Sf 2809

SF2809_2015_11 markup_2015_11_02.pdf

Health Benefits Election Form

SF 2809

OMB: 3206-0160

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0160 can be found here:

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Health Benefits Election Form

Uses for Standard Form (SF) 2809
Use this form to:

•

Switch designated eligible family member; or

•

Enroll or reenroll in the FEHB Program; or

•

Elect not to enroll in the FEHB Program (employees only); or

•

Change your FEHB enrollment; or

•

Cancel your FEHB enrollment; or

•

Suspend your FEHB enrollment (annuitants or former spouses
only).

Form Approved:
OMB No. 3206-0160

Item 9.

If you are covered by other health insurance, either in your
name or under a family member’s policy, check yes and
complete item 10.

Item 10.

Provide the information requested on any other health
insurance that covers you. An FEHB Self Plus One
enrollment covers the enrollee and one eligible family
member designated by the enrollee. An FEHB Self and
Family enrollment covers the enrollee and all eligible family
members. If you or a family member is covered under
another FEHB enrollment, check the FEHB box and .
Contact your Human Resources office or retirement system
immediately as this is a dual coverage situation. Some
examples of how this could occur are:

Who May Use SF 2809

•

1. Employees eligible to enroll in or currently enrolled in the FEHB
Program. Employees automatically participate in premium
conversion unless they waive it, see page 7.

You are enrolling in an FEHB Self Only plan while
your spouse has either an FEHB Self Plus One or Self
and Family plan, in which you are already covered.

•

You are enrolling in an FEHB Self Plus One plan while
you are also covered under your spouse’s FEHB Self
Plus One plan or FEHB Self and Family plan.

•

You are enrolling in an FEHB Self and Family plan
while your spouse is already enrolled in either a FEHB
Self Only plan, an FEHB Self Plus One plan that covers
you, or an FEHB Self and Family plan that covers you.

•

You are an employee under age 26 and have no eligible
family members. You are enrolling in your own FEHB
plan while you are covered under your parent’s FEHB
Self Plus One plan or Self and Family plan.

•

You are an annuitant who is reemployed in the Federal
government. You are enrolling in an FEHB plan as an
employee while you are covered under your own or a
family member’s FEHB plan.

2. Annuitants in retirement systems other than the Civil Service
Retirement System (CSRS) or Federal Employees Retirement
System (FERS), including individuals receiving monthly
compensation from the Office of Workers’ Compensation Programs
(OWCP).
Note: Civil Service Retirement System (CSRS) and Federal
Employees Retirement System (FERS) annuitants and former
spouses and children of CSRS/FERS annuitants -- Do not use
this form. Instead, use form OPM 2809, which is available at
www.opm.gov/forms/OPM-forms, or call the Retirement Information
Office toll-free at 1-888-767-6738.
3. Former spouses eligible to enroll in or currently enrolled in the
FEHB Program under the Spouse Equity law or similar statutes.
4. Individuals eligible for Temporary Continuation of Coverage (TCC)
under the FEHB Program, including:

•

Former employees (who separated from service);

No person may be covered under more than one FEHB
enrollment. However, in certain unusual circumstances, your
agency may allow you to enroll in order to:

•

Children who lose FEHB coverage; and

•

Former spouses who are not eligible for FEHB under item 3
above.

Enable an employee under age 26 who is covered under
a parent’s Self Plus One or Self and Family FEHB
enrollment to enroll in FEHB to cover his or her own
spouse and/or child;

•

Enable an employee under age 26 who is covered under
a parent’s Self Plus One or Self and Family FEHB
enrollment, but lives outside his or her parent’s HMO
service area, to have FEHB coverage;

•

Enable an employee who separates or divorces to enroll
in FEHB to cover family members who move outside
the HMO service area of the covering FEHB Self Plus
One or Self and Family enrollment.

Instructions for Completing SF 2809
Type or Print. We have not provided instructions for
those items that have an explanation on the form.
Part A — Enrollee and Family Member Information
You must complete this part.
Item 2.

See the Privacy Act and Public Burden Statements on page 5.

Item 5.

If you are separated but not divorced, you are still married.

Item 7.

If you have Medicare, check which Parts you have, including
prescription drug coverage under Medicare Part D.

Item 8.

If you have Medicare, enter your Medicare Claim Number.
This number is on your Medicare Card.

Previous edition is not usable

In these unusual situations, each enrollee must notify his or
her plan as to which family members are covered under
which enrollment. See Dual Enrollment information on
page 5.

Standard Form 2809
Revised November 2015

If your enrollment is for Self Plus One or Self and Family, complete the
family member information as appropriate. (If you need extra space for
additional family members, list them on a separate sheet and attach.)

Eligible children include your children born within marriage or adopted
children; stepchildren (may include children of your same-sex domestic
partner*); recognized natural children; or foster children who live with
you in a regular parent-child relationship.

Important: In order for your Self Plus One FEHB enrollment election to
be processed, you must complete the family member information for
your designated family member.

Other relatives (for example, your parents) are not eligible for coverage
even if they live with you and are dependent upon you.

The instructions for completing items 13 through 24 for your initial
family member also apply to the information you provide for additional
family members.
Item 14.

Item 17.

If you are a former spouse or survivor annuitant, family members
eligible for coverage under your Self Plus One or Self and Family
enrollment are the natural or adopted children under age 26 of both you
and your former or deceased spouse.

Provide the Social Security Number for this family member if
he/she has one. If your family member does not have a Social
Security Number, leave blank; benefits will not be withheld.
(See Privacy Act Statement on page 5.)

In some cases, a disabled child age 26 or older is eligible for coverage
under your Self Plus One or Self and Family enrollment if you provide
adequate medical certification of a mental or physical disability that
existed before his/her 26th birthday and renders the child incapable of
self-support.

Provide the code which indicates the relationship of each
eligible family member to you.
Code

Family Relationship

Spouse

Child under age 26

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 began before his/her 26th birthday.

Note: Your employing office can give you additional details about
family member eligibility including any certification or documentation
that may be required for coverage. Contact your employing office for
more information about covering foster child(ren), or child(ren) of your
same-sex domestic partner who you would marry but for your state’s
marriage law. “Employing office” means the office of an agency or
retirement system that is responsible for health benefits actions for an
employee, annuitant, former spouse eligible for coverage under the
Spouse Equity provisions, or individual eligible for TCC.

Survivor Benefits
Item 18.

If your family member does not live with you, enter his/her
home address.

Item 19.

