OPM 2809 April 2011 Markup

OPM 2809 April 2011 Markup.pdf

OPM 2809, Health Benefits Election Form

OPM 2809 April 2011 Markup

OMB: 3206-0141

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0141 can be found here:

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Health Benefits Election Form
changes since the 60-day FRN are in green.
Who May Use OPM Form 2809
Annuitants text added

•

Survivor annuitants text added

•

Former spouses

•

Children and former spouses who are eligible for temporary
continuation of coverage

Instructions for Completing OPM 2809
Type or print firmly. We have not provided
instructions for those items that require no further
explanation.

Item 1 added

Items 3 & 4 added

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

Item 6 added

Item 8.

TRICARE is a health care program for active duty and retired
members of the uniformed services, their families, and
survivors. This includes TRICARE for Life for members age
65 and older.

New para
for Item 8

Item 9.

If you have other group insurance (private, state, Medicaid,
Peace Corps, CHAMPVA), check the box.

Item 10.

Write the name of any other insurance you have.

Item 19.

If a family member has TRICARE (see item 8), check the
box.

Item 20.

If a family member has other group insurance (private, state,
Peace Corps, Medicaid), check the box.

Item 21.

Give the name of any other insurance this family member
has.

Unless you are a former spouse or survivor annuitant, family members
eligible for coverage under your Self and Family enrollment include
your spouse and your unmarried dependent children under age 26.
Eligible children include your legitimate or adopted children and
recognized natural children, stepchildren or foster children, if they live
with you in a regular parent-child relationship. A recognized natural
child also may be included if a judicial determination of support has
been obtained or you show that you provide regular and substantial
support for the child.

See the Privacy Act and Public Burden Statements on page 4.

If you have Medicare, show which Parts you have. Also
indicate whether you have prescription drug coverage under
the Medicare Part D Program.

If a family member has Medicare, show which Parts he/she
has on the line with his/her name. Check D if the family
member has prescription drug coverage under the Medicare
Part D Program.

Family Members Eligible for Coverage

You must complete this part.

Item 7.

Item 18.

Items 22 through 24 were added

Part A — Enrollee and Family Member Information.

Item 5.

Text in yellow was included with the 60-day FRN package.

Below: Text revised and items added

•

Item 2.

Form Approved:
OMB No. 3206-0141

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

Items 11 & 12 added

Complete information for family members only if your enrollment is for
Self and Family. (If you need extra space for additional family members,
list them on a separate sheet and attach.)

•

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

•

Children whose marriage ends before they reach age 26 become
eligible for coverage under your Self and Family enrollment from
the date the marriage ends until they reach age 26.
para deleted

paragraph inserted

Item 13.
item 15
added

Please provide Social Security numbers for your dependents,
if available. If not available, leave blank; benefits will not be
withheld. (See Privacy Act Statement on page 4.) item 14

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

Item 16.

Provide the code which indicates the relationship of each
eligible
family member to you.
item 16 was
This is now item
added.

Note: The Office of Personnel Management can give you additional
details about family member eligibility including any certification or
documentation that may be required for coverage.

17.

Code

Family Relationship

Spouse

Part B — Present Plan.

Unmarried dependent child under age 26

Adopted Child

You must complete this part if you are changing, canceling, or
suspending your enrollment.

Stepchild

Foster Child

Unmarried disabled child over age 26 incapable of selfsupport because of a physical or mental disability that
began before age 26.

Item 1.

Enter the name of the plan you are enrolled in, as shown on
the front cover of the plan brochure.

Item 2.

Enter the enrollment code of the plan.

Part C — New Plan.
Complete this part to enroll or change your enrollment in the Federal
Employees Health Benefits (FEHB) Program.

Previous editions are not usable.

OPM Form 2809
Revised April 2011

items 1 and 2 split.

Items 1
and 2.

New Item 2

Enter the plan name and enrollment code as shown on the
front cover of the brochure of the plan you want to be
enrolled in. The enrollment code shows the plan and option
you are electing and whether you are enrolling for Self Only
or Self and Family.

