Federal Employees Health Benefits Program
Employee Health Benefits Election Form Instructions Standard Form 2809 Revised July 1999
Contents
Use this form to: Enroll in the FEHB Program; or Elect not to enroll in the FEHB Program (employees only); or Change your FEHB enrollment from Self Only to Self and Family and/or from your present plan or option to another plan or option because of an event described in the table beginning on page 6; or Change your FEHB enrollment from Self and Family to Self Only; or Cancel your FEHB enrollment.
Who May Use SF 2809
Note: Civil Service Retirement System (CSRS) and Federal Employees Retirement System (FERS) annuitants and former spouses and children of CSRS/FERS annuitants -- Do not use this form. Instead, call the Retirement Information Office tollfree at 1-888-767-6738. Customers within the local calling distance to Washington, DC, should call 202-606-0500.
Type or Print Firmly Part A. You must complete this part.
Complete these items only if your enrollment is for Self and Family. (If you need extra space for additional family members, list them on a separate sheet and attach.)
Unless you are a former spouse or survivor annuitant, family members eligible for coverage under your Self and Family enrollment include your spouse and your unmarried dependent children under age 22. Eligible children include your legitimate or adopted children; and recognized children born out of wedlock, stepchildren or foster children, if they live with you in a regular parentchild relationship. A recognized child born out of wedlock also may be included if a judicial determination of support has been obtained or you show that you provide regular and substantial support for the child. 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 and Family enrollment are the unmarried dependent natural or adopted children under age 22 of both you and your former or deceased spouse. Children whose marriage ends before they reach age 22 become eligible for coverage under your Self and Family enrollment from the date the marriage ends until they reach age 22. In some cases, an unmarried, disabled child who is 22 years old or older is eligible for coverage under your Self and Family enrollment if you provide adequate medical certification of a mental or physical handicap that existed before his or her 22nd birthday and renders the child incapable of self-support. Note: Your employing office (see definition under Where to Obtain FEHB Guides and Brochures on page 3) can give you additional details about family member eligibility including the documentation required for coverage of a disabled child age 22 or older.
Part C. You must complete this part if you are changing your enrollment.
Part D. You must complete this part if you are newly enrolling or changing based on an event listed in the Table of Permissible Changes in Enrollment beginning on page 6. Do not complete this part if you are cancelling or changing from Self and Family to Self Only.
Part E. Place an X in the box provided only if you are an employee and you do not wish to enroll in the FEHB Program. (Be sure to read the information about electing not to enroll on page 4.) Part F. Place an X in the box provided only if you wish to cancel your FEHB enrollment. Also enter your present enrollment code in the space provided. (Be sure to read the information about cancelling your enrollment on page 4.) Part G. You must complete this part.
Leave Part H and Remarks section blank. They are for agency use only. If You Are Registering for Someone Else If you are registering for someone else under a written authorization from him or her to do so, sign your name in Part G and attach the written authorization. If you are registering for a former spouse eligible for coverage under the Spouse Equity provisions or for an individual eligible for temporary continuation of coverage as his or her courtappointed guardian, sign your name in Part G and attach evidence of your court-appointed guardianship. Guides to Federal Employees Health Benefits Plans (FEHB Guides) and Plan Brochures FEHB Guides contain enrollment, plan, and rate information. Be sure you have the correct guide for your enrollment category since more than one guide is issued. The different categories are:
Employees, non-Postal or Postal FEHB Plan brochures contain detailed information about plan benefits and the contractual description of coverage. Where to Obtain FEHB Guides and Brochures Your plan will send you its brochure before the beginning of each contract year. FEHB Guides and plan brochures are available from your employing office. Employing office means the office of an agency or retirement system that is responsible for health benefits actions for an employee, annuitant, former spouse eligible for coverage under the Spouse Equity provisions, or individual eligible for temporary continuation of coverage (TCC). You can also get copies of plan brochures by contacting the plans directly at the telephone numbers shown in the FEHB Guide. The FEHB Guide also shows which plans have their own website. The FEHB Guide, plan brochures, and other information, including links to plan websites, are available on the World Wide Web. Visit our website at http://www.opm.gov/insure. Employee Express is an automated system that allows some Federal employees to make changes using a touch-tone telephone, a personal computer or computer kiosk instead of a form. If you are not sure whether you can use Employee Express, call your employing office. Normally, you are not eligible to enroll if you are covered as a family member under someone elses enrollment in the FEHB Program. However, such dual enrollments may be permitted under certain circumstances in order to:
Protect the interests of children who otherwise would lose coverage as family members, orNo person (enrollee or family member) is entitled to receive benefits under more than one enrollment in the Program. (Each enrollee must notify his or her plan of the names of the persons to be covered under his or her enrollment who are not covered under the other enrollment.) Temporary Continuation of Coverage (TCC) While the employing office notifies a former employee of his or her eligibility for temporary continuation of coverage, the employing office must be notified when a child or former spouse becomes eligible.