If your family member has Medicare, check which Parts
(Part A [Hospital Insurance] and/or Part B [Medical
Insurance]) he/she has, including prescription drug
coverage under Medicare Part D.

Item 20.

If your family member has Medicare, enter his/her Medicare
Claim Number. This number is on his/her Medicare Card.

Item 21.

If your family member is covered by other group insurance,
such as private, state, or Medicaid, check the box and
complete item 22.

Item 22.

Provide the information requested on any other health
insurance that covers this family member. If your family
member is covered under another FEHB plan, see
instructions for item 10.

Item 23.

Enter email address, if applicable, for this family member.

Item 24.

Enter preferred telephone number, if applicable, for this
family member.

For your surviving family members to continue your FEHB enrollment
after your death, all of the following requirements must be met:

Self Plus One

•

You must have been enrolled for Self Plus One at the time of your
death; and

•

Your designated family member must be entitled to an annuity as
your survivor.
Note: The only survivor eligible to continue the health benefits enrollment is the designated family member covered under FEHB on the date
of death as long as that individual is entitled to a survivor annuity. No
other family members are entitled to continue the enrollment even
though they may be entitled to a survivor annuity.

Self and Family

•

You must have been enrolled for Self and Family at the time of your
death; and

•

At least one family member must be entitled to an annuity as your
survivor.
Note: All of your survivors who meet the definition of “family member”
can continue their health benefits coverage under your enrollment as
long as any one of them is entitled to a survivor annuity. If the survivor
annuitant is the only eligible family member, the retirement system will
automatically change the enrollment to Self Only.

Family Members Eligible for Coverage
Unless you are a former spouse or survivor annuitant, family members
eligible for coverage under your Self Plus One enrollment include one
eligible family member (spouse or child under age 26) designated by
you. A Self and Family enrollment includes you and all of your eligible
family members.

*If you would marry but you live in a state that does not allow same-sex couples to marry.

Standard Form 2809
Revised November 2015

Part B — FEHB Plan You Are Currently Enrolled In
Following each number is a letter, which identifies a specific Qualifying
Life Event (QLE); for example, the event code “1A” refers to the initial
opportunity to enroll for an employee who elected to participate in
premium conversion.

You must complete this part if you are changing, cancelling, or
suspending your enrollment.
Item 1.

Enter the name of the plan you are enrolled in from the front
cover of the plan brochure.

Item 2.

Enter your current enrollment code from your plan ID card.

Item 2.

Part C — FEHB Plan You Are Enrolling In or
Changing To
Complete this part to enroll or change your enrollment in the FEHB
Program.
Item 1.

Enter the name of the plan you are enrolling in or changing
to. The plan name is on the front cover of the brochure of the
plan you want to be enrolled in.

Item 2.

Enter the enrollment code of the plan you are enrolling in or
changing to. The enrollment code is on the front cover of the
brochure of the plan you want to be enrolled in, and shows
the plan and option you are electing and whether you are
enrolling for Self Only, Self Plus One, or Self and Family.

Part E — Election NOT to Enroll
Place an “X” in the box only if you are an employee and you do NOT
wish to enroll in the FEHB Program. Be sure to read the information
titled Employees Who Elect Not to Enroll or Who Cancel Their
Enrollment.

Part F — Cancellation of FEHB
Place an “X” in the box only if you wish to cancel your FEHB
enrollment. Also enter your current plan name and enrollment code in
Part B. Be sure to read the information titled Employees Who Elect Not
to Enroll or Who Cancel Their Enrollment.

To enroll in a Health Maintenance Organization (HMO), you must live
(or in some cases work) in a geographic area specified by the carrier.

Note For Parts E and F. If you are Electing Not to Enroll or
Cancelling your enrollment because you are covered as a spouse or
child under another FEHB enrollment, your agency must enter the
enrollee’s name, Social Security number, and FEHB enrollment code
in REMARKS.

To enroll in an employee organization plan, you must be or become a
member of the plan’s sponsoring organization, as specified by the
carrier.
Your signature in Part H authorizes deductions from your salary,
annuity, or compensation to cover your cost of the enrollment you elect
in this item, unless you are required to make direct payments to the
employing office.

Cancellation of Enrollment
Employees participating in premium conversion may cancel their FEHB
enrollment only during the open season or when they experience a
Qualifying Life Event. Employees who waived participation in premium
conversion, annuitants, former spouses, and individuals enrolled under
TCC may cancel their enrollment at any time. However, if you cancel,
neither you nor any family member covered by your enrollment are
entitled to a 31-day temporary extension of coverage, or to convert to
an individual, nongroup policy. Moreover, family members who lose
coverage because of your cancellation are not eligible for TCC. Be sure
to read the additional information below about cancelling your FEHB
enrollment.

Part D — Event That Permits You To Enroll, Change,
Or Cancel
Item 1.

Enter the date of the QLE using numbers to show month, day,
and complete year; e.g., 06/30/2011. If you are electing to
enroll, enter the date you became eligible to enroll (for
example, the date your appointment began). If you are
making an open season enrollment or change, enter the date
on which the open season begins.

Enter the event code that permits you to enroll, change, or
cancel based on a Qualifying Life Event (QLE) from the
Table of Permissible Changes in Enrollment that applies to
you.

Explanation of Table of Permissible Changes in Enrollment

Employees Who Elect Not to Enroll (Part E) or Who Cancel
Their Enrollment (Part F)

The tables on pages 7 through 14 illustrate when: an employee who
participates in premium conversion; annuitant; former spouse; person
eligible for TCC; or employee who waived participation in premium
conversion may enroll or change enrollment. The tables show those
permissible events that are found in the regulations at 5 CFR Parts 890
and 892.

To be eligible for an FEHB enrollment after you retire, you must retire:

•

Under a retirement system for Federal civilian employees, and

•

On an immediate annuity.

The tables have been organized by enrollee category. Each category is
designated by a number, which identifies the enrollee group, as follows:

In addition, you must be currently enrolled in a plan under the FEHB
Program and must have been enrolled (or covered as a family member)
in a plan under the Program for:

1. Employees who participate in premium conversion

•

The 5 years of service immediately before retirement (i.e.,
commencing date of annuity entitlement), or

•

If fewer than 5 years, all service since your first opportunity to
enroll. (Generally, your first opportunity to enroll is within 60 days
after your first appointment [in your Federal career] to a position
under which you are eligible to enroll under conditions that permit a
Government contribution toward the enrollment.)