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

Enter the event code that permits you to enroll, change, or
cancel. (See the Table of Permissible Changes in Enrollment
starting on page 5.)

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

If you cancel your enrollment for any other reason, you cannot
reenroll later, 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 stop the enrollment
because you acquire other FEHB coverage, your right to 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.

TCC enrollees.

Following each number is a letter which identifies a specific permissible
event; for example, the event code 2A refers to open season.
Item 2.

CHAMPVA

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. OPM 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.

The tables on pages 5 through 7 illustrate when an annuitant, former
spouse, or person eligible for Temporary Continuation of Coverage
(TCC) may enroll or change enrollment. The tables show those
permissible events that are found in FEHB regulations at 5 CFR Part
890.

Former spouses eligible for coverage under the Spouse Equity
provisions of FEHB law.

•

Annuitants Who Cancel Their Enrollment

Explanation of Table of Permissible Changes in Enrollment

Peace Corps, or

Initial the last box only if you wish to cancel your FEHB enrollment.
Also enter your present enrollment code in Part B. Be sure to read the
information below in the paragraph titled “Annuitants Who Cancel
Their Enrollment.”

Part D — Event Code.

Annuitants

•

You must submit documentation of eligibility for coverage under the
non-FEHB Program to the Office of Personnel Management.

Your signature in Part F authorizes deductions from your annuity to
cover your cost of the enrollment you elect in this item, unless you are
required to make direct payments.

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

You can reenroll in the FEHB Program if your other coverage ends.
If your coverage ends involuntarily, you can reenroll 31 days before
through 60 days after loss of coverage. If you want to reenroll in the
FEHB Program for a reason other than an involuntary loss of coverage,
you may do so during the next open season.

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.

Item 1.

•

Enter the date of the permissible event 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 annuity was restored). If
you are making an open season enrollment or change, enter
the date on which the open season begins.

Part E — Suspension/Cancellation.
Check a box only if you wish to suspend or cancel your FEHB
enrollment. Also enter your present enrollment code in Part B.

Part F — Signature.

You may suspend your FEHB enrollment because you are enrolling in
one of the following programs:

If you are registering for someone else under a written authorization
from that person to do so, sign your name in Part F and attach the written
authorization.

•

A Medicare HMO or Medicare Advantage plan,

•

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

Your retirement system cannot process your request unless you complete
this part.

If you are registering as the court-appointed guardian for a former
spouse eligible for coverage under the Spouse Equity provisions or for
an individual eligible for TCC, sign your name in Part F and attach
evidence of your court-appointed guardianship.

OPM Form 2809
Revised April 2011

General Information
be eligible to reenroll when you lose coverage under that family
member’s enrollment.

Dual Enrollment
Generally, you cannot be covered as an annuitant under your
own enrollment and as a family member under someone else’s
enrollment in the Federal Employees Health Benefits (FEHB) 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 who becomes the parent of a child to
enroll for Self and Family coverage.

If you suspend your FEHB Program enrollment to be covered by
a Medicare Advantage plan, Medicaid or a similar State-sponsored
program of medical assistance for the needy, TRICARE (including
Uniformed Services Family Health Plan or TRICARE for Life), Peace
Corps, or CHAMPVA, you will be eligible to enroll in the FEHB
Program if any of the above coverage ends.

Reenrollment Eligibility
If you cancel or suspend your enrollment as described above, you may
voluntarily reenroll in the FEHB Program during an annual open season.

No person (enrollee or family member) is entitled to receive benefits
under more than one enrollment in the Program. (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.)

If you involuntarily lose your Medicare Advantage plan, Medicaid or a
similar State-sponsored plan, TRICARE, Peace Corps, or CHAMPVA
coverage, you can reenroll in the FEHB Program effective the day after
your coverage ends. Your request to reenroll must be received at OPM
within the period beginning 31 days before and ending 60 days after
your coverage ends. Otherwise, you must wait until open season to
reenroll.

Enrollment in an HMO (Prepaid) Plan
To enroll in an HMO plan, you must live in the plan’s enrollment area as
stated in the plan brochure.

