of a mental or physical disability that existed before age 26 and for notifying the enrollee’s Carrier of its determination. If the child's medical condition is listed below, the Carrier may also approve coverage.

The dependent child is incapable of self-support when:

• they are certified by a state or Federal rehabilitation agency as unemployable;
• they are receiving: (a) benefits from Social Security as a disabled child; (b) survivor benefits from CSRS or FERS as a disabled child; or (c) benefits from OWCP as a disabled child;
• a medical certificate documents that: (a) the child is confined to an institution because of impairment due to a medical condition; (b) they require total supervisory, physical assistance, or custodial care; or (c) treatment, rehabilitation, educational training, or occupational accommodation has not and will not result in a self-supporting individual;
• a medical certificate describes a disability that appears on the list of medical conditions; or
• the enrollee submits acceptable documentation that the medical condition is not compatible with employment, that there is a medical reason to restrict the child from working, or that they may suffer injury or harm by working.

If the adult child age 26 or above earns some income (generally no more than the equivalent of the GS 5, step 1), it doesn't necessarily mean that they are capable of self-support. The employing office will take both the child's earnings and the condition or prognosis into consideration when determining whether they are incapable of self-support.

When Carrier May Approve Coverage

If the enrollee’s child has a medical condition listed, and their condition existed before reaching age 26, the enrollee doesn't need to ask their employing office for approval of continued coverage after the child reaches age 26. The enrollee’s Carrier may approve continued coverage of the child without referring the enrollee to the employing office.

When the Carrier determines the child's incapacity for self-support, it sends the approval notice to the enrollee and advises them to give a copy of the notice to their employing office. The employing office must file it with the enrollee’s other health benefits enrollment documentation in the enrollee’s Official Personnel Folder (OPF).

List of Medical Conditions that would Cause a Child to be Incapable of Self-Support During Adulthood

If a child has one of the following disabilities, noted in the medical certificate, and the disability existed before age 26, the employing office or Carrier can automatically extend continued coverage.

• AIDS - CDC classes A3, B3, C1, C2, and C3 (not seropositivity alone)
• Advanced Muscular Dystrophy
• Any malignancy with metastases or which is untreatable
• Chronic Hepatic Failure
• Chronic neurological disease, whatever the reason, with severe intellectual disabilities or neurologic impairment, for example:
  • Cerebral Palsy
  • Ectodermal Dysplasia
  • Encephalopathies
  • Uncontrollable Seizure Disorder
• Chronic Renal Failure
• Inborn errors of Metabolism with complications such as the following:
  • Adrenoleukodystrophy
  • Gaucher disease
  • Glycogen storage diseases
  • Homocysteinuria
  • Lesch-Nyhan disease
  • Mucopolysacharide disease
  • Nieman-Pick disease
  • Phenylketonuria
  • Primary hyperoxaluria
  • Tay-Sachs disease
• Intellectual Disabilities with IQ of 70 or less
• Osteogenesis Imperfecta
• Severe acquired or congenital Heart Disease with decompensation which is not correctable
• Severe Autism
• Severe Juvenile Rheumatoid Arthritis
• Severe Mental Illness requiring prolonged or repeated hospitalization
• Severe Organic Mental Disorder
• Xeroderma Pigmentosa

Note: This list doesn't include all the disabilities that may qualify a child over the age of 26 who is incapable of self-support for FEHB.

Medical Certificate

The child's doctor must complete a medical certificate for the employing office to make its determination of incapacity of self-support. To qualify for continued coverage as a family member, the certificate must establish that the child is incapable of self-support because of a physical or mental disability that existed before they reached age 26 and that can be expected to continue for more than one year. The certificate must include:

• the child's name and birth date;
• the type of disability;
• the period of time the disability has existed and the date the impairment began
• diagnosis and history of the specific medical condition(s), references to findings from previous examinations, treatment, and responses to treatment;
• clinical findings from the most recent physical examination, including objective findings of physical examination; results of laboratory tests, x-rays, EKGs, and other special evaluations or diagnostic procedures; and, in the case of psychiatric disease, the findings of mental status examinations and the results of psychological tests, if applicable;
• assessment of the current clinical status and plans for future treatment;
• assessment of degree to which the medical condition has become static or stabilized and an explanation of the medical basis for the conclusion;
• the probable future course and duration of the disability, including an estimate of the expected date of full or partial recovery, if any;
• the special supervisory, physical assistance, or custodial care requirements for the child;
• any treatments, rehabilitation programs, educational training, or occupational accommodation that would result in the child becoming self-supporting; and
• the doctor's name, signature, office address, and telephone number.

