Form OPM Form 2809 OPM Form 2809 Health Benefits Election Form

OPM 2809, Health Benefits Election Form

OPM2809_2015_11_MarkUp

Health Benefits Election Form

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⚠️ Notice: This form may be outdated.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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Form Approved:
OMB No. 3206-0141

Health Benefits Election Form
Who May Use OPM Form 2809

!
!
!
!

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.

Annuitants retired under the Civil Service Retirement System (CSRS)
or Federal Employees Retirement System (FERS)
Survivor annuitants under CSRS or FERS
Former spouses
Children and former spouses who are eligible for temporary
continuation of coverage

Instructions for Completing OPM 2809
Type or print firmly.

Item 11.

If applicable, provide your email address.

Item 12.

Provide your day time telephone number.

Part A — Enrollee and Family Member Information.

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

You must complete this part.
Item 1.

Enter your legal name.

Item 2.

Provide your Social Security number.

Item 3.

Enter your date of birth.

The instructions for completing items 13 through 24 for your initial family
member also apply to the information you provide for additional family
members in items 25 through 48.

Item 4.

Enter your sex.

Item 14.

Item 5.

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

Item 6.

Enter your emailing address.

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

Item 7.

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

Item 15.

Provide the date of birth of the family member.

Item 16.

Provide sex of family member.

Item 8.

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

Item 17.

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

Item 9.

If you are covered by other health insurance (private, state,
Medicaid, Peace Corps, TRICARE, CHAMPVA, or another
FEHB enrollment), either in your name or under a family
member’s policy, check yes and complete item 10.

Code

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.
Item 10.

Write the name of any other 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 OPM immediately as this is a dual coverage situation.
Some examples of how this could occur are:

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 an FEHB Self
Only plan, an FEHB Self Plus One plan that covers you,
or an FEHB Self and Family plan that covers you.

Previous editions are not usable.

Family Relationship

01
19
09
17

Spouse

Foster Child

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.

Child under age 26
Adopted Child
Stepchild

Item 18.

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

Item 19.

If a family member has Medicare, check which Parts 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.

Indicate whether the family member has health coverage other
than Medicare.

Item 22.

If a family member has TRICARE (see item 9), or other
group insurance (private, state, Medicaid, Peace Corps, or
another FEHB enrollment), check the box. Give the name
and policy number of any other insurance this family member
has.
OPM Form 2809
Revised November 2015

Item 23.

Enter email address, if applicable, for your spouse or adult
child.

Item 24.

Enter the preferred telephone number, if applicable, of your
spouse or adult child.

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.

Part B — FEHB Plan You Are Currently Enrolled In.

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.

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

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.

Item 1.

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

Item 2.

Enter the current enrollment code from your plan ID card.

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

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

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.

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

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

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 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.

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

Part D — Event That Permits You to Enroll, Change
or Cancel.
Item 1.

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.

Explanation of Table of Permissible Changes in Enrollment
The tables on pages 5 through 8 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 the FEHB regulations at 5 CFR
Parts 890 and 892.

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

!
!

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 starting on
page 5.

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

At least one family member must be entitled to an annuity as your
survivor.

*If you would marry but you live in a state that does not allow same-sex
couples to marry.
2

Annuitants, including individuals receiving monthly
compensation from the Office of Workers’ Compensation
Programs

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

OPM Form 2809
Revised November 2015

TCC enrollees.

Reemployed annuitants and Survivor Annuitants who are
eligible for FEHB coverage unless you waive participation in
premium conversion.

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, 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.

Following each number is a letter which identifies a specific Qualifying
Life Event (QLE); for example, the event code 2A refers to open season.
Item 2.

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

If you cancel your enrollment for any other reason, you cannot 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.

Part F — Signature.
Your retirement system cannot process your request unless you complete
this part.

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.

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.

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

!
!
!
!
!

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.

