OPM 2809 Health Benefits Election Form

SF 2809 Federal Employees Health Benefits Program Election Form; OPM 2809 Health Benefits Election Form

OPM2809 Updated_2024_10_09

Health Benefits Election Form

OMB: 3206-0160

Document [pdf]

Download: pdf | pdf

OMB Approval 3206-0160

Health Benefits Election Form
Federal Employees
Health Benefits Program

Who May Use OPM Form 2809
• Annuitants retired under the Civil Service Retirement System (CSRS) or

•
•
•
•

Only for Postal Service annuitants covered under a PSHB
plan, if you are claiming an exception from the requirement to
enroll in Medicare Part B, or providing documentation that you
are not subject to the Medicare Part B requirement, select the
reason for this exception from the following five listed options:
(1) Enrolled in Veterans Affairs (VA) healthcare benefits;
(2) Eligible for health services from the Indian Health Service
(IHS); (3) Resides outside the United States - includes the
States, District of Columbia, the Commonwealth of Puerto Rico,
the Virgin Islands, Guam, American Samoa, and the Northern
Mariana Islands; (4) Enrollee not required to enroll - Postal
Service Medicare covered annuitant who was not both entitled
to Medicare Part A and enrolled in Part B on or before January
1, 2025 or was a Postal Service employee who was at least 64
years of age or older on or before January 1, 2025; or (5)
Medicare A-Section 1818 or 1818A of the Social Security Act
[42 U.S.C. 1395i-2, 1395i-2a] (uncommon) - applies to
individuals who (1) pay the full premiums for Part A because
they do not meet the requirements for premium-free Medicare
Part A and are over age 65 or (2) pay the full premium for Part
A because they are no longer entitled to Social Security
Disability Benefits but chose to continue Medicare coverage
beyond the disability termination date. Note that some of these
exceptions are temporary.

Federal Employees' Retirement System (FERS), electing or changing
either there FEHB or Postal Service Health Benefit (PSHB) coverage
under the FEHB Program;
Survivor annuitants under CSRS or FERS;
Former spouses;
Children and former spouses who are eligible for temporary continuation
of coverage; and
An OPM appointed representative payee or court appointed guardian of
the eligible member.

Instructions for Completing OPM 2809
Type or print firmly.
Part A — Enrollee Information
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.

Item 4.

Enter your sex.

Item 5.

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

Item 6.

Enter your mailing address.

Item 7.

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

Item 8.

If you have Medicare, enter your Medicare Beneficiary
Identifier (MBI). This number is on your Medicare card.

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.

For Postal Service annuitants covered under a PSHB plan,
who are electing an exception (#1 - #5) from the Medicare Part
B requirement, attach the following supporting documentation
for the applicable numbered options (see preceding paragraph):
(1) documentation from the VA confirming current enrollment
in VA healthcare benefits, (2) documentation from the IHS
confirming eligibility for health services, (3) documentation
confirming residency outside of the United States and its
territories, (4) documentation confirming enrollee not required
to enroll in Medicare Part B, or (5) documentation from the
Social Security Administration confirming enrollment in
Medicare A-Section 1818 or 1818A of the Social Security Act
[42 U.S.C 1395i-2, 1395i-2a] (uncommon).
For more information on exceptions to the PSHB Medicare Part
B requirement, visit https://www.opm.gov/healthcare-insurance/
pshb/.

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.

Check or write the name and policy number of any other
insurance that covers you. An FEHB/PSHB Self Plus One
enrollment covers the enrollee and one eligible family member
designated by the enrollee. An FEHB/PSHB Self and Family
enrollment covers the enrollee and all eligible family members.
If you or a family member is covered under another FEHB/
PSHB enrollment, check the FEHB/PSHB box and STOP.
Contact OPM immediately as this is a dual coverage situation.

Previous editions are not usable.

Item 11.

If applicable, provide your email address.

Item 12.

Provide your daytime telephone number.

