Under federal regulations, specific family members are eligible for Federal Employees Health Benefits (FEHB) Program coverage. The 'Family Members' chapter of the FEHB Handbook provides comprehensive information about eligible family members.
Eligible Family Members: Who Can You Include?
Your Current Spouse
The FEHB Program allows you to extend coverage to your current spouse. However, former spouses are not eligible for coverage, even if a court order mandates health insurance provision.
Coverage for Spouses in Common Law Marriages
Spouses in valid common-law marriages may also qualify for FEHB coverage. To be recognized under the program, the common law marriage must originate in a state where such unions are legally acknowledged.
Your Children Under Age 26
Children under 26 are eligible for coverage under your FEHB plan if they fall into one of the following categories:
Biological children
Legally adopted children
Stepchildren (as long as you remain married to their biological parent)
Foster children, provided that:
You are their primary source of financial support.
You have a parent-child relationship with them.
You receive approval from your agency to include them in your plan.
Documentation Requirements for Stepchildren
For a stepchild to qualify, you must:
Provide a birth certificate listing your current spouse as a parent.
Verify your spouse's eligibility for FEHB, even if they are not enrolled in the plan.
Important: A stepchild generally loses FEHB coverage if you divorce, your marriage is annulled, or their biological parent passes away.
Coverage for Married Children
Your married children under 26 can remain on your FEHB plan, but their spouse and children are not eligible for coverage.
When Does Coverage End?
In most cases, a child’s eligibility ends on their 26th birthday. They must be removed from your plan unless they qualify as a dependent with a disability.
Your Adult Child with a Disability
If your child is over 26 and incapable of self-support due to a disability, they may still qualify for FEHB coverage. To be eligible, the following conditions must be met:
The disability must have existed before the child turned 26.
The disability must be expected to last for at least one year.
Proper medical documentation is required to maintain coverage under these circumstances.
Who Is Not Eligible for Coverage?
The following family members do not qualify for FEHB coverage:
Former spouses (eligibility ends after divorce)
Children turning 26 (unless they meet disability criteria)
Parents of the plan holder
Grandchildren (unless they meet foster child requirements)
Domestic partners
Exceptions for grandchildren may apply if they are legally classified as foster children under your agency’s regulations. To determine eligibility, consult your Servicing Human Resources Office (SHRO) benefits specialist.
What To Do if a Family Member Becomes Ineligible
If a covered family member loses eligibility, take the following steps:
Notify Your SHRO
Inform your Servicing Human Resources Office (SHRO) within 60 days of the change.
Review Their Coverage Options
Your now-ineligible family member may be eligible for continued coverage through:
Temporary Continuation of Coverage (TCC)
Coverage as a former spouse (if applicable)
Consider Changing Your Plan
The change in family status may allow you to adjust your FEHB plan or enrollment type.
Taking timely action ensures smooth transitions and avoids coverage gaps.
Annual Verification Requirement
As an FEHB participant, you are required to verify the eligibility of all covered family members annually.
Key Responsibilities:
Review the eligibility rules outlined in the FEHB Handbook.
Promptly report any changes in family member eligibility.
Remove ineligible dependents immediately by contacting your SHRO or FEHB Carrier.
Consequences of Non-Compliance
Failure to verify eligibility can lead to fraudulent coverage and improper payments. Serious violations may result in:
Higher premiums for all FEHB participants
Legal penalties, including:
Fines up to $10,000
Imprisonment for up to 5 years (per 18 U.S.C. 1001)
Strict enforcement helps protect the integrity of the FEHB Program and ensures fair premium rates for all participants.
Final Thoughts
Understanding FEHB eligibility rules is crucial to ensuring the right family members receive coverage while avoiding legal and financial risks. By staying informed and proactively managing your plan, you can maximize your federal health benefits while ensuring compliance with program regulations.
For detailed guidance, refer to the "Family Members" section in the FEHB Handbook or consult your SHRO benefits specialist.
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