For the eligible child of an enrollee, the enrollee must notify the employing office within 60 days after the qualifying event occurs; e.g., child reaches age 22.An individual eligible for temporary continuation of coverage who wants to continue FEHB coverage may choose any plan (for which he or she is eligible), option, and type of enrollment. The time limits for a former employee, child, or former spouse to file the SF 2809 with the employing office appear in event number 4A in the table on page 8. Note: If someone other than the enrollee notifies the employing office of the childís eligibility for temporary continuation of coverage within the specified time period, the childís opportunity to file the SF 2809 ends 60 days after the qualifying event. If someone other than the enrollee or the former spouse notifies the employing office of the former spouseís eligibility for continued coverage within the specified time period, the former spouseís opportunity to file the SF 2809 ends 60 days after the change in status. Except for open season, most enrollments and changes of enrollments are effective on the first day of the pay period after the employing office receives the SF 2809 or other appropriate request. Your employing office can give you the specific date on which your enrollment or enrollment change will take effect. Note 1: If you are changing your enrollment from Self and Family to Self Only so that your spouse can enroll for Self Only, you should coordinate the effective date of your spouseís enrollment with the effective date of your enrollment change to avoid a gap in your spouseís coverage. Note 2: If you are cancelling your enrollment and intend to be covered under someone elseís enrollment at the time you cancel, you should coordinate the effective date of your cancellation with the effective date of your new coverage to avoid a gap in your coverage. You may cancel your enrollment at any time. (If you are a United States Postal Service employee, consult your employing office or information provided by your agency.) However, if you cancel, neither you nor any family member covered by your enrollment are entitled to a 31-day temporary extension of coverage, or to convert to an individual, nongroup policy. Moreover, family members who lose coverage because of your cancellation are not eligible for temporary continuation of coverage. (Be sure to read the additional information below about cancelling your enrollment.) Employees Who Elect Not to Enroll or Who Cancel Their Enrollment To be eligible for an FEHB enrollment after you retire, you must retire:
Under a retirement system for Federal civilian employees, andIn addition, you must be currently enrolled in a plan under the FEHB Program and must have been enrolled (or covered as a family member) in a plan under the Program for:
The 5 years of service immediately before retirement (i.e., commencing date of annuity entitlement), orIf you do not enroll at your first opportunity or if you cancel your enrollment, you may later enroll or reenroll only under the circumstances explained in the table beginning on page 6. Some employees delay their enrollment or reenrollment until they are nearing 5 years before retirement in order to qualify for FEHB coverage as a retiree; however, there is always the risk that they will retire earlier than expected and not be able to meet the 5-year requirement for continuing FEHB coverage into retirement. Please understand that when you elect not to enroll or cancel your enrollment you are voluntarily accepting this risk. An alternative would be to enroll in or change to a lower cost plan so that you meet the requirements for continuation of your FEHB enrollment after retirement. Note for temporary employees eligible for FEHB under 5 U.S.C. 8906a: Your decision not to enroll or to cancel your enrollment will not affect your future eligibility to continue FEHB enrollment after retirement. Annuitants Who Cancel Their Enrollment Generally, you cannot reenroll as an annuitant unless you are continuously covered as a family member under another persons enrollment in the FEHB Program during the period between your cancellation and reenrollment. Your employing office 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. If you cancel your FEHB enrollment because you are enrolling in a Medicare HMO, or Medicaid or similar State-sponsored program, you can reenroll in the FEHB Program if your coverage ends. If your coverage ends involuntarily, you can reenroll 31 days before through 60 days after loss of coverage. If your coverage ends voluntarily because you disenroll, you can reenroll during the next open season. If you cancel your enrollment for any other reason, you cannot later reenroll, and you and any family members covered by your enrollment are not entitled to a 31-day temporary extension of coverage or to convert to an individual policy. Former Spouses (Spouse Equity) Who Cancel Their Enrollment Generally, if you cancel your enrollment in the FEHB Program, you cannot reenroll as a former spouse. However, if you stop the enrollment because you acquire other FEHB coverage, your right to FEHB coverage under the spouse equity provisions continues. You may reenroll as a former spouse when the other FEHB coverage ends. 