Note: Documentation must be provided before any change can be effective
such as suspending/cancelling of benefits.

-1-

OPM Form 2809
Revised November 2024

Part B — Family Member Information

(4) Enrollee not required to enroll - Postal Service Medicare
covered annuitant who was not both entitled to Medicare Part A
and enrolled in Part B on or before January 1, 2025 or was a
Postal Service employee who was at least 64 years of age or
older on or before January 1, 2025; or (5) Medicare A-Section
1818 or 181A of the Social Security Act [42 U.S.C. 1395i-2,
1395i-2a] (uncommon) - applies to individuals who (1) do not
meet the requirements for premium free Medicare Part A and are
over age 65 or (2) pay the full premium for Part A because they
are no longer entitled to Social Security Disability Benefits but
chose to continue Medicare coverage beyond the disability
termination date. Note that some of these exceptions are
temporary.

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.)
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 13.

Enter the legal name of the family member.

Item 14.

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 5.)

Item 15.

Provide the date of birth of the family member.

Item 16.

Provide the sex of the family member.

Item 17.

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

Code

01
19
09
17
10
99

Family Relationship

Spouse
Child under age 26
Adopted Child
Stepchild
Foster Child
Disabled child age 26 or older who is incapable of
self-support because of a physical or mental disability that
began before their 26th birthday.

Item 18.

If your family member does not live with you, enter their home
address.

Item 19.

If a family member has Medicare, check which Parts they have,
including prescription drug coverage under Medicare
Part D. Medicare covered family members covered under
PSHB are required to enroll in Medicare Part B. The only
applicable five exceptions to the Medicare Part B requirement
are listed in the second paragraph in the instructions for Item
22 shown below.

Item 20.

For family member(s) of Postal Service annuitants covered
under a PSHB plan, who are electing an exception (#1 - #5)
from the Medicare Part B requirement, attach the following
supporting documentation for the applicable numbered options
(see preceding paragraph): (1) documentation from the VA
confirming current enrollment in VA healthcare benefits,
(2) documentation from the IHS confirming eligibility for health
services, (3) documentation confirming residency outside of the
United States and its territories, (4) documentation confirming
enrollee not required to enroll in Medicare Part B, or
(5) documentation from the Social Security Administration
confirming enrollment in Medicare A-Section 1818 or 1818A of
the Social Security Act [42 U.S.C. 13951-2, 1395i-2a]
(uncommon).
For more information on exceptions to the PSHB Medicare Part
B requirement, visit https://www.opm.gov/healthcare-insurance/
pshb/.

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

Item 22.

If a family member has TRICARE, or other group insurance
(see item 9), check the box. Give the name and policy number of
any other insurance this family member has. If the family
member is covered under another FEHB/PSHB enrollment,
contact OPM immediately as this is a dual coverage situation
(see item 10).

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

Item 24.

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

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

If your family member has Medicare, enter their Medicare
Beneficiary Identifier. This number is on their Medicare card.

Item 21.

Item 23.

Eligible children include your children born within marriage or adopted
children; stepchildren, recognized natural children, or foster children who
live with you in a regular parent-child relationship.
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.

Only for Postal Service annuitants covered under a PSHB
plan, if your Medicare covered family member is claiming an
exception from the requirement to enroll in Medicare Part B, or
providing documentation that you are not subject to the
Medicare Part B requirement, select the reason for this exception
from the following five listed options: (1) Enrolled in Veterans
Affairs (VA) healthcare benefits; (2) Eligible for health services
from the Indian Health Service (IHS); (3) Resides outside the
United States - includes the States, District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands, Guam,
American Samoa, and the Northern Mariana Islands;

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
their 26th birthday and renders the child incapable of self-support.
Note: Documentation must be provided before any change can be effective
such as for adding/removing family members or suspending/cancelling of
benefits. 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.

-2-

OPM Form 2809
Revised November 2024

Survivor Benefits

Explanation of Table of Permissible Changes in Enrollment

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

The tables on pages 6 through 9 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 Program regulations at 5 CFR Parts 890 and 892.