Enrollment in a Fee-for-Service Plan

If you cancel your Federal Employees Health Benefits (FEHB)
enrollment, you cannot later reenroll, and you and any family members
will not be entitled to a temporary extension of coverage or conversion
to individual coverage. Former spouses who cancel can never reenroll as
former spouses.

If you enroll in a fee-for-service plan sponsored by an employee
organization, you must be (or become) a member of the organization that
sponsors the plan. Your membership will be verified.

Self Only Enrollment
A Self Only enrollment provides benefits just for you.

Effective Dates of Changes
1. Open Season changes for annuitants take effect January 1.

Self and Family Enrollment

2. Non-Open Season changes (except cancellations) take effect the first
day of the month following the month in which the Office of
Personnel Management (OPM) receives your OPM Form 2809.
Note: A change from Self Only to Self and Family due to the birth
of a child or addition of a child as a new family member is effective
the first day of the month in which the child is born or becomes an
eligible family member.

A Self and Family enrollment provides benefits for you and your family
as described on page 1.
If your present enrollment is Self Only, you must change to a Self and
Family enrollment if you want to provide coverage for a new eligible
family member. See the table starting on page 5 for events which allow
you to change to a Self and Family enrollment.

3. Cancellations: Your cancellation will take effect the end of the
month in which OPM receives your completed OPM Form 2809.

Changes in Enrollment
After the Office of Personnel Management (OPM) processes your
request to enroll or change your enrollment, OPM will send you written
confirmation. Your health plan will mail a new identification (I.D.) card
to you as soon as possible. (OPM does not issue I.D. cards.) If you
should need health services before you receive your new I.D. card, show
the written confirmation you receive from OPM to the doctor or hospital.
They can then verify your new coverage with the plan.

Future Changes in Your Status
When your home or mailing address changes, you need to notify the
Office of Personnel Management immediately. Call our toll-free
number 1-888-767-6738 (TTY: 1-800-878-5707). Or, write to the
Change-of-Address Section, P.O. Box 440, Boyers, PA 16017-0440. Be
sure to include your new address, your name, and your retirement claim
number. You also need to notify your health benefits plan. If the family
member(s) covered by your health benefits enrollment change, you must
inform your health benefits plan. You must notify the Office of
Personnel Management immediately if you become the only person
covered by a Self and Family enrollment so that your enrollment can
be changed to Self Only. You must also inform the Office of Personnel
Management if you change your name or add family members.

Suspension or Cancellation of Enrollment
You may suspend or cancel your enrollment at any time for one of
several reasons.
If you cancel your enrollment because you are going to be continuously
covered as a family member under another person’s FEHB enrollment
during the period between your cancellation and reenrollment, you will

OPM Form 2809
Revised April 2011

For more information call our toll-free number 1-888-767-6738, write to us, visit our web site, or send email.
Mailing Address:

Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045

Web site:

http://www.opm.gov/retire

Email:

[email protected]

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. This information will be shared 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. This information may be
disclosed 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.
Executive Order 9397 (November 22, 1943) allows Federal agencies to use the Social Security Number as an individual identifier to
distinguish between people with the same or similar names. Failure to furnish the requested information may result in the U.S. Office of
Personnel Management’s (OPM) inability to ensure the prompt payment of your and/or your family’s claims for health benefits services or
supplies.
We estimate this form takes an average of 45 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, (3206-0141), Washington, D.C.
20415-3430. The OMB number 3206-0141 is currently valid. OPM may not collect this information, and you are not required to respond,
unless this number is displayed.

OPM Form 2809
Revised April 2011

Tables of Permissible Changes in FEHB Enrollment
Enrollment May Be Cancelled or Changed From Family to Self Only at Any Time
Events That Permit
Enrollment or Change

Code

Event

Change Permitted

From Not
Enrolled to
Enrolled

From Self
Only to Self
and Family

Time Limits

From One
Plan or
Option to
Another

When You Must File Health
Benefits Election Form With
the Office of Personnel
Management

Annuitant/Survivor Annuitant
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, legal separation, or divorce.
Note: Survivors cannot change plans because of the death of
the annuitant.

