Pay & Benefits

OPM to crack down on ineligible health insurance enrollees

In an effort to cut spending on ineligible participants, OPM outlined an expanded verification process for family members of health insurance enrollees.

Drew Friedman@dfriedmanWFED

June 1, 2026 6:15 pm

3 min read

Enrollees in the government’s health insurance programs will soon face tighter requirements when adding family members to their plans.

A final rule from the Office of Personnel Management, which will be published Tuesday to the Federal Register, will expand the eligibility verification process for family members of insurance enrollees. The regulations affect plan members in the Federal Employees Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) programs.

Once the final rule takes effect in July, FEHB and PSHB enrollees will have to provide documentation, such as marriage certificates, tax returns or birth certificates, confirming that family members added to their plans are eligible for benefits. The rule applies to members who are added during either Open Season or a qualifying life event (QLE), such as a birth, adoption or marriage.

OPM said the upcoming changes will improve integrity and create more “sustainable” health insurance programs, which cover more than 8 million federal employees, retirees and their families.

“This regulation is necessary to address the presence of ineligible family members covered by the FEHB program,” OPM said in its final rule. “There are ineligible family members participating in the program and more can be done to identify and remove them from coverage.”

A family member’s eligibility for federal health insurance depends on their relationship to the federal enrollee. Children under age 26 and spouses qualify as eligible FEHB and PSHB dependents. But grandchildren, parents, former spouses and domestic partners are not authorized to receive program benefits.

OPM estimated there were a combined 4 million family members enrolled in the FEHB and PSHB programs in 2025. Based on preliminary data, roughly 3% of enrolled family members are ineligible for benefits, OPM said.

Ineligible family members on federal health plans contribute to rising premiums and increase administrative costs for the insurance program, the Government Accountability Office has reported. In 2019, a report from OPM’s inspector general office called ineligible FEHB members a “known area of substantial fraud.”

Concerns about FEHB family member eligibility escalated after a 2022 GAO report found OPM has no clear way to identify or remove ineligible family members, costing up to $1 billion annually.

In 2024, OPM tried to start weeding out ineligible participants by requiring validation of a random 10% sample of participants. But that requirement has not fully taken shape.

“Due to high transactions in Open Season 2024 and staffing challenges in 2025, many agencies did not reach the 10% threshold or did not report when OPM requested audit information,” the final rule stated.

In 2025, GAO also found that recent staffing losses within OPM were hindering the agency’s ability to address ongoing fraud risks in the FEHB program.

Historically, the responsibility of verifying enrollees was mostly delegated to insurance carriers — up until 2018, when OPM issued regulations attempting to address the issue.

The final rule this week builds on OPM’s 2018 regulations, now requiring members to verify family members’ eligibility in all instances — including during Open Season. Currently, members only need to provide proof of eligibility during a QLE, although OPM or health carriers may request proof in additional instances.

The final rule stems from requirements of the FEHB Protection Act, which was enacted last summer. The legislation, included as part of the One Big Beautiful Bill Act, required OPM to create an eligibility verification process and a method for removing currently enrolled ineligible members.

OPM’s new process would require verifying roughly 100,000 family members each year, the final rule said. In addition to expanding the eligibility verification process, OPM said it is preparing an audit of currently enrolled family members.

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