2. Annuitants (other than CSRS/FERS annuitants), including
individuals receiving monthly compensation from the Office of
Workers’ Compensation Programs
3. Former spouses eligible for coverage under the Spouse Equity
provision of FEHB law
4. TCC enrollees

If you do not enroll at your first opportunity or if you cancel your
enrollment, you may later enroll or reenroll only under the circumstances

5. Employees who waived participation in premium conversion
3

Standard Form 2809 Revised November 2015

Note 1: If you become covered by a regular enrollment in the FEHB
Program, either in your own right or under the enrollment of someone
else, your TCC enrollment is suspended. You will need to send
documentation of the new enrollment to the employing office
maintaining your TCC enrollment so that they can stop the TCC
enrollment. If your new FEHB coverage stops before the TCC
enrollment would have expired, the TCC enrollment can be reinstated
for the remainder of the original eligibility period (18 months for
separated employees or 36 months for eligible family members who lose
coverage).

explained in the table beginning on page 7. Some employees delay their
enrollment or reenrollment until they are nearing 5 years before
retirement in order to qualify for FEHB coverage as a retiree; however,
there is always the risk that they will retire earlier than expected and not
be able to meet the 5-year requirement for continuing FEHB coverage
into retirement. When you elect not to enroll or cancel your enrollment
you are voluntarily accepting this risk. An alternative would be to
enroll in or change to a lower cost plan so that you meet the
requirements for continuation of your FEHB enrollment after retirement.
Note for temporary [under 5 U.S.C. 8906a] employees eligible for
FEHB without a Government contribution: Your decision not to enroll
or to cancel your enrollment will not affect your future eligibility to
continue FEHB enrollment after retirement.

Note 2: Former spouses (Spouse Equity) and TCC enrollees who fail to
pay their premiums within specified timeframes are considered to have
voluntarily cancelled their enrollment.

Annuitants Who Cancel Their Enrollment

Part G — Suspension of FEHB

CSRS and FERS annuitants and their eligible family members should
not use this form but use form RI 79-9, Health Benefits
Cancellation/Suspension Confirmation, which is available at
www.opm.gov/forms/Retirement-and-Insurance-Forms, or call
1-888-767-6738.

Generally, you cannot reenroll as an annuitant unless you are
continuously covered as a family member under another person’s
enrollment in the FEHB Program during the period between your
cancellation and reenrollment. Your employing office or retirement
system can advise you on events that allow eligible annuitants to
reenroll. If you cancel your enrollment because you are covered under
another FEHB enrollment, you can reenroll from 31 days before through
60 days after you lose that coverage under the other enrollment.

Place an “X” in the box only if you are an annuitant or former spouse
and wish to suspend your FEHB enrollment. Also enter your current plan
name and enrollment code in Part B.
You may suspend your FEHB enrollment because you are enrolling in
one of the following programs:

If you cancel your enrollment for any other reason, you cannot later
reenroll, and you and any family members covered by your enrollment
are not entitled to a 31-day temporary extension of coverage or to
convert to an individual policy.

Former Spouses (Spouse Equity) Who Cancel Their Enrollment
Generally, if you cancel your enrollment in the FEHB Program, you
cannot reenroll as a former spouse. However, if you cancel the
enrollment because you become covered under FEHB as a new spouse
or employee, your eligibility for FEHB coverage under the Spouse
Equity provisions continues. You may reenroll as a former spouse from
31 days before through 60 days after you lose coverage under the other
FEHB enrollment.

•

A Medicare Advantage plan or Medicare HMO,

•

Medicaid or similar State-sponsored program of medical assistance
for the needy,

•

TRICARE (including Uniformed Services Family Health Plan or
TRICARE for Life),

•

CHAMPVA, or

•

Peace Corps.

You can reenroll in the FEHB Program if your other coverage ends.
If your coverage ends involuntarily, you can reenroll from 31 days
before your other coverage ends through 60 days after your other
coverage ends. If your coverage ends voluntarily because you disenroll,
you can reenroll during the next open season.
You must submit documentation of eligibility for coverage under the
non-FEHB Program to the office that maintains your enrollment. That
office must enter in REMARKS the reason for your suspension.

Part H — Signature
Your agency, retirement system, or office maintaining your enrollment
cannot process your request unless you complete this part.

Temporary Continuation of Coverage (TCC) Enrollees Who
Cancel Their Enrollment
If you cancel your TCC enrollment, you cannot reenroll. Your family
members who lose coverage because of your cancellation cannot enroll
for TCC in their own right nor can they convert to a nongroup policy.
Family members who are Federal employees or annuitants may enroll in
the FEHB Program when you cancel your coverage if they are eligible
for FEHB coverage in their own right.

If you are registering for someone else under a written authorization
from him or her to do so, sign your name in Part H and attach the written
authorization.
If you are registering for a former spouse eligible for coverage under the
Spouse Equity provisions or for an individual eligible for TCC as his
or her court-appointed guardian, sign your name in Part H and attach
evidence of your court-appointed guardianship.

Standard Form 2809
Revised November 2015

Part I - Agency or Retirement System Information
and Remarks

•

Leave this section blank as it is for agency or retirement system use only.

For the eligible former spouse of an enrollee, the enrollee or the
former spouse must notify the employing office within 60 days after
the former spouse’s change in status; e.g., the date of the divorce.

An individual eligible for TCC who wants to continue FEHB coverage
may choose any plan, option, and type of enrollment for which he or she
is eligible. The time limit for a former employee, child, or former spouse
to enroll with the employing office is within 60 days after the Qualifying
Life Event, or receiving notice of eligibility, whichever is later.

Electronic Enrollments
Many agencies use automated systems that allow their employees to
make changes using a touch-tone telephone, or a computer instead of
a form. This may be Employee Express or another automated system.
If you are not sure whether the electronic enrollment option is available
to you, contact your employing office.

Effective Dates
Except for open season, most enrollments and changes of enrollment are
effective on the first day of the pay period after the employing office
receives this form and that follows a pay period during any part of which
the employee is in pay status. Your employing office can give you the
specific date on which your enrollment or enrollment change will take
effect.

Dual Enrollment
No person (enrollee or family member) is entitled to receive benefits
under more than one enrollment in the FEHB Program. Normally, you
are not eligible to enroll if you are covered as a family member under
someone else’s enrollment in the Program. However, such dual
enrollments may be permitted under certain circumstances in order to:

•

Protect the interests of children who otherwise would lose coverage
as family members, or

•

Enable an employee who is under age 26 and covered under a
parent’s enrollment and marries or becomes the parent of a child to
enroll for Self Plus One or Self and Family coverage.