Self Plus One

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

The tables have been organized by enrollee category. Each category is
designated by a number, which identifies the enrollee group, as follows:
2. Annuitants, including individuals receiving monthly compensation
from the Office of Workers’ Compensation Programs in lieu of their
retirement benefit;

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 the FEHB Program 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.

3.
4.
5.

Self and Family

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

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

Former spouses eligible for coverage under the Spouse Equity
provisions of FEHB law;
TCC enrollees; and
Reemployed annuitants and Survivor annuitants who are eligible for
FEHB coverage unless you waive participation in premium conversion.

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

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 C — FEHB/PSHB Plan You Are Currently
Enrolled In

Enter the date of the QLE using numbers to show month, day,
and complete year; e.g., 06/30/2021. 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 F — Election to Suspend/Cancel
You must INITIAL a box only if you wish to suspend or cancel your
enrollment in the FEHB Program. Also enter your current enrollment code
in Part C.

You must complete this part if you are changing, canceling, or suspending
your enrollment.
• Enter the enrollment code of the plan you are currently enrolled in,
found on your ID card.

You may suspend your enrollment in the FEHB Program because you are
enrolling in one of the following programs:
• A Medicare HMO or Medicare Advantage plan;
• Medicaid or similar State-sponsored program of medical assistance for
individuals with limited income and resources;
• TRICARE (including Uniformed Services Family Health Plan or
TRICARE for Life);
• Peace Corps; or
• CHAMPVA.
You must submit documentation of eligibility for coverage under the nonFEHB Program to OPM.

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

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

INITIAL the last box only if you wish to cancel your enrollment in the
FEHB Program for reasons other than to be covered under a FEHB Program
of a spouse. Also enter the enrollment code for your current plan in Part C.
Be sure to read the information below in the paragraph titled “Annuitants
Who Cancel Their Enrollment.”

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

Part E — Event That Permits You to Enroll, Change, or
Cancel
Enter the event code that permits you to enroll, change, or
Item 1.

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
Program enrollment, you can reenroll from 31 days before through 60 days
after you lose that coverage under the other enrollment.

cancel based on open season or a Qualifying Life Event (QLE)
from the Table of Permissible Changes in Enrollment starting on
page 6.

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.
-3-

OPM Form 2809
Revised November 2024

Former Spouses (Spouse Equity) Who Cancel Their Enrollment

Self Plus One and Self and Family Enrollment

Generally, if you cancel your enrollment in the FEHB Program as a former
spouse, you cannot reenroll. However, if you cancel the enrollment because
you become covered under a FEHB/PSHB plan as a new spouse, your
eligibility for FEHB Program 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/PSHB plan.

A Self Plus One and Self and Family enrollment provides benefits for you
and your family as described on page 1.
If your current enrollment is Self Only, you must change to a Self Plus One
or Self and Family enrollment if you want to provide coverage for an
eligible family member. See the table starting on page 6 for events which
allow you to change to a Self Plus One or Self and Family enrollment.

Changes in Enrollment
After 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.

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

Suspension or Cancellation of Enrollment

If you are registering for someone else as their OPM appointed and
approved Representative Payee, sign your name in Part G.

You may suspend or cancel your enrollment at any time for one of several
reasons.

If you are registering as the court-appointed guardian or conservator for an
FEHB eligible enrollee, sign your name in Part G and attach a certified copy
of your court-appointed guardianship or conservatorship.

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 individuals with limited income and resources, 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.

General Information
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 as an annuitant
under your own enrollment and be covered 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 their own spouse and/or child;

If you cancel your enrollment because you are going to be continuously
covered as a family member under another person’s enrollment in the
FEHB Program, you will be eligible to reenroll if you lose coverage
under that family member’s enrollment.