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 payments; for example:

Yes

N/A

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

•
•
•
•

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;
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 Only of the
covering enrollment.

Yes

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

Annuitant 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 federally-sponsored health
benefits program;
Note: Annuitants who previously suspended FEHB to use a
Medicare Advantage Plan, TRICARE, Peace Corps, or
CHAMPVA, see codes 2C and 2D.
Loss of coverage under Medicaid or similar
State-sponsored program;
Note: Annuitants who previously suspended FEHB to use
Medicaid or a similar State-sponsored program, see codes
2C and 2D.
Loss of coverage due to termination of membership in the
employee organization sponsoring the FEHB plan;
Loss of coverage under a non-Federal health plan.

Events That Permit
Enrollment or Change

Code

Event

Change Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

When You Must File Health
Benefits Election Form With
the Office of Personnel
Management

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 outside the geographic area from
which the carrier accepts enrollments, or if already outside this
area, moves further from this area.

N/A

Yes

When you or a family member
notify OPM of a change of address
outside the plan’s service area.

Employee in an overseas post of duty retirees 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

OPM will advise annuitant of the
options.

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

Annuity is not sufficient to make withholdings for plan in
which enrolled.

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

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.

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.

Events That Permit
Enrollment or Change

Code

Event

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

•

•
•

Change Permitted

Time Limits
When You Must File Health
Benefits Election Form With
the Office of Personnel
Management

From Not
Enrolled to
Enrolled

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

N/A

Yes

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

Loss of coverage under another federally-sponsored health
benefits program;
Note: Former spouses who previously suspended FEHB to
use a Medicare Advantage plan, TRICARE, Peace Corps,
or CHAMPVA, see codes 3D and 3E.
Loss of coverage under Medicaid or similar
State-sponsored program;
Note: Former spouses who previously suspended FEHB to
use Medicaid or a similar State-sponsored program, see
codes 3D and 3E.
Loss of coverage due to termination of membership in the
employee organization sponsoring the FEHB plan;
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 outside the
geographic area from which the carrier accepts enrollments,
or if already outside this area, moves further from this area.

N/A

Yes

When you or a family member
notify OPM of a change of address
outside the plan’s service area.

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 not sufficient to make FEHB
withholdings for plan in which enrolled.

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

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

Former spouse
Child who ceases to qualify as a family
member

Yes

N/A

Yes

N/A

Open Season:
•
•

Former spouse
Child who ceases to qualify as a family
member

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

As announced by OPM.
No

Yes

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

Yes

From 31 days before through 60
days after event.

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

Yes

From 31 days before through 60
days after event.

Reenrollment of a 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.

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.

Events That Permit
Enrollment or Change

Code

Event

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

Change Permitted

Time Limits
When You Must File Health
Benefits Election Form With
the Office of Personnel
Management

From Not
Enrolled to
Enrolled

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

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 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 outside the geographic area from
which the carrier accepts enrollments, or if already outside
this area, moves further from this area.

N/A

Yes

When you or a family member
notify OPM of a change of address
outside the plan’s service area.

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.)

Each page of the actual form is now 2 pages (i.e., Copy 1- Enrollee; Copy 2 - New Carrier)
Form Approved:
OMB No. 3206-0141

Health Benefits Election Form
For Use By Annuitants and Former Spouses of Annuitants

Federal Employees
Health Benefits Program

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

2. Social Security Number 3. Date of birth

__/__/____

6. Mailing address (including ZIP Code)

7. Medicare

# 11. email address and # 12. Preferred telephone added
12. Name of family member (last, first, middle initial)

18. Medicare

additional fields added for each family member
Name of family member (last, first, middle initial)

Social Security Number

Address (if different from enrollee)

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

Social Security Number

Address (if different from enrollee)

Part B - Present Plan

Yes
No
9. Other insurance

15. Sex

16. Relationship code

M
F
19. TRICARE

20. Other insurance
22. Insurance policy no.

__/__/____

Sex

Relationship code

M
TRICARE

F
Other insurance

D
Insurance policy no.