Note 1: If you are changing your FEHB enrollment from Self Plus One
or Self and Family to Self Only so that your spouse can enroll for Self
Only, you should coordinate the effective date of your spouse’s
enrollment with the effective date of your enrollment change to avoid a
gap in your spouse’s coverage.

Each enrollee must notify his or her plan of the names of the persons to
be covered under his or her enrollment who are not covered under the
other enrollment. See instructions for item 10 for more information.

Note 2: If you are cancelling your FEHB enrollment and intend to be
covered under someone else’s enrollment at the time you cancel, you
should coordinate the effective date of your cancellation with the
effective date of your new coverage to avoid a gap in your coverage.

Temporary Continuation of Coverage (TCC)

Agency Distribution of SF 2809

The employing office must notify a former employee of his or her
eligibility for TCC. The enrollee, child, former spouse, or their
representative must notify the employing office when a child or former
spouse becomes eligible.

Agencies must distribute one copy of the completed SF 2809 to each of
the following, as appropriate:

•

For the eligible child of an enrollee, the enrollee must notify the
employing office within 60 days after the qualifying event occurs;
e.g., child reaches age 26.

•

Official Personnel Folder

•

New Carrier

•

Old Carrier

•

Payroll Office

•

Enrollee

Privacy Act and Public Burden Statements
The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits Program under Chapter 89, title 5, U.S.
Code. The principal use of this information will be to share it with the health insurance carrier you select so that it may (1) identify your enrollment in the plan,
(2) verify your and/or your family’s eligibility for payment of a claim for health benefits services or supplies, and (3) coordinate payment of claims with other carriers
with whom you might also make a claim for payment of benefits. Other routine uses include disclosures to other Federal agencies or Congressional offices which may
have a need to know it in connection with your application for a job, license, grant, or other benefit. It may also be shared and is subject to verification, via paper,
electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or Social Security administrative agencies to
determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition, to the
extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local
law enforcement agency. While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your
enrollment.
We request that you provide your Social Security Number so that it may be used as your individual identifier in the FEHB Program, and for other purposes. Executive
Order 13478 (November 18, 2009) allows Federal agencies to use Social Security Numbers as individual identifiers to distinguish between people of same or similar
names. In addition, a mandatory insurer reporting law (Section 111 of Public Law number 110-173) requires your health insurance carrier to report your Social Security
Number or your Medicare Claim Number in order to properly coordinate benefits between your health plan and Medicare. Also, Section 6055 of the Internal Revenue
Code requires your health insurance plan to report, to the Internal Revenue Service (IRS), information necessary to confirm that you and your covered family members
have minimum essential coverage from your health plan. The information required from your health insurance plan includes a Social Security Number for yourself and
each of your covered family members. Failure to furnish your Social Security Number and/or Medicare Claim Number may result in the US. Office of Personnel
Management’s (OPM) inability to ensure the prompt payment of your and/or family’s claims for health benefits services or supplies, proper coordination with Medicare
and proper health insurance status reporting to the IRS.
We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed
form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel
Management, Retirement Services Publications Team, (3206-0160), Washington, D.C. 20415-3430. The OMB number, 3206-0160 is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is displayed.

Standard Form 2809
Revised November 2015

Federal Employees Receiving Premium Conversion Tax Benefits
Table of Permissible Changes in FEHB Enrollment and Premium Conversion Election
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay for their share of FEHB premiums with pre-tax dollars. Premium conversion plans are governed by Section 125 of the
Internal Revenue Code, and IRS rules govern when a participant may change his or her election outside of the annual open season. All employees who enroll in the FEHB Program automatically receive
premium conversion tax benefits, unless they waive participation. When an employee experiences a Qualifying Life Event (QLE) as described below, certain changes to the employee’s FEHB coverage
(including change to Self Only and cancellation) and premium conversion election may be permitted, so long as they are because of and consistent with the QLE’s. If you are covering child(ren) of your
same-sex domestic partner who you would marry but for your state’s marriage law, contact your employing office for more information on premium conversion availability and other tax considerations. For more
information about premium conversion, please visit www.opm.gov/healthcare-insurance/healthcare.
Qualifying Life Events (QLE’s) that May
Permit Change in FEHB Enrollment,
Designated Family Member or
Premium Conversion Election
Event
Code

Event

Change that May
Be Permitted

From Not
Enrolled
to
Enrolled

From Self
Only to Self
Plus One or
Self and
Family

Premium Conversion
Change that May Be
Permitted

Time Limits in which
Change
May Be Permitted
When You Must File
Health Benefits Election
Form With Your
Employing Office

From One
Plan or
Option to
Another

Cancel or
Change to
Self Plus
One or
Self Only

Switch
Designated
Family
Member

Participate

Waive

Employee electing to receive or receiving premium conversion tax benefits

Initial opportunity to enroll, for example:
• New employee
• Change from excluded position
• Temporary employee who completes 1 year of service and is
eligible to enroll under 5 USC 8906a

Yes

N/A

Automatic
Unless Waived

Yes

Within 60 days after
becoming eligible

Open Season

Yes

As announced by OPM

Yes

Within 60 days after change
in family status

Change in family status that results in increase or decrease in
number of eligible family members, for example:
• Marriage, divorce, annulment
• Birth, adoption, acquiring foster child or stepchild, issuance of
court order requiring employee to provide coverage for child
• Last child loses coverage, for example, child reaches age 26,
disabled child becomes capable of self-support, child acquires
other coverage by court order
• Death of spouse or eligible family member

Yes

Employees may enroll or change
beginning 31 days before the event.

Any change in employee’s employment status that could result in
entitlement to coverage, for example:
• Reemployment after a break in service of more than 3 days
• Return to pay status from nonpay status, or return to receiving
pay sufficient to cover premium withholdings, if coverage
terminated (If coverage did not terminate, see 1G.)

Yes

N/A

Automatic
Unless Waived

Yes

Within 60 days after
employment status change

Any change in employee’s employment status that could affect cost
of insurance, including:
• Change from temporary appointment with eligibility for
coverage under 5 USC 8906a to appointment that permits
receipt of government contribution
• Change from full time to part-time career or the reverse

Yes

Within 60 days after
employment status change

Employee restored to civilian position after serving in uniformed
services.2

Yes

Within 60 days after return
to civilian position

7
7

Change that May
Be Permitted

Qualifying Life Events (QLE’s) that May
Permit Change in FEHB Enrollment,
Designated Family Member or
Premium Conversion Election
Event
Code

Premium Conversion
Change that May Be
Permitted

Time Limits in which
Change
May Be Permitted
When You Must File
Health Benefits Election
Form With Your
Employing Office

Event

From Not
Enrolled
to
Enrolled

From Self
Only to Self
Plus One or
Self and
Family

From One
Plan or
Option to
Another

Cancel or
Change to
Self Plus
One or
Self Only

Switch
Designated
Family
Member

Participate

Waive

Employee, spouse or eligible family member:
• Begins nonpay status or insufficient pay3 or
• Ends nonpay status or insufficient pay if coverage continued
• (If employee’s coverage terminated, see 1D.)
• (If spouse’s or eligible family member’s coverage terminated, see
1M.)