Reenrollment Eligibility
If you suspend or cancel your enrollment for the reasons described above,
you may voluntarily reenroll in the FEHB Program during an annual open
season.
If you suspend your enrollment to be covered by a Medicare Advantage
plan, Medicaid or a similar State-sponsored program of medical assistance
for individuals with limited income and resources, 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.

• 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 their
parent’s HMO service area, to have FEHB coverage; or

• 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 their plan as to which
family members are covered under which enrollment.

If you cancel your enrollment in a FEHB/PSHB plan for a reason other than
becoming covered under another FEHB/PSHB plan, 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.

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

Effective Dates of Changes

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.

Open season changes for annuitants take effect January 1.

Non-open season changes (except cancellations) take effect the first
day of the month following the month in which 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.

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

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

-4-

OPM Form 2809
Revised November 2024

Future Changes in Your Status

Failure to furnish your Social Security Number or Medicare Number may
result in OPM's inability to ensure the prompt payment of you or your
family's claims for health benefits, the proper coordination with Medicare,
and the proper health insurance status reporting to the Internal Revenue
Service. Additionally, for USPS employees, annuitants, or their family
members it may result in OPM's inability to determine eligibility for PSHB
coverage.

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. Hearing impaired users should use the Federal Relay
Service by dialing 711 or their local communications provider to reach a
Communications Assistant. A change can also be reported by writing to
the Retirement Operations Center, U.S. Office of Personnel Management,
P.O. Box 45, Boyers, PA 16017-0045. 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 OPM 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 OPM if
you change your name or add family members.

Public Burden Statement

The public reporting burden to complete this information collection is
estimated at 35 minutes per response, including time for reviewing
instructions, searching data sources, gathering and maintaining the data
needed, completing and reviewing the collected information. An agency
may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect
of this collection information, including suggestions for reducing this
burden to the Office of Personnel Management, RS Publications Team at
RSPublicationsTeam@opm.gov. Current information regarding this
collection of information - including all background materials - can be
found at https:/www.reginfo.gov/public/do/PRAMain by using the search
function to enter either the title of the collection or 3206-0141.

For more information, call our toll-free number 1-888-767-6738, write
to us, or visit us online.
Mailing Address: Retirement Operations Center
U.S. Office of Personnel Management
P.O. Box 45
Boyers, PA 16017-0045
Websites: General Information - www.opm.gov/retirement-center/
Submit Help Request - www.opm.gov/support/retirement/contact
Privacy Act Statement

The information you provide on this form is needed to document your
enrollment in either the Federal Employees Health Benefits (FEHB) or
Postal Service Health Benefits (PSHB) plan within the Federal Employees
Health Benefits Program (FEHB Program) under chapter 89 of title 5,
United States Code. Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act
Statement serves to inform you of why OPM is requesting the information
on this form. Authority: OPM is authorized to collect the information
requested on this form pursuant to chapter 89 of title 5, United States Code,
sections 8905 and 8905a, which, specify the opportunities and conditions
under which a retiree, survivor annuitant, or former spouse of a retiree is
eligible to enroll or to change enrollment in the FEHB Program. OPM is
authorized to collect your Social Security number by Executive Order 9397
(November 22, 1943), as amended by Executive Order 13478 (November
18, 2008). Purpose: OPM is requesting this information to elect, cancel,
suspend, or change health benefits enrollment. OPM, Retirement Services
determines whether all conditions permitting enrollment or change in
enrollment are met and implements the action. Routine Uses: The
information requested on this form may be shared as a "routine use" to other
Federal agencies and third-parties when it is necessary to process your
application. For example, OPM may share your information with other
Federal, state, or local agencies and organizations in order to determine
benefits under their programs, to obtain information necessary for a
determination of your disability retirement benefits, or to report income for
tax purposes. OPM may also share your information with law enforcement
agencies if it becomes aware of a violation or potential violation of civil or
criminal law. A complete list of the routine uses can be found in the OPM/
CENTRAL 1 Civil Service Retirement and Insurance Records system of
records notice, available at www.opm.gov/privacy. Consequences of
Failure to Provide Information: Providing this information is voluntary,
however, failure to provide it may result in a delay in processing your
enrollment. We request that you provide your family member's Social
Security Number so that it may be used as an individual identifier in the
FEHB or PSHB Program, and for other purposes. Your health insurance
carrier also needs to report your Social Security Number or your Medicare
Number in order to properly coordinate benefits between your health plan
and Medicare.