When to Submit Certificate

The enrollee may submit the medical certificate to the employing office when they first enroll to cover the child under a Self Plus One or Self and Family enrollment. To maintain continued coverage for the child after they reach age 26, the enrollee must submit the medical certificate within 60 days of the child reaching age 26.

If the employing office determines that the child qualifies for FEHB because they are incapable of self-support, the employing office must notify the enrollee’s Carrier by letter. The letter must identify the enrollee by name and social security number and state the name and date of birth of the disabled child as well as the duration of the approval.

Use of Physicians

In making its medical determinations, the employing office must use a physician's services unless the child's condition is one for which it can automatically extend continued coverage. The employing office may request assistance from the Office of Personnel Management, Healthcare and Insurance, at P.O. Box 436, Washington, D.C. 20044, for example, if no physician is available.

Duration and Approval of Incapacity for Self-Support

Depending on the child's medical certificate, the employing office may approve coverage due to disability for a limited period of time (1 year, for example), or without time limitation.

Renewal of Medical Certificate

If the employing office approves the child's medical certificate for a limited period of time, it must remind the enrollee, at least 60 days before the date the certificate expires, to submit either a new certificate or a statement that they will not submit a new certificate. If it is renewed, the employing office must notify the enrollee’s Carrier of the new expiration date.

Failure to Renew Certificate

If the enrollee doesn't renew a medical certificate for a disabled child age 26 or over, the child's status as a family member automatically ends and they are no longer covered. The employing office must notify the enrollee and the Carrier that the child is no longer covered.

Late Certificates

If the enrollee submits a medical certificate for a child after a previous certificate has expired, or after their child reaches age 26, the employing office must determine whether the disability existed before age 26. If the employing office determines that it did, and the enrollee continuously had a Self and Family enrollment, the child is considered to have been a covered family member continuously since age 26.

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Removal of Ineligible Individuals 

An employing office, an FEHB Carrier (CL 2020-16), or OPM 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/FEHB Carrier/OPM sends the employee a request for appropriate documentation of the family member or members’ relationship (see Sample Letter Agency/Tribal Employer 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 documents as indicated in the section entitled FEHB Family Member Eligibility Documents.

Sample Letter 

Agency/Tribal Employer Request 

For Verification of Family Member Eligibility 

 

For Employing Office/Tribal Employer Use 

[Insert Date] 

[Insert Employee Name and Address] 

Dear [Employee]: 

We are conducting an eligibility review of certain family members covered under your Federal Employees Health Benefits (FEHB) enrollment. 5 CFR 890.308(f) allows for an employing office to request that an employee verify the eligibility of any or all family members covered under the employee’s FEHB enrollment at any time. 

Our records show that the following family member(s) is/are being provided coverage under your [(Self Plus One) (Self and Family)] enrollment.  

1. [Insert Name of Covered Family Member] 

1. [Insert Name of Covered Family Member] 

Eligible family members are limited to:  

• Your current spouse 
• Your children under age 26, including: 

• • Adopted children 
  • Stepchildren 
  • Foster children under certain circumstances 

• An adult child incapable of self-support because of a mental or physical disability that existed before age 26   

Please see the U.S. Office of Personnel Management website (https://www.opm.gov/healthcare-insurance/healthcare/reference-materials/reference/eligibility-for-health-benefits/ ) for more information on eligible family members.  

You must comply with this request and submit documentation of each family member’s eligibility within 60 calendar days from the date of this notice. Please see the attached FEHB Family Member Eligibility Documents for information on appropriate documentation.  If you do not submit appropriate documentation that confirms eligibility of your family member(s) to be covered under your FEHB enrollment, the person(s) will be removed from coverage under your FEHB enrollment 60 calendar days from the date of this notice.  