Yes

Within 60 days after
employment status change

Salary of temporary employee insufficient to make withholdings for
plan in which enrolled.

N/A

Yes

Within 60 days after receiving notice from employing
office

Employee (or covered family member) enrolled in FEHB health
maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts
enrollments or, if already outside the area, moves further from this
area.4

N/A

Yes

N/A

Yes

Upon notifying employing
office of move

(see 1M)

Transfer from post of duty within a State of the United States or the
District of Columbia to post of duty outside a State of the United
States or District of Columbia, or reverse.

Yes

(see 1M)

Yes

Within 60 days after arriving at new post

Employees may enroll or change
beginning 31 days before leaving the old
post of duty.

Separation from Federal employment when the employee or
employee’s spouse is pregnant.

Yes

N/A

During employee’s final
pay period

Employee becomes entitled to Medicare and wants to change to
another plan or option. 5

Yes
(Changes
may be
made only
once.)

N/A

(see 1P)

Any time beginning on the
30th day before becoming
eligible for Medicare

Yes

Employee or eligible family member loses coverage under FEHB or
another group insurance plan including the following:
• Loss of coverage under another FEHB enrollment due to termination, cancellation, or change to Self Plus One or Self Only of the
covering enrollment
• Loss of coverage due to termination of membership in employee
organization sponsoring the FEHB plan6
• Loss of coverage under another federally-sponsored health
benefits program, including: TRICARE, Medicare, Indian Health
Service
• Loss of coverage under Medicaid or similar State-sponsored
program of medical assistance for the needy
• Loss of coverage under a non-Federal health plan, including
foreign, state or local government, private sector
• Loss of coverage due to change in worksite or residence
(Employees in an FEHB HMO, also see 1I.)

Yes

Employees may enroll or change
beginning 31 days before the event.

Yes

Within 60 days after loss of
coverage

Change that May
Be Permitted

Qualifying Life Events (QLE’s) that May
Permit Change in FEHB Enrollment,
Designated Family Member or
Premium Conversion Election
Event
Code

Premium Conversion
Election Change that
May Be
Permitted

Time Limits in which
Change
May Be Permitted
When You Must File
Health Benefits Election
Form With Your
Employing Office

Event

From Not
Enrolled
to
Enrolled

From Self
Only to Self
Plus One or
Self and
Family

From One
Plan or
Option to
Another

Cancel or
Change to
Self Plus
One or
Self Only

Switch
Designated
Family
Member

Participate

Waive

Loss of coverage under a non-Federal group health plan because an
employee moves out of the commuting area to accept another position and the employee’s non-Federally employed spouse terminates
employment to accompany the employee.

Yes

From 31 days before the
employee leaves the commuting area to 180 days
after arriving in the new
commuting area

Employee or eligible family member loses coverage due to discontinuance in whole or part of FEHB plan.7

Yes

During open season, unless
OPM sets a different time

Enrolled employee or eligible family member gains coverage under
FEHB or another group insurance plan, including the following:
• Medicare (Employees who become eligible for Medicare and
want to change plans or options, see 1L.)
• TRICARE for Life, due to enrollment in Medicare.
• TRICARE due to change in employment status, including: (1)
entry into active military service, (2) retirement from reserve military service under Chapter 67, title 10.
• Health insurance acquired due to change of worksite or residence
that affects eligibility for coverage
• Health insurance acquired due to spouse’s or eligible family
member’s change in employment status (includes state, local, or
foreign government or private sector employment).8

Yes9

Yes

Within 60 days after QLE

Change in spouse’s or eligible family member’s coverage options
under a health plan, for example:
• Employer starts or stops offering a different type of coverage
(If no other coverage is available, also see 1M.)
• Change in cost of coverage
• HMO adds a geographic service area that now makes spouse
eligible to enroll in that HMO
• HMO removes a geographic area that makes spouse ineligible
for coverage under that HMO, but other plans or options are
available (If no other coverage is available, see 1M)

Yes9

Yes

Within 60 days after QLE

Employee or eligible family member becomes eligible for assistance
under Medicaid or a State Children’s Health Insurance Program
(CHIP).

Yes

Yes9

Yes

Within 60 days after the
date the employee or family
member becomes eligible
for assistance.

(If you are a United States Postal Service employee, these rules may be different. Consult your employing office or information provided by your agency.)
1.

Employees may change to Self Only outside of open season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment. Employees may change to Self Plus One outside of
Open Season only if the QLE causes only one family member to be eligible under the FEHB enrollment. Employees may cancel enrollment outside of open season only if the QLE caused the enrollee and all eligible
family members to acquire other health insurance coverage.

Employees who enter active military service are given the opportunity to terminate coverage. Termination for this reason does not count against the employee for purposes of meeting the requirements for continuing
coverage after retirement. Additional information on the FEHB coverage of employees who return from active military service is available in the Frequently Asked Questions section of the FEHB website at
www.opm.gov/healthcare-insurance/healthcare.

(Listing continued on the reverse)

Employees who begin nonpay status or insufficient pay must be given an opportunity to elect to continue or terminate coverage. A termination differs from a cancellation as it allows conversion to nongroup coverage
and does not count against the employee for purposes of meeting the requirements for continuing coverage after retirement.

This code reflects the FEHB regulation that gives employees enrolled in an FEHB HMO who change from Self Only or Self Plus One to Self and Family or from one plan or option to another a different timeframe
than that allowed under 1M. For change to Self-Only or Self Plus One, cancellation, or change in premium conversion status, see 1M.

This code reflects the FEHB regulation that gives employees enrolled in FEHB a one-time opportunity to change plans or options under a different timeframe than that allowed by 1P. For change to Self Only or
Self Plus One, cancellation, or change in premium conversion status, see 1P.

If employee’s membership terminates (e.g., for failure to pay membership dues), the employee organization will notify the agency to terminate the enrollment.