-5-

Tables of Permissible Changes in FEHB Program 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 Not
Enrolled to
Enrolled

From Self
Only
to Self
Plus One
or Self
and Family

Time Limits

From
Switch
One
Designated
Plan or
Family
Option
Member
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, or divorce.
Note: Survivor's 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 Program
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 loses this coverage under one of these programs.

May reenroll

N/A

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

Reenrollment of annuitant who suspended FEHB Program
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:
• Disability annuitant who was enrolled in the FEHB
Program, 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 the FEHB
Program immediately before survivor annuity
terminated because of remarriage and whose annuity
is restored;
• Surviving child who was covered by the FEHB
Program immediately before survivor annuity
terminated because student status ended and whose
survivor annuity is restored; or
• Surviving child who was covered by the FEHB
Program immediately before survivor annuity
terminated because of marriage and whose survivor
annuity is restored.

Yes

N/A

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

Annuitant or eligible family member loses FEHB Program
coverage due to termination, cancellation, or change to Self
Plus One or 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
another group insurance plan, for example:
• 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/PSHB plan;
• Loss of coverage under Medicaid or similar Statesponsored program (but see events 2C and 2D); or
• Loss of coverage under a non-Federal health plan.

Yes

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

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

N/A

Yes

During open season, unless
OPM sets a different time.

-6-

QLE’s That Permit
Enrollment or Change
Event
Code

Change Permitted

Time Limits

Event

From Not
Enrolled to
Enrolled

From Self
Only
to Self
Plus One
or Self
and Family

From
Switch
One
Designated
Plan or
Family
Option
Member
to
Another

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
notifies 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 withholding for the FEHB/
PSHB plan in which enrolled.

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

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 the
FEHB Program. 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 enrollment in
the FEHB Program 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.

Reenrollment of former spouse who suspended enrollment in
the FEHB Program to enroll in 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 Program 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

-7-

QLE’s That Permit
Enrollment or Change
Event
Code

Event

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

Change Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only
to Self
Plus One
or Self
and Family

From
Switch
One
Designated
Plan or
Family
Option
Member
to
Another

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

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 a FEHB/
PSHB plan 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 a FEHB/
PSHB plan 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/PSHB
plan;
• Loss of coverage under a non-Federal health plan.
3H

Former spouse or eligible family member loses coverage due
to the discontinuance, in whole or part, of an FEHB/PSHB
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
notifies 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 withholdings
for a FEHB/PSHB plan in which enrolled.

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

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

Former spouse

Yes

N/A

Child who ceases to qualify as a family member

Yes

N/A

Open Season:
•

Former spouse

•

Child who ceases to qualify as a family member

Yes

N/A

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

Yes

As announced by OPM.

Change in family status (except former spouse); for example,
marriage, birth or death of family member, adoption, 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/PSHB plan
coverage and who loses the other FEHB/PSHB plan coverage
before the TCC period of eligibility (18 or 36 months) expires.

May reenroll

N/A

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

-8-

QLE’s That Permit
Enrollment or Change
Event
Code

Event

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

Change Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only
to Self
Plus One
or Self
and Family

From
Switch
One
Designated
Plan or
Family
Option
Member
to
Another

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

Yes

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

Loss of coverage under another FEHB/PSHB plan 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/PSHB plan;
• Loss of coverage under Medicaid or similar Statesponsored program;
• Loss of coverage under a non-Federal health plan.
4G

Enrollee or eligible family member loses coverage due to the
discontinuance, in whole or part, of an FEHB/PSHB 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
notifies 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.)

Employees Who Are Not Participating in Premium Conversion

Initial opportunity to enroll.

