Last Updated: October 8, 2026 Reading Time: 8 min

"OPM releases fraud numbers" is the headline, and the number attached to it is $2.4 billion to $4 billion a year. That figure is real, in the sense that it appears in an OPM document. It is not a measurement. OPM Director Scott Kupor wrote in June that outside experts estimate large health programs "may see" 3 to 5% abuse, and that on an $80 billion program "that means $2.4-$4 billion in annual savings." Every figure OPM has measured is far smaller: $531.5 million in carrier-reported 2025 results, of which $21.9 million was money recovered after payment, and a 0.14% improper-payment rate for experience-rated carriers. Here is what each number is, FedTools' computation of all six on one scale, and what an enrollee has to do between November 9 and December 14.

Frequently Asked Questions

Did OPM find $2.4 to $4 billion in FEHB fraud?

No. OPM's director wrote in June 2026 that experts estimate large health programs "may see" 3 to 5% abuse, and that on an $80 billion program this means $2.4 to $4 billion in potential annual savings. OPM named no study and reported no fraud loss of that size.

What has OPM reported so far?

Carrier special investigation units reported $531.5 million in 2025 anti-fraud results: $237.7 million in claims stopped or reduced before payment, $271.9 million in estimated losses prevented by billing and policy changes, and $21.9 million recovered after payment.

Does the crackdown change who I can cover?

No. Eligibility is unchanged. Since July 2, 2026, under 5 C.F.R. § 890.302(a)(1), you must give proof of eligibility for every family member you add, including at Open Season, and your carrier, agency, or OPM can ask for proof at any time.

What documents do I need at Open Season?

For a spouse, a government-issued marriage certificate; if you have been married 12 months or more, OPM also asks for the front page of your most recent tax return or proof of shared residence and finances. A common-law spouse has separate requirements. For a child under 26, OPM accepts any one of several documents listing the child and you, such as a birth certificate, certificate of live birth, tax-return front page, or court order; an adopted child can use a final adoption decree or placement-agency letter, among others. A foster child, and a disabled child 26 or older, need additional documents. You can black out Social Security numbers and personal financial information.

What if my plan asks me to re-verify someone already covered?

Send the proof. Under 5 C.F.R. § 890.308(e)(1), if you do not, the family member's coverage ends 60 calendar days after the date of the notice. You can ask your agency to reconsider within 60 calendar days of the carrier's decision, and coverage is restored retroactively if you later provide acceptable proof.

What happens if a covered family member turns out to be ineligible?

Under 5 C.F.R. § 890.308(e)(3), removal normally takes effect going forward. If fraud or intentional misrepresentation of a material fact is found, the removal reaches back to the date the person stopped being eligible.

I am divorced and my former spouse is still on my plan. What should I do?

Tell your carrier now. OPM's guidance says a former spouse cannot remain covered as a family member once the divorce or annulment is final, even under a court order, and it is the enrollee's responsibility to report it. Your former spouse may qualify for Spouse Equity coverage, Temporary Continuation of Coverage, or conversion.

Is OPM looking at my medical claims?

OPM's director says the claims data its analysts use is pseudonymized and "cannot be mapped back to any plan participant."

Does this apply to Postal Service Health Benefits?

Yes. Under 5 C.F.R. § 890.1607(b)(1), the same proof rule applies to PSHB; the Postal Service makes the eligibility determinations, and OPM handles certain VA and Indian Health Service exception cases.

When is Open Season and how early should I submit documents?

November 9 through December 14, 2026. OPM says agencies "should make every effort to verify new family members within 30 days" of receiving documents, so submit early in the window.