Employee’s failure to select another FEHB plan is deemed a cancellation for purposes of meeting the requirements for continuing coverage after retirement.

Under IRS rules, this includes start/stop of employment or nonpay status, strike or lockout, and change in worksite.

Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage. Employees may change to Self Plus One outside of Open
Season only if the QLE caused all but one eligible family member to acquire other health insurance coverage. Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all
eligible family members to acquire other health insurance coverage.

Tables of Permissible Changes in FEHB Enrollment for Individuals Who Are Not Participating
in Premium Conversion
Enrollment May Be Cancelled or Changed from Self and Family to Self Plus One or Self Only or from Self Plus
One to Self Only at Any Time
QLE’s That Permit
Enrollment or Change

Event
Code

Event

Change that May Be Permitted

From Self
Only to Self
Plus One or
Self
and Family

From Not
Enrolled to
Enrolled

Time Limits

From
Switch
When You Must File Health
One
Designated
Benefits Election Form With
Plan or
Family
Your Employing Office
Option
Member
to
Another

Annuitant (Includes Compensationers)
Note for enrolled survivor annuitants: A change in family status based on additional family members can only occur if the additional
eligible family members are family members of the deceased employee or annuitant.

Open Season

Yes

As announced by OPM.

Change in family status; for example: marriage, birth or
death of family member, adoption, or divorce.

Yes

From 31 days before through 60
days after the event.

Reenrollment of annuitant who suspended FEHB
enrollment to enroll in a Medicare Advantage plan,
Medicaid or similar State-sponsored program, or to use
TRICARE (including Uniformed Services Family Health
Plan and TRICARE for Life), Peace Corps, or
CHAMPVA, and who later involuntarily loses this
coverage under one of these programs.

May Reenroll

N/A

From 31 days before through 60
days after involuntary loss of
coverage.

Reenrollment of annuitant who suspended FEHB enrollment to enroll in a Medicare Advantage plan, Medicaid,
or similar State-sponsored program, or to use TRICARE
(including Uniformed Services Family Health Plan or
TRICARE for Life), Peace Corps, or CHAMPVA, and
who wants to reenroll in the FEHB Program for any
reason other than an involuntary loss of coverage.

May Reenroll

N/A

During open season.

Restoration of annuity or compensation (OWCP)
payments, for example:

Yes

N/A

Within 60 days after the retirement system or OWCP mails a
notice of insurance eligibility.

Yes

From 31 days before through 60
days after date of loss of coverage.

•

•
•

•

Disability annuitant who was enrolled in FEHB, and
whose annuity terminated due to restoration of earning
capacity or recovery from disability, and whose
annuity is restored;
Compensationer whose compensation terminated
because of recovery from injury or disease and whose
compensation is restored due to a recurrence of
medical condition;
Surviving spouse who was covered by FEHB
immediately before survivor annuity terminated
because of remarriage and whose annuity is restored;
Surviving child who was covered by FEHB
immediately before survivor annuity terminated
because student status ended and whose survivor
annuity is restored;
Surviving child who was covered by FEHB immediately before survivor annuity terminated because of
marriage and whose survivor annuity is restored.

Annuitant or eligible family member loses FEHB
coverage due to termination, cancellation, or change to
Self Plus One or Self Only of the covering enrollment.

QLE’s That Permit
Enrollment or Change

Event
Code

Event

Change that May Be Permitted

From Not
Enrolled to
Enrolled

From Self
Only to Self
Plus One or
Self
and Family

Yes

From 31 days before through 60
days after loss of coverage.

Annuitant or eligible family member loses coverage
under another group insurance plan, for example:
•
•
•
•

Time Limits

From
Switch
When You Must File Health
One
Designated
Benefits Election Form With
Plan or
Family
Your Employing Office
Option
Member
to
Another

Loss of coverage under another federally-sponsored
health benefits program;
Loss of coverage due to termination of membership in
the employee organization sponsoring the FEHB plan;
Loss of coverage under Medicaid or similar
State-sponsored program (but see events 2C and 2D);
Loss of coverage under a non-Federal health plan.

Annuitant or eligible family member loses coverage due
to the discontinuance, in whole or part, of an FEHB plan.

N/A

Yes

During open season, unless
OPM sets a different time.

Annuitant or covered family member in a Health
Maintenance Organization (HMO) moves or becomes
employed outside the geographic area from which the
carrier accepts enrollments, or if already outside this area,
moves or becomes employed further from this area.

N/A

Yes

Upon notifying the employing
office of the move or change of
place of employment.

Employee in an overseas post of duty retires or dies.

Yes

Within 60 days after retirement
or death.

An enrolled annuitant separates from duty after serving
31 days or more in a uniformed service.

N/A

Yes

Within 60 days after separation
from the uniformed service.

On becoming eligible for Medicare.

N/A

Yes

At any time beginning on the
30th day before becoming eligible for Medicare.

N/A

Yes

Employing office will advise
annuitant of the options.

(This change may be made only once in a lifetime.)
2M

Annuitant’s annuity is insufficient to make withholdings
for plan in which enrolled.

Former Spouse Under The Spouse Equity Provisions
Note: Former spouse may change to Self Plus One or Self and Family only if family members are also eligible family members of the
employee or annuitant.

Initial opportunity to enroll. Former spouse must be
eligible to enroll under the authority of the Civil Service
Retirement Spouse Equity Act of 1984 (P.L. 98-615), as
amended, the Intelligence Authorization Act of 1986
(P.L. 99-569), or the Foreign Relations Authorization
Act, Fiscal Years 1988 and 1989 (P.L. 100-204).

Yes

N/A

Generally, must apply within
60 days after dissolution of
marriage. However, if a retiring
employee elects to provide a
former spouse annuity or
insurable interest annuity for
the former spouse, the former
spouse must apply within 60
days after OPM’s notice of
eligibility for FEHB. May enroll
any time after employing office
establishes eligibility.

Open Season.

Yes

As announced by OPM.

Change in family status based on addition of family
members who are also eligible family members of the
employee or annuitant.

Yes

From 31 days before through 60
days after change in family
status.

Reenrollment of former spouse who suspended FEHB
enrollment to enroll in a Medicare Advantage plan,
Medicaid, or similar State-sponsored program, or to
use TRICARE (including Uniformed Services Family
Health Plan or TRICARE for Life), Peace Corps, or
CHAMPVA, and who later involuntarily loses this
coverage under one of these programs.

May reenroll

N/A

From 31 days before through 60
days after involuntary loss of
coverage.