Send the documentation to: 

[Insert specific instructions to receive documents requested] 

Any intentional false statement or willful misrepresentation, such as including an ineligible family member on an FEHB health plan, is a violation of the law (18 U.S.C. 1001).  

If you have questions about this request, you may contact us at:  

[Insert Contact Information]   

 

[Signature] 

Attachment FEHB Family Member Eligibility Documents 

Cc: [FEHB Carrier] 

 

Documents used as proof of family member eligibility  

Accepted documents include, but are not limited to, copies of birth certificates, marriage certificates, and, if applicable, other proof of family member eligibility.  See FEHB Family Member Eligibility Documents for a list of acceptable documents.  

Foster Child:  The employing office must initially determine a foster child’s 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 a declaration of common law marriage. See FEHB Family Member Eligibility Documents, see below for the requirements.  

Employing Office actions 

Receipt of Eligibility Verification Documents  

If the employing office determines that the documentation received verifies eligibility of the family member(s), the employing office must notify the employee, the family member (see Sample Letter Receipt of Eligibility Verification Documents), and the FEHB Carrier.   

Sample Letter - Receipt of Eligibility Verification Documents 

[Insert Date] 

[Insert Employee Name and Address] 

We have reviewed the documents you submitted in response to our request to verify that the person(s) listed below are eligible for coverage under your Federal Employees Health Benefits Program enrollment. 

We have determined that the documentation you submitted verifies current eligibility for the family member(s) listed. 

1. [Insert Name of Verified Family Member]

No changes will be made to your enrollment, and you do not need to take any further action.  Thank you for your prompt attention to our request.  Please retain a copy of this letter for your records.  

[Signature] 

CC: FEHB Carrier/Employing Office/Tribal Employer 

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 a FEHB Carrier in an employee’s official personnel folder.  

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 Sample Letter “Verification Documents Not Received” or 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 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.  

 

Sample Letter:  Verification Documents Not Received  

[Insert Date]  

[Insert Employee Name and Address]  

On [insert date of initial request notice] we notified you that we are requesting documentation to verify whether the person(s) listed below are eligible for coverage under your Federal Employees Health Benefits (FEHB) Program enrollment. Our records show that the following person(s) are being provided coverage under your [(Self Plus One) (Self and Family)] enrollment:  

1. [insert name of covered family member] 
2. [insert name of covered family member] 

In order to verify eligibility, we requested that you submit to us appropriate documentation that demonstrates the relationship between you and each listed person.  

Because we have not received a reply from you, we must remove the above listed person(s) from your FEHB enrollment. This means the person(s) listed will no longer have coverage under your FEHB enrollment.  

The effective date of removal is [insert removal date – day 61 from date of initial request notice].  

Please contact the employing office listed below to discuss whether these individuals may be eligible for either temporary continuation of coverage (TCC) or Spouse Equity Act coverage.  

This is an initial decision. You or the affected person have the right to request reconsideration of this decision. A request for reconsideration must be filed with the employing office listed below within 60 calendar days from the date of this letter. A request for reconsideration must be made in writing and must include your name, address, Social Security Number (or other personal identifier, e.g., plan member number), your family member’s name, the name of your FEHB plan, reason(s) for the request, and, if applicable, retirement claim number. Please also include a copy of this letter.  

Requesting reconsideration will not change the effective date of removal listed above. However, if the reconsideration decision overturns the initial decision to remove the family member(s), [the FEHB Carrier/we] will reinstate coverage retroactively so there is no gap in coverage.  

Send your request for reconsideration to:  

[insert employing office/tribal employer contact information]  

The above office will issue a final decision to you within 30 calendar days of receipt of your request for reconsideration. If you need more time to submit your reconsideration request, please contact the employing office listed above in writing. If the removal of the ineligible family member results in your enrollment decreasing from three or more individuals to two individuals or from two individuals to one individual, you are eligible to decrease your enrollment type to Self Plus One or Self Only, respectively, within 60 days. We encourage you to consider reducing your enrollment type since that may decrease your FEHB premium costs.  

You must contact your employing office and submit a Standard Form (SF) 2809 (Event Code 1C) to request the change in enrollment type.  