Rumor vs. What OPM Published

Claim circulating What the source says Where
"OPM found $2.4 to $4 billion in FEHB fraud" "Experts estimate that large programs such as FEHBP may see rates of abuse between 3-5%. On an $80 billion annual spend ... that means $2.4-$4 billion in annual savings." An estimate of potential savings, no study named OPM Director's post, June 11, 2026
"OPM recovered $500 million" "More than $500 million in anti-fraud savings for calendar year 2025": $237.7 million in claims stopped before payment, $271.9 million in estimated losses prevented, $21.9 million recovered after payment OPM news release on the Task Force results
"GAO says ineligible dependents cost $1 billion" "OPM has estimated these related improper payments could cost the program up to approximately $1 billion per year." OPM's upper-bound estimate, as GAO reported it in 2022 GAO-23-105222
"Fraud is rampant in FEHB claims" Experience-rated carriers "properly paid 99.86 percent of payments" in OPM's FY2025 report, based on 2024 sampling; improper and unknown payments totaled $94.8 million, of which $26.9 million were overpayments paymentaccuracy.gov, OPM
"The crackdown changes who you can cover" The June 2026 rule amends only the proof requirement in 5 C.F.R. § 890.302(a)(1) and its PSHB counterpart, § 890.1607(b). Eligibility rules are unchanged FR Doc. 2026-11022
"Ineligible dependents are driving premiums" For the roughly 100,000 family members OPM expects to verify each year, its central projection is that 2025 premium rates would have been 0.018% lower without the ineligible ones (about $13.1 million on $72.7 billion, FedTools arithmetic). Premium savings over the next decade annualize to about $18.0 million a year FR Doc. 2026-11022, regulatory analysis

Where the $2.4 Billion Comes From

OPM Director Scott Kupor's June 11, 2026 post, "A Day Late and a Dollar Short," makes three statements in sequence. First: "This year, we will spend about $80 billion on these insurance programs." Second: "Experts estimate that large programs such as FEHBP may see rates of abuse between 3-5%." Third: "On an $80 billion annual spend ... that means $2.4-$4 billion in annual savings."

The abuse rate is attributed to unnamed experts and is described as a rate large programs "may see," not a rate measured on FEHB. The result is labeled savings. Neither OPM's improper-payment reporting, GAO's 2022 report, nor OPM's own June 2026 verification rule contains a $2.4 billion FEHB fraud figure. The same post says OPM will "scramble, or pseudonymize" member IDs in the claims data its analysts review, and that Congress funded OPM's first FEHB enrollment verification program.

What OPM Has Measured

Three published figures describe what has been found, as opposed to what might be saved.

The carrier results. OPM and the White House fraud task force announced "more than $500 million in anti-fraud savings for calendar year 2025" across FEHB and PSHB, compiled "in coordination with the Special Investigation Units" of the carriers. The breakdown: $237.7 million in claims stopped or reduced before payment, $271.9 million in losses the carriers estimate were prevented by billing and policy changes, and $21.9 million recovered after payment.

The improper-payment rate. In OPM's Payment Integrity reporting for FY2025, based on 2024 sampling, experience-rated FEHB carriers "properly paid 99.86 percent of payments" and "improperly paid 0.14 percent." The $94.8 million total breaks into $26.9 million in overpayments, $44.5 million in technically improper payments and underpayments, and $23.4 million that could not be classified. Improper is not the same as fraud, and the estimate covers only experience-rated fee-for-service carriers, not community-rated HMOs.

OPM's own cost of ineligible dependents. The June 2026 family-member verification rule, in its regulatory analysis, says that in 2024 reviews of more than 19,000 cases "almost 2% of FEHB and PSHB family members have been confirmed to be ineligible," with "up to 4.36%" that "could be deemed ineligible due to non-responses or insufficient documentation." Assuming about 100,000 family members are verified each year, its central projection is that 2025 premium rates "would have been 0.018% lower" without those ineligible family members; on about $72.7 billion in FY2025 premiums, that is about $13.1 million, by FedTools' arithmetic. The rule's separate decade projection annualizes the premium savings at $18.0 million a year at a 3% discount rate. The older "up to approximately $1 billion per year" figure is OPM's own upper-bound estimate, as GAO reported it in December 2022.

All Six Numbers on One Scale

FedTools computed each published figure as a share of program cost, using two bases because they cover different periods: Kupor's $80 billion 2026 spending estimate and the $72.7 billion in FY2025 premiums from the verification rule.