QLE’s That Permit
Enrollment or Change

Event
Code

Event

Reenrollment of former spouse who suspended FEHB
enrollment to enroll in a Medicare Advantage plan,
Medicaid, or similar State-sponsored program, or to use
TRICARE (including Uniformed Services Family Health
Plan or TRICARE for Life), Peace Corps, or
CHAMPVA, and who wants to reenroll in the FEHB
Program for any reason other than an involuntary loss of
coverage.

Change that May Be Permitted

Time Limits

From Self
From
Switch
Only to Self
One
Designated
Plus One or
Plan or
Family
Self
Option to
Member
and Family
Another

From Not
Enrolled to
Enrolled

When You Must File Health
Benefits Election Form With
Your Employing Office

May reenroll

N/A

During open season.

Former spouse or eligible child loses FEHB coverage
due to termination, cancellation, or change to Self Only
of the covering enrollment.

Yes

From 31 days before through 60
days after date of loss of coverage.

Enrolled former spouse or eligible child loses coverage
under another group insurance plan, for example:

N/A

Yes

From 31 days before through 60
days after loss of coverage.

•
•
•
•

Loss of coverage under another federally-sponsored
health benefits program;
Loss of coverage due to termination of membership in
the employee organization sponsoring the FEHB plan;
Loss of coverage under Medicaid or similar
State-sponsored program (but see 3D and 3E);
Loss of coverage under a non-Federal health plan.

Former spouse or eligible family member loses coverage
due to the discontinuance, in whole or part, of an FEHB
plan.

N/A

Yes

During open season, unless
OPM sets a different time.

Former spouse or covered family member in a Health
Maintenance Organization (HMO) moves or becomes
employed outside the geographic area from which the
carrier accepts enrollments, or if already outside this
area, moves or becomes employed further from this area.

N/A

Yes

Upon notifying the employing
office of the move or change of
place of employment.

On becoming eligible for Medicare

N/A

Yes

At any time beginning the 30th
day before becoming eligible for
Medicare.

Yes

Retirement system will advise
former spouse of options.

(This change may be made only once in a lifetime.)
3K

Former spouse’s annuity is insufficient to make FEHB
withholdings for plan in which enrolled.

Temporary Continuation of Coverage (TCC) For Eligible Former Employees, Former Spouses, and Children.
Note: Former spouse may change to Self Plus One or Self and Family only if family members are also eligible family members of the
employee or annuitant.

Opportunity to enroll for continued coverage under TCC
provisions:
•
•
•

Yes
Yes
Yes

Yes
N/A
N/A

N/A

No
No
No

Yes
Yes
Yes

Yes

Open Season:
•
•
•

Former employee
Former spouse
Child who ceases to qualify as a family
member

Change in family status (except former spouse); for
example, marriage, birth or death of family member,
adoption, or divorce.

Within 60 days after the qualifying event, or receiving notice of
eligibility, whichever is later.

As announced by OPM.

From 31 days before through 60
days after event.

QLE’s That Permit
Enrollment or Change

Event
Code

Event

Change in family status of former spouse, based on
addition of family members who are eligible family
members of the employee or annuitant.

Reenrollment of a former employee, former spouse, or
child whose TCC enrollment was terminated because of
other FEHB coverage and who loses the other FEHB
coverage before the TCC period of eligibility (18 or 36
months) expires.

Enrollee or eligible family member loses coverage
under FEHB or another group insurance plan, for
example:
•

•
•
•
•

Change that May Be Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only to Self
Plus One or
Self and
Family

From
Switch
When You Must File Health
One
Designated
Benefits Election Form With
Plan or
Family
Your Employing Office
Option
Member
to
Another

Yes

From 31 days before through 60
days after event.

May reenroll

N/A

From 31 days before through 60
days after the event. Enrollment
is retroactive to the date of the
loss of the other FEHB coverage.

Yes

From 31 days before through 60
days after loss of coverage.

Loss of coverage under another FEHB enrollment
due to termination, cancellation, or change to Self
Plus One or Self Only of the covering enrollment
(but see event 4E);
Loss of coverage under another federally-sponsored
health benefits program;
Loss of coverage due to termination of membership
in the employee organization sponsoring the FEHB
plan;
Loss of coverage under Medicaid or similar
State-sponsored program;
Loss of coverage under a non-Federal health plan.

Enrollee or eligible family member loses coverage due
to the discontinuance, in whole or part, of an FEHB
plan.

N/A

Yes

During open season, unless
OPM sets a different time.

Enrollee or covered family member in a Health
Maintenance Organization (HMO) moves or becomes
employed outside the geographic area from which the
carrier accepts enrollments, or if already outside this
area, moves or becomes employed further from this
area.

N/A

Yes

Upon notifying the employing
office of the move or change of
place of employment.

On becoming eligible for Medicare.

N/A

Yes

At any time beginning on the
30th day before becoming eligible for Medicare.

(This change may be made only once in a lifetime.)

Employees Who Are Not Participating In Premium Conversion

Initial opportunity to enroll.

Yes

N/A

Within 60 days after becoming
eligible.

Open Season.

Yes

As announced by OPM.

Change in family status; for example: marriage, birth or
death of family member, adoption, or divorce

Yes

From 31 days before through 60
days after event.

QLE’s That Permit
Enrollment or Change

Event
Code

Event

Change in employment status, for example:
•
•
•
•
•
•

Change that May Be Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only to Self
Plus One or
Self and
Family

From
Switch
One
Designated
Plan or
Family
Option
Member
to
Another

Yes

Within 60 days of employment
status change.

Reemployment after a break in service of more than 3
days;
Return to pay status following loss of coverage due to
expiration of 365 days of LWOP status or termination
of coverage during LWOP;
Return to pay sufficient to make withholdings
after termination of coverage during a period of
insufficient pay;
Restoration to civilian position after serving in
uniformed services;
Change from temporary appointment to appointment
that entitles employee receipt of Government
contribution;
Change to or from part-time career employment.

When You Must File Health
Benefits Election Form With
Your Employing Office

Separation from Federal employment when the
employee is employee’s spouse is pregnant.

Yes

Enrollment or change must
occur during final pay period of
employment.

Transfer from a post of duty within the United States to
a post of duty outside the United States, or reverse.

Yes

From 31 days before leaving old
post through 60 days after arriving at new post.

Employee or eligible family member loses coverage
under FEHB or another group insurance plan, for
example:

Yes

From 31 days before through 60
days after loss of coverage.