Yes

N/A

Within 60 days after becoming
eligible.

Open Season

Yes

As announced by OPM

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

Yes

From 31 days before through
60 days after event.

Change in employment status, for example:

Yes

Within 60 days of employment
status change.

•

Reemployment after a break in service of more than
3 days;

•

Return to pay status following loss of coverage due to
expiration of 365 days of LWOP status or termination of
coverage during LWOP;
• Return to pay sufficient to make withholdings after
termination of coverage during a period of insufficient pay;
• Restoration to civilian position after serving in uniformed
services;
• Change from temporary appointment to appointment that
entitles employee receipt of Government contribution; or
•

Change to or from part-time career employment.

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

Yes

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

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

Yes

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

-9-

QLE’s That Permit
Enrollment or Change
Event
Code

Event

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

Change Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only
to Self
Plus One
or Self
and Family

From
Switch
One
Designated
Plan or
Family
Option
Member
to
Another

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

Yes

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

Loss of coverage under another FEHB/PSHB enrollment
due to termination, cancellation, or change to Self Only of
the covering enrollment;

•

Loss of coverage under another Federally-sponsored health
benefits program;
• Loss of coverage due to termination of membership in the
employee organization sponsoring the FEHB/PSHB plan;
• Loss of coverage under Medicaid or similar
State-sponsored program; or
• Loss of coverage under a non-Federal health plan.
5H

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

N/A

Yes

During Open Season, unless
OPM sets a different time.

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

Yes

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

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

N/A

Yes

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

On becoming eligible for Medicare (This change may be made
only once in a lifetime.)

N/A

Yes

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

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

Yes

N/A

Within 60 days after becoming
eligible.

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

N/A

Yes

Within 60 days after receiving
notice from employing office.

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

Yes

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

- 10 -

Health Benefits Election Form

OMB Approval 3206-0141

For Use By Annuitants and Former Spouses of Annuitants

Federal Employees
Health Benefits Program

Use this form to enroll, elect not to enroll, change, suspend or cancel your health insurance coverage in the
Federal Employees Health Benefits Program (FEHB Program) which includes FEHB and Postal Service Health Benefits (PSHB) plans.
Read the instructions carefully to understand your election and to find the codes referenced in this form.

Part A - Enrollee Information
1. Enrollee name (last, first, middle initial)

2. Social Security Number

3. Date of birth (mm/dd/yyyy)

5. Are you married?

4. Sex

Male

Female

6. Mailing address (including ZIP Code)

Prefer not to answer

Yes

7. If you are covered by Medicare, 8. Medicare Beneficiary Identifier
check all that apply.

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/
PSHB

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

Other

Name of other insurance: ______________________________________________

Policy Number: ____________________________

(Postal Service Annuitants Only) Are you claiming an exception to the Medicare Part B enrollment requirement? If so, please select one of the exceptions and attach the
required supporting documentation.

Enrolled in VA healthcare benefits
Eligible for health services from IHS
11. Email address

Resides abroad
Enrollee not required to enroll
Medicare A - Section 1818/1818A (uncommon)
12. Preferred telephone number

Part B - Family Member Information (Please duplicate this section as needed for any additional family members.)
List all eligible family members you want covered by your enrollment. Your family member's enrollment is not complete without the required eligibility
documents. See https:www.opm.gov/healthcare-insurance/healthcare/eligibility/ for more information on required documents. You must submit a new OPM
2809 to remove any family member who becomes ineligible.
13. Name of family member (last, first, middle initial)

14. Social Security Number

16. Sex

15. Date of birth (mm/dd/yyyy)

17. Relationship code

Male

Female

18. Address (if different from enrollee)

Prefer not to answer
19. If this family member is covered 20. Medicare Beneficiary Identifier
by Medicare, check all that apply.

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/
PSHB

Other

Name of other insurance: ______________________________________________

Policy Number: ____________________________

(Postal Service Annuitants Only) Is your family member claiming an exception to the Medicare Part B enrollment requirement? If so, please select one of the exceptions and
attach the required supporting documentation.