Date of birth

__/__/____

Medicare
A
B
Name of Insurance

Date of birth

Medicare
A
B
Name of insurance

M
8. TRICARE

11. Insurance policy no.

__/__/____

A
B
21. Name of insurance

5. Are you married?

13. Social Security Number 14. Date of birth

17. Address (if different from enrollee)

1. Plan name

A
B
10. Name of insurance

4. Sex

Sex

Relationship code

M
TRICARE

F
Other insurance

Part C - New Plan

Insurance policy no.

Part D - Event Code

2. Enrollment code 1. Plan name

2. Enrollment code 1. Event code

2. Date of event

__/__/____
Part E - Election to Suspend/Cancel (fill in this part if you wish to suspend/cancel your enrollment in the FEHBP. See page 2 of the instructions.)
I elect to suspend or cancel my enrollment and have initialed the appropriate box below.
Name
I will be covered under the FEHB enrollment of:

Social Security Number

I am covered by a Medicare Advantage plan, Medicaid or a similar State-sponsored program of medical assistance for the needy. I am enclosing evidence of my coverage.
I will be using CHAMPVA, TRICARE, or TRICARE for Life (enrollees over age 65 with Medicare Parts A and B). I am enclosing copies of my CHAMPVA authorization
card or my Uniformed Services identification card and, if over age 65, my Medicare card showing Parts A and B.
I am or will be covered by Peace Corps volunteer health benefits. I am enclosing evidence of my coverage.
I am cancelling my enrollment for reasons other than the three situations shown above. I understand I can never reenroll in the FEHBP.

Part F - Signature (all who register or cancel must fill in this part)
WARNING:

Any intentionally false statement on 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.)
3. Date (mm/dd/yyyy)
1. Your signature (do not print)
4. Retirement Claim Number
2. Telephone number

__/__/____

email address field added
Part G - To be Completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services Programs
Washington, D.C. 20415

2. Date received in OPM

3. Effective date of action

__/__/____

5. Signature of authorized agency official

4. Payroll office number

24 90 0002
6. Date

__/__/____

Remarks (For use by OPM only.)

U.S. Office of Personnel Management
Previous edition is not usable.

Copy 1 - Enrollee

OPM Form 2809
Revised April 2011

Same changes as page 9

Form Approved:
OMB No. 3206-0141

Health Benefits Election Form
For Use By Annuitants and Former Spouses of Annuitants

Federal Employees
Health Benefits Program

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

2. Social Security Number 3. Date of birth

__/__/____

6. Mailing address (including ZIP Code)

7. Medicare
A
B
10. Name of insurance

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

18. Medicare

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

Social Security Number

Address (if different from enrollee)

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

Social Security Number

Address (if different from enrollee)

Part B - Present Plan
1. Plan name

Yes
No
9. Other insurance

15. Sex

16. Relationship code

M
F
19. TRICARE

20. Other insurance
22. Insurance policy no.

__/__/____

Sex

Relationship code

M
TRICARE

F
Other insurance

D
Insurance policy no.

Date of birth

__/__/____

Medicare
A
B
Name of Insurance

Date of birth

Medicare
A
B
Name of insurance

M
8. TRICARE

11. Insurance policy no.

__/__/____

A
B
21. Name of insurance

5. Are you married?

13. Social Security Number 14. Date of birth

17. Address (if different from enrollee)

4. Sex

Sex

Relationship code

M
TRICARE

F
Other insurance

Part C - New Plan

Insurance policy no.

Part D - Event Code

2. Enrollment code 1. Plan name

2. Enrollment code 1. Event code

2. Date of event

Social Security Number

Part F - Signature (all who register or cancel must fill in this part)
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.)
3. Date (mm/dd/yyyy)
1. Your signature (do not print)
4. Retirement Claim Number
2. Telephone number

__/__/____
Part G - To be completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services Programs
Washington, D.C. 20415

2. Date received in OPM

__/__/____

3. Effective date of action

__/__/____

5. Signature of authorized agency official

4. Payroll office number

24 90 0002
6. Date

__/__/____

Remarks (For use by OPM only.)