•
•
•
•
•

Loss of coverage under another FEHB enrollment
due to termination, cancellation, or change to Self
Plus One or Self Only of the covering enrollment;
Loss of coverage under another federally-sponsored
health benefits program;
Loss of coverage due to termination of membership
in the employee organization sponsoring the FEHB
plan;
Loss of coverage under Medicaid or similar
State-sponsored program;
Loss of coverage under a non-Federal health plan.

Enrollee or eligible family member loses coverage due
to the discontinuance, in whole or part, of an FEHB
plan.

N/A

Yes

During open season, unless
OPM sets a different time.

Loss of coverage under a non-Federal group health plan
because an employee moves out of the commuting area
to accept another position and the employee’s
non-federally employed spouse terminates employment
to accompany the employee.

Yes

From 31 days before the
employee leaves the commuting
area through 180 days after
arriving in the new commuting
area.

Employee or covered family member in a Health
Maintenance Organization (HMO) moves or becomes
employed outside the geographic area from which the
carrier accepts enrollments, or if already outside the
area, moves or becomes employed further from this
area.

N/A

Yes

Upon notifying the employing
office of the move or change of
place of employment.

QLE’s That Permit
Enrollment or Change

Event
Code

Event

On becoming eligible for Medicare

Change that May Be Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only to Self
Plus One or
Self
and Family

From
Switch
When You Must File Health
One
Designated
Benefits Election Form With
Plan or
Family
Your Employing Office
Option
Member
to
Another

N/A

At any time beginning on the
30th day before becoming
eligible for Medicare.

(This change may be made only once in a lifetime.)
5L

Temporary employee completes one year of continuous
service in accordance with 5 U.S.C. Section 8906a.

Yes

N/A

Within 60 days after becoming
eligible.

Salary of temporary employee insufficient to make
withholdings for plan in which enrolled.

N/A

Yes

Within 60 days after receiving
notice from employing office.

Employee or eligible family member becomes eligible for
assistance under Medicaid or a State Children’s Health
Insurance Program (CHIP).

Yes

Within 60 days after the date the
employee or family member
becomes eligible for assistance.

Form Approved:
OMB No. 3206-0160

Health Benefits Election Form

Federal Employees
Health Benefits Program

Part A - Enrollee and Family Member Information (for additional family members use a separate sheet and attach)
1. Enrollee name (last, first, middle initial)

2. Social Security Number 3. Date of birth (mm/dd/yyyy)

4. Sex

5. Are you married?

6. Home mailing address (including ZIP Code)

M
F
Yes
7. If you are covered by Medicare, 8. Medicare Claim Number
check all that apply.

-------------------------------------------------------------------

A
B
D
9. Are you covered by insurance other than Medicare?
Yes, indicate in item 10 below.

10. Indicate the type(s) of other insurance:
TRICARE
FEHB

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the
enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.

11. Email address

12. Preferred telephone number

13. Name of family member (last, first, middle initial)

14. Social Security Number 15. Date of birth (mm/dd/yyyy)

16. Sex

17. Relationship code

18. Address (if different from enrollee)

M
F
19. If this family member is covered 20. Medicare Claim Number
by Medicare, check all that apply.

-------------------------------------------------------------------

A
B
D
21. Is this family member covered by insurance other than Medicare?
Yes, indicate in item 22 below.

22. Indicate the type(s) of other insurance:
TRICARE
FEHB

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

23. Email address (if applicable, enter email address of your spouse or adult child)

25. Name of family member (last, first, middle initial)

24. Preferred telephone number (if applicable, enter preferred phone number of
your spouse or adult child)

26. Social Security Number 27. Date of birth (mm/dd/yyyy)

28. Sex

29. Relationship code

30. Address (if different from enrollee)

M
F
31. If this family member is covered 32. Medicare Claim Number
by Medicare, check all that apply.

-------------------------------------------------------------------

A
B
D
33. Is this family member covered by insurance other than Medicare?
Yes, indicate in item 34 below.

34. Indicate the type(s) of other insurance:
TRICARE
FEHB

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

35. Email address (if applicable, enter email address of your spouse or adult child)

37. Name of family member (last, first, middle initial)

36. Preferred telephone number (if applicable, enter preferred phone number of
your spouse or adult child)

38. Social Security Number 39. Date of birth (mm/dd/yyyy)

40. Sex

41. Relationship code

42. Address (if different from enrollee)

M
F
43. If this family member is covered 44. Medicare Claim Number
by Medicare, check all that apply.

-------------------------------------------------------------------

A
B
D
45. Is this family member covered by insurance other than Medicare?
Yes, indicate in item 46 below.

46. Indicate the type(s) of other insurance
TRICARE
Other
Name of other insurance: ______________________________________________
Policy Number: _____________________
FEHB An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the
enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.
47. Email address (if applicable, enter email address of your spouse or adult child)
48. Preferred telephone number (if applicable, enter preferred phone number of
your spouse or adult child)
(Continued on the reverse)
U.S. Office of Personnel Management

For agency distribution of copies, see page 5 of the instructions.

Standard Form 2809
Revised November 2015
Previous edition is not usable.

Enrollee name: _________________________________________________________

Date of birth: ____________________________

Part B - FEHB Plan You Are Currently Enrolled In (if applicable)

Part C - FEHB Plan You Are Enrolling In or Changing To

1. Plan name

2. Enrollment code

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 6) Part E - Election NOT to Enroll (Employees Only)
1. Event code

2. Date of event

I do NOT want to enroll in the FEHB Program.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding this election.
Part F - Cancellation of FEHB

Part G - Suspension of FEHB (Annuitants/Former Spouses Only)

I CANCEL my enrollment.

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding cancellation of enrollment.

My signature in Part H certifies that I have read and understand the
information on page 4 regarding suspension of enrollment.

Part H - Signature
WARNING: Any intentionally false statement in this application 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.)
1. Your signature (do not print)
2. Date (mm/dd/yyyy)

Part I -To be completed by agency or retirement system
REMARKS

1. Date received (mm/dd/yyyy)

2. Effective date of action (mm/dd/yyyy)

3. Personnel telephone number

(

)

5. Authorizing official (please print)

4. Name and address of agency or retirement system

6. Signature of authorized agency official

7. Payroll office number

8. Payroll office contact (please print)

9. Payroll telephone number

(

)

Standard Form 2809
Reverse of revised November 2015
Previous edition is not usable

File Type	application/pdf
File Title	Printing H:\FORMFLOW\FORMS\SF\SF2809.FRP
Author	CSBENSON
File Modified	2015-11-02
File Created	2015-06-18