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. If you cancel your FEHB enrollment because you are enrolling in a Medicare HMO, or Medicaid or similar State-sponsored program, you can reenroll in the FEHB Program if your coverage ends. If your coverage ends involuntarily, you can reenroll 31 days before through 60 days after loss of coverage. If your coverage ends voluntarily because you disenroll, you can reenroll during the next open season. If you cancel your enrollment for any other reason, you cannot later reenroll, and you and any family members covered by your enrollment are not entitled to a 31-day temporary extension of coverage or to convert to an individual policy. Temporary Continuation of Coverage Enrollees Who Cancel Their Enrollment If you cancel your TCC enrollment, you cannot reenroll. Your family members who lose coverage because of your cancellation cannot enroll for TCC in their own right nor can they convert to a nongroup policy. However, family members who are Federal employees or annuitants may enroll in the FEHB Program when you cancel your coverage if they are eligible for FEHB coverage in their own right. Note 1: If you become covered by a regular enrollment in the FEHB Program, either in your own right or under the enrollment of someone else, your TCC enrollment is suspended. You will need to send documentation of the new enrollment to the employing office maintaining your TCC enrollment so that they can stop the TCC enrollment. If your new FEHB coverage stops before the TCC enrollment would have expired, the TCC enrollment can be reinstated for the remainder of the original eligibility period (18 months for separated employees). Note 2: Former spouses (spouse equity) and temporary continuation of coverage enrollees who fail to pay their premiums within specified time frames are considered to have voluntarily cancelled their enrollment. Explanation of Table of Permissible Changes in Enrollment The table on pages 6 through 9 illustrates when an employee, former spouse, or person eligible for TCC may enroll or change enrollment. The table shows those permissible events that are found in the regulations at 5 CFR Part 890. The table has been organized by enrollee category. Each category is designated by a number, which identifies the enrollee group, as follows:
1 EmployeesNote: Category 2 has been reserved for annuitants (other than CSRS/FERS annuitants), including individuals receiving monthly compensation from the Office of Workersí Compensation Programs, who will be using another edition of this form, SF 2809-1. Following each number is a letter, which identifies a specific permissible event; for example, the event code 1A refers to an employees initial opportunity to enroll. At Part D of the SF 2809, Health Benefits Election Form, you must designate your two-character event code (for example, 1A) and the date of the event using numbers to show month, day, and complete year; e.g., 06/30/1998. The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits Program under Chapter 89, title 5, U.S. Code. This information will be shared with the health insurance carrier you select so that it may (1) identify your enrollment in the plan, (2) verify your and/or your familys eligibility for payment of a claim for health benefits services or supplies, and (3) coordinate payment of claims with other carriers with whom you might also make a claim for payment of benefits. This information may be disclosed to other Federal agencies or Congressional offices which may have a need to know it in connection with your application for a job, license, grant, or other benefit. It may also be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or social security administrative agencies to determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition, to the extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local law enforcement agency. While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your enrollment. We request that you provide your Social Security Number so that it may be used as your individual identifier in the Federal Employees Health Benefits Program. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a Social Security Number or tax identification number. This is an amendment to title 31, Section 7701. Failure to furnish the requested information may result in OPMs inability to ensure the prompt payment of your and/or your familys claims for health benefits services or supplies. Agencies other than the Office of Personnel Management may have further routine uses for disclosure of information from the records system in which they file copies of this form. If this is the case, they should provide you with any such uses which are applicable at the time they ask you to complete this form. We think 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, Reports and Forms Manager, (3206-0160), Washington, D.C. 20415-7900. The OMB number, 3206-0160 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Table of Permissible Changes in Enrollment for SF 2809Enrollment May Be Cancelled or Changed From Family to Self Only at Any Time*
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