Form RI 79-9 – Fill Out and Use This PDF

I am cancelling my FEHBP enrollment to be covered under a family member's FEHBP enrollment. If you are cancelling your FEHBP enrollment because you will be covered under your spouse's FEHBP enrollment and your spouse is a Federal employee, please include with this form a copy of your spouse's SF 2809, Health Benefits Registration Form, showing the change to a family enrollment. If your spouse is an annuitant, please give OPM your spouse's name and annuity claim number.

If you cancel FEHBP coverage for this reason, OPM will coordinate the effective date with the effective date of your new coverage under your spouse's enrollment.

Re-enrollment eligibility: As long as you are continuously covered as a family member on your spouse's FEHBP enrollment, you will be eligible to resume your own enrollment if your coverage under your spouse's enrollment ends for any reason.

I am cancelling my FEHBP coverage for reasons other than the situation described in Part A. OPM will cancel your enrollment effective the end of the month in which OPM receives this signed and dated form. Any health benefits premiums you pay for a period after the cancellation effective date will be refunded in one of your future monthly annuity payments.

Re-enrollment eligibility: If you check this block to cancel your FEHB enrollment, you will not be eligible to reenroll in the FEHBP. Additionally, if you cancel your FEHBP enrollment, you and any family members covered by your enrollment will not be entitled to the free 31-day extension of coverage to convert to an individual health benefits contract or to enroll for Temporary Continuation of Coverage.

By signing, you certify that you have read and understand the information on cancelling FEHBP coverage. You understand that if you checked block B, you will never again be eligible to enroll in the Federal Employees Health Benefits Program. Signature, Daytime telephone no. (including area code) and Date.

I am suspending my Federal Employees Health Benefits Program (FEHBP) enrollment because I am enrolled in a Medicare Advantage health plan. Please note: Medicare Parts A and Bare not the same as a Medicare Advantage health plan.

You cannot suspend your FEHBP enrollment if you are covered by Medicare Parts A and/or Bonly.

To suspend your FEHBP coverage for this reason, you must give OPM documentation that shows the effective date of your Medicare Advantage health plan coverage.

If OPM receives this form within 31 days before to 31 days after the effective date of your Medicare Advantage health plan enrollment, OPM will suspend your FEHBP coverage at the close of business the day before your Medicare Advantage health plan enrollment begins. Otherwise, OPM will suspend your FEHBP coverage at the end of the month in which OPM receives your documentation.

I am suspending my FEHBP enrollment to use TRICARE, TRICARE for Life (enrollees over age 65 with Medicare Parts A and B), Peace Corps, or CHAMPVA.

Please tell OPM the date you want to suspend your FEHBP to use TRICARE, TRICARE for Life, Peace Corps, or CHAMPVA.

Carefully consider the effective date of your suspension. Once OPM processes your request, OPM is not able to change the effective date.

To suspend your FEHBP coverage for this reason, you must give OPM evidence of your eligibility for TRICARE, TRICARE for Life, Peace Corps, or CHAMPVA.

Please send OPM a copy of your Uniformed Services Identification (I.D.) card and if over age 65, you must also send OPM a copy of your Medicare card showing enrollment in both Medicare Parts A and B (required for TRICARE for Life).

To document your eligibility for CHAMPVA, please send OPM a copy of your CHAMPVA Authorization Card (A-card).

I am suspending my FEHBP enrollment because I am eligible for coverage under Medicaid or a similar state-sponsored program of medical assistance for the needy.

To suspend your FEHBP coverage for this reason, you must give OPM evidence of your eligibility for Medicaid or a similar state-sponsored program of medical assistance for the needy. You may send OPM a copy of an enrollment card or a letter of eligibility which shows the effective date of your Medicaid or similar state-sponsored program coverage.

If OPM receives this signed form and documentation within 31 days before to 31 days after the effective date of your Medicaid or similar state-sponsored enrollment, OPM will suspend your FEHBP coverage at the close of business the day before your Medicaid or similar state-sponsored program coverage begins.

The following information applies to blocks C, D and E. Re-enrollment: You may voluntarily re-enroll in the FEHBP during an annual open season.

If you involuntarily lose your coverage under one of the programs mentioned in blocks C, D and E, you can re-enroll in the FEHBP effective the day after your coverage ends. You must provide evidence of your involuntary loss of coverage.

Your request to re-enroll must be received at the Office of Personnel Management (OPM) within the period beginning 31 days before and ending 60 days after your coverage ends. Otherwise, you must wait until open season to re-enroll.

By signing, you certify that you have read and understand the information on suspending FEHBP coverage. You have checked the block relating to your suspension, and you have enclosed the appropriate documentation.