Any intentional false statement or willful misrepresentation, such as including an ineligible family member on a 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.  

If you have questions about this letter, you may contact us at:  

[insert contact information]  

[Signature]  

cc: [employing office/tribal employer/FEHB Carrier] 

 

 Sample Letter: Information Provided Does Not Verify Family Member Eligibility  

For employing office/tribal employer use  

[insert date]  

[insert employee name and address]  

We have reviewed the documents you submitted to verify FEHB eligibility for your family member(s). Based on our review, the documents are not sufficient to verify eligibility. Therefore, we have determined that the person(s) listed below are not eligible for coverage under your FEHB enrollment effective [insert date]  

1. [insert name of ineligible family member] 
2. [insert name of ineligible family member] 

The documentation submitted was not approved due to:  

[insert reason]  

Please contact us to discuss whether these individuals may be eligible for either temporary continuation of coverage (TCC) or Spouse Equity Act coverage.  

This is an initial decision. You or the affected person have the right to request that we reconsider this decision. A request for reconsideration must be filed with the employing office listed below within 60 calendar days from the date of this letter. A request for reconsideration must be made in writing and must include your name, address, Social Security Number (or other personal identifier, e.g., plan member number), your family member’s name, the name of your FEHB plan, reason(s) for the request, and, if applicable, retirement claim number. Please also include a copy of this letter.  

Requesting reconsideration will not change the effective date of removal listed above. However, 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.  

Send your request for reconsideration to:  

[insert contact information]  

The above office will issue a final decision to you within 30 calendar days of receipt of your request for reconsideration. If you need more time to submit your reconsideration request, please contact the employing office listed above in writing.  

If the removal of the ineligible family member(s) results in your enrollment decreasing from three or more individuals to two individuals or from two individuals to one individual, you are eligible to decrease your enrollment type to Self Plus One or Self Only, respectively, within 60 calendar days. Contact us to submit a Standard Form (SF) 2809 (Event Code 1C) to request the change in enrollment type. We encourage you to consider reducing your enrollment type since that may decrease your FEHB premium costs.  

As a reminder, any intentionally false statement or willful misrepresentation, such as including ineligible family members on a 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.  

If you have questions about this letter, you may contact us at:  

[insert employing office/tribal employer info]  

[Signature]  

cc: [FEHB Carrier] 

Employee or family member requests for an extension

If an employee or family member requests 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), then employing offices may grant a reasonable extension to the deadline.

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 1C) per the agency’s FEHB enrollment process to request the change in enrollment type. 

The use of event code 1C under this situation is limited to decreasing the enrollment type only.

Effective date of ineligible family member removal

The removal is effective on the date listed in the initial determination letter (Sample Letter Agency/Tribal Employer 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.

Reconsideration

Reconsideration process after removal of an ineligible family member

The employing office must have a reconsideration process for decisions regarding the 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 who 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 Sample Letter “Verification Documents Not Received” and 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. 

Tribal Employer Note: Tribal employers must establish or identify an independent dispute resolution panel to adjudicate appeals of determinations made by a tribal employer regarding a tribal employee’s eligibility or a family member’s eligibility to participate or change participation in the FEHB Program. This panel must be authorized to enforce eligibility decisions.

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.

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.

Temporary Extension of Coverage, Conversion, and/or Temporary Continuation of Coverage for a Family Member Removed for Ineligibility

An individual removed from an enrollment may be eligible for a 31-day temporary extension of coverage, temporary continuation of coverage (TCC), conversion, or Spouse Equity Act coverage in certain limited circumstances; see 5 CFR 890.308(g). Any such opportunity still begins on the date that a family member loses eligibility and is valid until the end of the appropriate regulatory window.

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 Act 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 or temporary continuation of coverage.

Removal of Eligible Family Members

An eligible family member may be removed from a Self Plus One or a Self and Family enrollment if a request from the enrollee or the family member is submitted to the enrollee's employing office for approval at any time during the plan year.

Definition of Removal

A removal only removes the family member from coverage under an existing enrollment and does not change the enrollment type or premium amount. An enrollee can change enrollment type from Self Plus One to Self Only and from Self and Family to Self Plus One if they have a qualifying life event. Annuitants and employees not participating in premium conversion can reduce enrollment type at any time.