Enrolled in VA healthcare benefits
Eligible for health services from IHS
23. Email address

Resides abroad
Enrollee not required to enroll
Medicare A - Section 1818/1818A (uncommon)
24. Preferred telephone number

(Part B continued on page 2)
U.S. Office of Personnel Management
Previous edition is not usable.

Copy 1 - Enrollee

(Page 1 of 3) OPM Form 2809
Revised November 2024

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

26. Social Security Number

28. Sex

27. Date of birth (mm/dd/yyyy)

29. Relationship code

Male

Female

30. Address (if different from enrollee)

Prefer not to answer
31. If this family member is covered 32. Medicare Beneficiary Identifier
by Medicare, check all that apply.

33. Is this family member covered by insurance other than Medicare?

Yes, indicate in item 22 below.

34. Indicate the type(s) of other insurance

TRICARE
FEHB/
PSHB

Other

Name of other insurance: ______________________________________________

Policy Number: ____________________________

Enrolled in VA healthcare benefits
Eligible for health services from IHS
35. Email address

Resides abroad
Enrollee not required to enroll
Medicare A - Section 1818/1818A (uncommon)
36. Preferred telephone number

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

38. Social Security Number

40. Sex

39. Date of birth (mm/dd/yyyy)

41. Relationship code

Male

Female

42. Address (if different from enrollee)

Prefer not to answer
43. If this family member is covered 44. Medicare Beneficiary Identifier
by Medicare, check all that apply.

45. Is this family member covered by insurance other than Medicare?

Yes, indicate in item 22 below.

46. Indicate the type(s) of other insurance

TRICARE
FEHB/
PSHB

Other

Name of other insurance: ______________________________________________

Policy Number: ____________________________

Enrolled in VA healthcare benefits
Eligible for health services from IHS

Resides abroad
Enrollee not required to enroll
Medicare A - Section 1818/1818A (uncommon)

47. Email address

48. Preferred telephone number

Part C - FEHB/PSHB Plan You Are Currently Enrolled In
(if applicable)

Part D - FEHB/PSHB Plan You Are Enrolling In or Changing To
(if applicable)

Enrollment code

Part E - Event That Permits You to Enroll, Change, or Cancel
(see pages 3-4)
1. Event code

2. Date of event (mm/dd/yyyy)

Copy 1 - Enrollee

(Page 2 of 3) OPM Form 2809
Revised November 2024

Part F - Election to Suspend/Cancel
(Fill in this part if you wish to suspend/cancel your enrollment in the FEHB Program. See pages 3-4 of the instructions.)
I elect to suspend or cancel my enrollment and have initialed the appropriate box below.

I am cancelling my FEHB Program enrollment to
be covered under the FEHB Program enrollment of:

Name

Social Security Number

I am suspending my FEHB Program enrollment because I am covered by Medicare Advantage plan, Medicaid or a similar state-sponsored program of
medical assistance for individuals with limited income and resources. I am enclosing evidence of my coverage.
I am suspending my FEHB Program enrollment because I am covered under 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 suspending my FEHB Program enrollment because I am covered by Peace Corps volunteer health benefits. I am enclosing evidence of my coverage.
I am cancelling my enrollment for reasons other than the situations listed above. I understand I can never reenroll in the FEHB Program.
Part G - Signature (you 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 of birth (mm/dd/yyyy)

4. Email Address

3. Retirement Claim Number

5. Preferred telephone number

Part H - 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

4. Payroll office number

24 90 0002
5. Signature of authorized agency official

6. Date (mm/dd/yyyy)

Remarks (For use by OPM only.)

Copy 1 - Enrollee

(Page 3 of 3) OPM Form 2809
Revised November 2024

File Type	application/pdf
File Title	OPM2809_2024_11
Author	CSBENSON
File Modified	2024-10-09
File Created	2024-05-06