Figure Source Amount Share of $80B Share of $72.7B What it is
"Potential savings" range OPM Director's post $2.4B to $4.0B 3.0% to 5.0% (by construction) 3.30% to 5.50% Hypothetical: an unnamed expert rate times spending
Ineligible family members, upper estimate OPM via GAO, 2022 up to about $1.0B 1.25% 1.38% Upper-bound FEHB-only estimate, shown against both bases for scale
2025 carrier-reported anti-fraud results OPM release $531.5M 0.66% 0.73% Mostly claims stopped or losses prevented
of which recovered after payment OPM release $21.9M 0.027% 0.030% Cash clawed back
Improper and unknown payments, experience-rated carriers paymentaccuracy.gov $94.8M 0.12% 0.13% Errors including underpayments; experience-rated carriers only
Premium savings from new verifications, OPM central projection FR Doc. 2026-11022 about $18.0M a year, annualized over the next decade 0.0225% 0.025% Projected savings from about 100,000 verifications a year (OPM separately states 2025 rates would have been 0.018% lower)

FedTools analysis of OPM and GAO figures, rounded once at the end. The $531.5 million in reported results equals 22% of the low end of the director's savings range and 13% of the high end. Of that $531.5 million, 4.1% was money recovered after payment. The verification rule's projection and the "$1 billion" figure still cited from 2022 measure different populations with different methods, so this analysis does not compare them.

One extrapolation, labeled as such: the rule says about 4 million family members were covered in 2025, about 2.1 million children and 1.9 million spouses. If the 2024 review rates held across all of them, about 80,000 would be confirmed ineligible, and the rule's "up to 4.36%" who "could be deemed ineligible due to non-responses or insufficient documentation" would be up to about 174,400 people. The rule does not say how those two groups overlap, and it cautions that its sample may not be representative. That is FedTools arithmetic, not an OPM count, and it shows that missing paperwork, as well as ineligibility, can cost someone coverage.

Does This Affect You at Open Season?

Three questions decide it.

Are you adding anyone? Since July 2, 2026, 5 C.F.R. § 890.302(a)(1)(i) requires proof of eligibility "to the employing office, the carrier, or OPM" whenever a family member is added, at your initial enrollment, "any open season," or a qualifying life event. Outside Open Season you also document the life event itself. OPM's document table lists accepted options, for example: a government-issued marriage certificate for a spouse, plus, for a marriage of 12 months or more, a recent tax-return front page or proof of common residence and financial interdependence; for a child under 26, any one of a birth certificate, certificate of live birth, tax-return front page, paternity record, or court order listing the child and you; for an adopted child, a final adoption decree, placement-agency letter, tax-return front page, or court order; for a stepchild, a birth certificate or adoption decree listing your current spouse, among others; separate document sets for a foster child and a common-law spouse; and a medical certificate for a disabled child 26 or older. You may remove Social Security numbers and personal financial information. Our family verification documents guide has the full list.

Is a former spouse still on your enrollment? OPM's guidance is direct: after a divorce or annulment is final, the former spouse "cannot remain covered as a family member," and it is the enrollee's responsibility to inform the carrier or agency. A court order does not change that. The former spouse may qualify for Spouse Equity coverage, Temporary Continuation of Coverage, or conversion.

Could a request for proof arrive later? Yes, at any time. In 2025 OPM began requiring agencies to self-audit 10% of family-member eligibility, and the rule says OPM "is also preparing for the family member eligibility audit required by" the statute that funded the program. Keep documents for everyone you cover, not only new additions.

What a Fraud Finding Changes

Two clocks and one exception govern a challenged family member under 5 C.F.R. § 890.308(e). If a carrier sends a verification notice and you do not respond, the individual "will no longer be covered 60 calendar days after the date of the notice." You may request reconsideration by your employing office "within 60 calendar days after the date of the carrier's initial decision," and acceptable proof restores coverage retroactively.

The exception is the one that matters for the words "fraud" and "intentional misrepresentation." Removal "shall be prospective unless the record shows" fraud or intentional misrepresentation of a material fact; then it is effective back to the date eligibility was lost. An honest error ends coverage going forward. A fraud finding backdates it. The regulation does not say what happens to claims paid in between, and this article does not guess.

Compare Plans Before You Add Anyone

Pick two plans and your enrollment type in the FEHB Plan Comparison with the 2027 plan year selected to see each plan's 2027 enrollee share side by side. If adding a family member requires a different enrollment type, such as moving from Self Only to Self Plus One, compare that type's premiums before Open Season rather than after.

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