Form Ri 79 9 – Fill Out and Use This PDF

Spouse's name (Last, first, middle)

Spouse's claim number

B.

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

Reenrollment 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.

We will cancel your enrollment effective the end of the month in which we receive 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.

Reenrollment 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.

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SUSPENSION INFORMATION IS SHOWN ON THE REVERSE

Previous editions are not usable.

RI 79-9 Revised August 2014

C.

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 B are 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 B only. Any

Questions: Call Medicare at 1-800-633-4227.

D.

E.

These Medicare Advantage health plans are Health Maintenance Organizations or Fee-For-Service plans approved by the Centers for Medicare and Medicaid Services (CMS). If you are enrolled in a Medicare supplemental plan and are not sure if it qualifies as a Medicare Advantage health plan, call Medicare at the number shown above. To suspend your FEHBP coverage for this reason, you must give us documentation that shows the effective date of your Medicare Advantage health plan coverage. If we receive this form within 31 days before to 31 days after the effective date of your Medicare Advantage health plan enrollment, we will suspend your FEHBP coverage at the close of business the day before your Medicare Advantage health plan enrollment begins. Otherwise, we will suspend your FEHBP coverage at the end of the month in which we receive 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 suspend my FEHBP enrollment effective

_______________________________. (Carefully consider the effective date of your suspension. Once we

process your request, we are not able to change the effective date.)

To suspend your FEHBP coverage for this reason, you must give us evidence of your eligibility for TRICARE, TRICARE for Life, Peace Corps, or CHAMPVA. Please send us a copy of your Uniformed Services Identification (I.D.) card and if over age 65, you must also send us 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 us a copy of your CHAMPVA Authorization Card (A-card). Please tell us the date you want to suspend your FEHBP to use TRICARE, TRICARE for Life, Peace Corps, or CHAMPVA. Special note: If we receive this signed form and the eligibility documentation within 31 days before to 31 days after the date you designate above, we will suspend your FEHBP coverage on that date. Otherwise, we will suspend your FEHBP coverage at the end of the month in which we receive your documentation.

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 us evidence of your eligibility for Medicaid or a similar state-sponsored program of medical assistance for the needy. You may send us 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 we receive this signed form and documentation within 31 days before to 31 days after the effective date of your Medicaid or similar state-sponsored enrollment, we will suspend your FEHBP coverage at the close of business the day before your Medicaid or state-sponsored program coverage begins. Otherwise, we will suspend your FEHBP coverage at the end of the month in which we receive your documentation.

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