A Medicare HMO or Medicare Advantage plan,
Medicaid or similar State-sponsored program of medical assistance
for the needy,
TRICARE (including Uniformed Services Family Health Plan or
TRICARE for Life),

General Information

Peace Corps, or

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

CHAMPVA

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

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.”

Annuitants Who Cancel Their Enrollment
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.

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.

In these unusual situations, each enrollee must notify his or her plan as to
which family members are covered under which enrollment.

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 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.

OPM Form 2809
Revised November 2015

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: 1-855-887-4957). 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 Self Plus One, or 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.

Self and Family Enrollment
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.

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.

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

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

Mailing Address:

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

Website:

www.opm.gov/retirement-services/

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 (FEHB) 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.

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.
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.

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) as amended by Executive Order 13478 (November 18, 2009), allows Federal
agencies to use the Social Security Number as an individual identifier to distinguish
between people with the same or similar names. In addition, a mandatory Insurer
Reporting Law (Section 111 of Public Law No. 110-173) requires your health
insurance carrier to report, as directed by the Secretary of the Department of Health
and Human Services (“Secretary”), information that the Secretary requires for
purposes of coordination of benefits between your health plan and Medicare. In order
to properly coordinate Medicare payments with other insurance and/or workers’
compensation benefits, Medicare relies on your health insurance carrier to collect
Medicare Claim Numbers or Social Security Numbers from you and your eligible
dependents. We therefore request that you provide a Medicare Claim Number or a
Social Security Number for yourself and each of your eligible dependents. 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.

If you cancel your FEHB enrollment for a reason other than your
becoming covered under another 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.

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

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, (3206-0141), 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.

3. Cancellations: Your cancellation will take effect the end of the
month in which OPM receives your completed OPM Form 2809.
4

OPM Form 2809
Revised November 2015

Tables of Permissible Changes in FEHB Enrollment
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 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
the Office of Personnel
Option
Member
Management
to
Another

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, 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.

Note: Survivors cannot change plans because of the death
of the annuitant.
2C

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.

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;
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 Permitted

Time Limits

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:

From
Switch
When You Must File Health
One
Designated
Benefits Election Form With
Plan or
Family
the Office of Personnel
Option
Member
Management
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.
2H

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 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

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 Plus One or 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

Yes

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 Permitted

Time Limits

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

From Not
Enrolled to
Enrolled

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

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;
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 Plus One or Self and Family only if family members are also eligible family members of
the annuitant.

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

Yes

N/A

Yes

N/A

Yes

Open Season:
•
•

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.

N/A

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

Yes

As announced by OPM.

Yes

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.

Change Permitted

From Not
Enrolled to
Enrolled

Time Limits

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

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

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.

Enrollee 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
(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.)

Health Benefits Election Form

Form Approved:
OMB No. 3206-0141

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 (mm/dd/yyyy)

4. Sex

5. Are you married?

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

6. Mailing address (including ZIP Code)
-------------------------------------------------------------------

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 9 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

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

18. Address (if different from enrollee)
-------------------------------------------------------------------

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

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

30. Address (if different from enrollee)
-------------------------------------------------------------------

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

__/__/____
M
F
43. If this family member is covered 44. Medicare Claim Number
y Medicare, check all that apply.

42. Address (if different from enrollee)
-------------------------------------------------------------------

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
FEHB

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

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

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

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

Copy 1 - Enrollee

Page 1 of 2
OPM Form 2809
Revised November 2015

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

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

2. Enrollment code 1. Plan name

2. Enrollment code

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 2)
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

Social Security Number

I will be covered under the FEHB enrollment of:

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.)

1. Your signature (do not print)

2. Date (mm/dd/yyyy)

3. Retirement Claim Number

__/__/____
4. Email Address

5. Preferred telephone number

Part G - To be Completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services
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.)