U.S. Office of Personnel Management
Previous edition is not usable.

Copy 2 - New Carrier

OPM Form 2809
Revised April 2011

same changes as page 9

Form Approved:
OMB No. 3206-0141

Health Benefits Election Form
For Use By Annuitants and Former Spouses of Annuitants

Federal Employees
Health Benefits Program

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

2. Social Security Number 3. Date of birth

__/__/____

6. Mailing address (including ZIP Code)

7. Medicare
A
B
10. Name of insurance

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

18. Medicare

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

Social Security Number

Address (if different from enrollee)

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

Social Security Number

Address (if different from enrollee)

Part B - Present Plan
1. Plan name

Yes
No
9. Other insurance

15. Sex

16. Relationship code

M
F
19. TRICARE

20. Other insurance
22. Insurance policy no.

__/__/____

Sex

Relationship code

M
TRICARE

F
Other insurance

D
Insurance policy no.

Date of birth

__/__/____

Medicare
A
B
Name of Insurance

Date of birth

Medicare
A
B
Name of insurance

M
8. TRICARE

11. Insurance policy no.

__/__/____

A
B
21. Name of insurance

5. Are you married?

13. Social Security Number 14. Date of birth

17. Address (if different from enrollee)

4. Sex

Sex

Relationship code

M
TRICARE

F
Other insurance

Part C - New Plan

Insurance policy no.

Part D - Event Code

2. Enrollment code 1. Plan name

2. Enrollment code 1. Event code

2. Date of event

Social Security Number

Part F - Signature (all who register or cancel must fill in this part)
WARNING:

__/__/____
Part G - To be completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services Programs
Washington, D.C. 20415

2. Date received in OPM

__/__/____

3. Effective date of action

__/__/____

5. Signature of authorized agency official

4. Payroll office number

24 90 0002
6. Date

__/__/____

Remarks (For use by OPM only.)

U.S. Office of Personnel Management
Previous edition is not usable.

Copy 3 - Old Carrier

OPM Form 2809
Revised April 2011

Same changes as page 9
Form Approved:
OMB No. 3206-0141

Health Benefits Election Form
For Use By Annuitants and Former Spouses of Annuitants

Federal Employees
Health Benefits Program

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

2. Social Security Number 3. Date of birth

__/__/____

6. Mailing address (including ZIP Code)

7. Medicare
A
B
10. Name of insurance

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

18. Medicare

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

Social Security Number

Address (if different from enrollee)

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

Social Security Number

Address (if different from enrollee)

Part B - Present Plan
1. Plan name

Yes
No
9. Other insurance

15. Sex

16. Relationship code

M
F
19. TRICARE

20. Other insurance
22. Insurance policy no.

__/__/____

Sex

Relationship code

M
TRICARE

F
Other insurance

D
Insurance policy no.

Date of birth

__/__/____

Medicare
A
B
Name of Insurance

Date of birth

Medicare
A
B
Name of insurance

M
8. TRICARE

11. Insurance policy no.

__/__/____

A
B
21. Name of insurance

5. Are you married?

13. Social Security Number 14. Date of birth

17. Address (if different from enrollee)

4. Sex

Sex

Relationship code

M
TRICARE

F
Other insurance

Part C - New Plan

Insurance policy no.

Part D - Event Code

2. Enrollment code 1. Plan name

2. Enrollment code 1. Event code

2. Date of event

Social Security Number

Part F - Signature (all who register or cancel must fill in this part)
WARNING:

__/__/____
Part G - To be completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services Programs
Washington, D.C. 20415

2. Date received in OPM

3. Effective date of action

__/__/____

5. Signature of authorized agency official

4. Payroll office number

24 90 0002
6. Date

__/__/____

Remarks (For use by OPM only.)

U.S. Office of Personnel Management
Previous edition is not usable.

Copy 4 - Case File

OPM Form 2809
Revised April 2011

File Type	application/pdf
File Title	C:\OPM 2809\OPM 2809 (03-11).vp
Author	phyllis
File Modified	2013-04-22
File Created	2011-02-17