If an enrollee chooses to remove all existing family members and does not change enrollment type based on a QLE (if enrolled in premium conversion) the enrollee must continue to pay Self and Family or Self Plus One premiums.  A removal of all existing family members does not allow an agency to change an enrollment to Self Only based on there being no eligible family members on the enrollment as described in 5 C.F.R. 890.301(e)(2).

For example, an enrollee (Jose) covers his wife (Joy) and his daughter (Sarah, under age 26) on a Self and Family enrollment.  Sarah gets a job and becomes eligible for other coverage through her work and no longer needs FEHB coverage under her father’s enrollment. Jose does not want to pay for a Self and Family enrollment now that his daughter no longer needs FEHB coverage.  In this situation, Jose should reduce coverage from Self and Family to Self Plus One under QLE code 1P.

However, under the following example a removal would be appropriate: Jose covers Joy, Sarah, and their son Jamal under his FEHB Self and Family enrollment.  Sarah’s employer-sponsored coverage is in the form of a High-Deductible Health Plan with a Health Savings Account (HSA) with contributions from her employer. For Sarah to receive coverage under her employer’s plan, per IRS rules she cannot be also covered under her father’s FEHB plan. As such, Jose needs to remove her from his coverage.  Jose or Sarah should submit a formal request for removal so that Sarah is not covered.  Jose would then maintain Self and Family coverage for himself, Joy, and Jamal.

Interaction with Dual Enrollment

The removal of an eligible family member from an existing enrollment alone is not considered a Qualifying Life Event (QLE) under the FEHB Program and does not provide the opportunity for an employee in premium conversion to decrease plan coverage from Self and Family to a Self Plus One or Self Only enrollment unless an enrollee has a separate QLE. A Federal employee who is of the age of majority in their state, but under age 26, or a spouse of another Federal employee can be removed from an enrollment. The "age of majority" is the age at which a child legally becomes an adult and is governed by state law. In most states the age is 18; however, some states allow minors to be emancipated through a court action.

However, this removal is not a QLE that would allow the adult child or spouse to enroll in their own FEHB enrollment, unless the adult child has a spouse and/or child(ren) to cover. For more information on dual enrollment see Enrollment Chapter.

Removal of Eligible Spouse

A spouse may be removed if the enrollee provides a notarized request for removal that is signed by both the enrollee and the spouse. See BAL 18-201.

Removal of Eligible Child

An eligible adult child (who has reached the age of majority) may be removed from a Self Plus One or a Self and Family enrollment if the child is no longer dependent upon the enrollee. The “age of majority” is the age at which a child legally becomes an adult and is governed by state law. The adult child may remove themselves or the enrollee may initiate the removal.  However, if a court order exists requiring coverage for an adult child, the child cannot be removed.

Enrollee Initiated Removals

• The enrollee must provide proof that the child is no longer a dependent.
• The enrollee must also provide the last known contact information for the child. Proof can include a certification from the enrollee that the child is no longer a tax dependent.

Adult Child Initiated Removals

• The child must provide a notarized request for removal to the employing office.

Effective Date of Removal

Removal of a child as described above is effective:

• the first day of the third pay period following the date the request is approved by the employing office for employees who pay health benefit premiums bi-weekly; or
• the second pay period following the date that the request is approved by the employing office for enrollees who pay premiums monthly or through other pay frequencies.

Removal Treated as Cancellation

Removal of an eligible family member described above is considered a cancellation. Removed family members are not eligible for a 31-day extension of coverage, temporary continuation of coverage (TCC), or conversion.

If an eligible family member is removed as described above, they may only regain coverage under the applicable Self Plus One or Self and Family enrollment if requested by the enrollee during the annual open season or within 60 days of the family member losing other health insurance coverage. The enrollee must also provide written consent to reinstatement of coverage from the family member and demonstrate eligibility as a family member to the employing office.

Employing Office Responsibilities

If an employing office approves a request for removal, the employing office must notify the enrollee and the Carrier of the removal immediately. For removals of an eligible child by the enrollee, the employing office must also immediately notify the child of the removal using the last known contact provided by the enrollee.

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