Copy 1 - Enrollee

Page 2 of 2
OPM Form 2809
Revised November 2015

Health Benefits Election Form

Form Approved:
OMB No. 3206-0141

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 (mm/dd/yyyy)

4. Sex

5. Are you married?

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

6. Mailing address (including ZIP Code)
-------------------------------------------------------------------

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: _____________________

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

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

18. Address (if different from enrollee)
-------------------------------------------------------------------

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

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

30. Address (if different from enrollee)
-------------------------------------------------------------------

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

__/__/____
M
F
43. If this family member is covered 44. Medicare Claim Number
y Medicare, check all that apply.

42. Address (if different from enrollee)
-------------------------------------------------------------------

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
FEHB

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

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

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

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

Copy 2 - New Carrier

Page 1 of 2
OPM Form 2809
Revised November 2015

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

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

2. Enrollment code 1. Plan name

2. Enrollment code

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 2)
1. Event code

2. Date of event

Social Security Number

I will be covered under the FEHB enrollment of:

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

1. Your signature (do not print)

2. Date (mm/dd/yyyy)

3. Retirement Claim Number

__/__/____
4. Email Address

5. Preferred telephone number

Part G - To be Completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services
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.)

Copy 2 - New Carrier

Page 2 of 2
OPM Form 2809
Revised November 2015

Health Benefits Election Form

Form Approved:
OMB No. 3206-0141

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 (mm/dd/yyyy)

4. Sex

5. Are you married?

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

6. Mailing address (including ZIP Code)
-------------------------------------------------------------------

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: _____________________

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

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

18. Address (if different from enrollee)
-------------------------------------------------------------------

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

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

30. Address (if different from enrollee)
-------------------------------------------------------------------

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

__/__/____
M
F
43. If this family member is covered 44. Medicare Claim Number
y Medicare, check all that apply.

42. Address (if different from enrollee)
-------------------------------------------------------------------

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
FEHB

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

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

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

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

Copy 3 - Old Carrier

Page 1 of 2
OPM Form 2809
Revised November 2015

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

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

2. Enrollment code 1. Plan name

2. Enrollment code

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 2)
1. Event code

2. Date of event

Social Security Number

I will be covered under the FEHB enrollment of:

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

1. Your signature (do not print)

2. Date (mm/dd/yyyy)

3. Retirement Claim Number

__/__/____
4. Email Address

5. Preferred telephone number

Part G - To be Completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services
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.)

Copy 3 - Old Carrier

Page 2 of 2
OPM Form 2809
Revised November 2015

Health Benefits Election Form

Form Approved:
OMB No. 3206-0141

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 (mm/dd/yyyy)

4. Sex

5. Are you married?

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

6. Mailing address (including ZIP Code)
-------------------------------------------------------------------

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: _____________________

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

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

18. Address (if different from enrollee)
-------------------------------------------------------------------

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

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

30. Address (if different from enrollee)
-------------------------------------------------------------------

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

__/__/____
M
F
43. If this family member is covered 44. Medicare Claim Number
y Medicare, check all that apply.

42. Address (if different from enrollee)
-------------------------------------------------------------------

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
FEHB

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

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

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

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

Copy 4 - Case File

Page 1 of 2
OPM Form 2809
Revised November 2015

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

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

2. Enrollment code 1. Plan name

2. Enrollment code

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 2)
1. Event code

2. Date of event

Social Security Number

I will be covered under the FEHB enrollment of:

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

1. Your signature (do not print)

2. Date (mm/dd/yyyy)

3. Retirement Claim Number

__/__/____
4. Email Address

5. Preferred telephone number

Part G - To be Completed by OPM
1. Name and address
U.S. Office of Personnel Management
Retirement Services
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.)

Copy 4 - Case File

Page 2 of 2
OPM Form 2809
Revised November 2015

File Type	application/pdf
File Title	P:\RSSP\ASB\FORMS\FORMS FOLDER\OPM\OPM2809\Ventura\2015_11\OPM2809_Instructions_2015.vp
Author	CSBENSON
File Modified	2015-06-26
File Created	2015-05-21