Standard Form 2809 PDF Details

Standard Form 2809 is a legal form used to make declaratory judgments. The form can be used by individuals, businesses, or other entities to seek a court's binding declaration of the rights, status, or other legal relations of the parties involved in the case. Standard Form 2809 is also known as a "Declaratory Judgment Action." By using this form, you may be able to avoid costly and time-consuming litigation in the future. If you are considering filing a Standard Form 2809, it is important to understand the specific requirements and procedures involved. Speak with an experienced attorney who can help you file your claim successfully.

This article holds specifics of standard form 2809. It's advised that you look at this info before you begin fiddling with the PDF.

QuestionAnswer
Form NameStandard Form 2809
Form Length18 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 30 sec
Other namesgovform 2809, benefits form, what is form 2809, form 2809 printable

Form Preview Example

If you are separated but not divorced, you are still married.
If you have Medicare, check which Parts you have, including prescription drug coverage under Medicare Part D.
If you have Medicare, enter your Medicare Beneficiary Identifier (MBI). This number is on your Medicare Card.
See the Privacy Act and Public Burden Statements on page 5.

Health Benefits Election Form

Form Approved: OMB No. 3206-0160

Uses for Standard Form (SF) 2809

Use this form to:

Switch designated eligible family member; or

Enroll or reenroll in the FEHB Program; or

Elect not to enroll in the FEHB Program (employees only); or

Change your FEHB enrollment; or

Cancel your FEHB enrollment; or

Suspend your FEHB enrollment (annuitants or former spouses only).

Who May Use SF 2809

1.Employees eligible to enroll in or currently enrolled in the FEHB Program. Employees automatically participate in premium conversion unless they waive it, see page 6.

2.Annuitants in retirement systems other than the Civil Service Retirement System (CSRS) or Federal Employees Retirement System (FERS), including individuals receiving monthly compensation from the Office of Workers’ Compensation Programs (OWCP).

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, use form OPM 2809, which is available at www.opm.gov/forms/OPM-forms, or call the Retirement Information Office toll-free at 1-888-767-6738.

3.Former spouses eligible to enroll in or currently enrolled in the FEHB Program under the Spouse Equity law or similar statutes.

4.Individuals eligible for Temporary Continuation of Coverage (TCC) under the FEHB Program, including:

Former employees (who separated from service);

Children who lose FEHB coverage; and

Former spouses who are not eligible for FEHB under item 3 above.

Instructions for Completing SF 2809

Type or Print. We have not provided instructions for those items that have an explanation on the form.

Part A — Enrollee and Family Member Information

You must complete this part.

Item 2.

Item 5.

Item 7.

Item 8.

Item 9. If you are covered by other health insurance, either in your name or under a family member’s policy, check yes and complete item 10.

Item 10. Provide the information requested on any other health 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

stop. Contact your Human Resources office or retirement system 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 a FEHB Self Only plan, an FEHB Self Plus One plan that covers you, or an FEHB Self and Family plan that covers you.

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.

No person may be covered under more than one FEHB enrollment. However, in certain unusual circumstances, your agency may allow you to enroll 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;

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. See Dual Enrollment information on page 5.

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Standard Form 2809

Previous edition is not usable

Revised November 2019

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

Important: In order for your Self Plus One FEHB enrollment election to be processed, you must complete the family member information for your designated family member.

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

Item 14. Provide the Social Security Number for this family member if he/she has one. If your family member does not have a Social Security Number, leave blank; benefits will not be withheld.

(See Privacy Act Statement on page 5.)

Item 17. Provide the code which indicates the relationship of each eligible family member to you.

Code

Family Relationship

 

 

01

Spouse

19

Child under age 26

09

Adopted Child under age 26

17

Stepchild under age 26

10

Foster Child under age 26

99Disabled 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.

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.

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.

Note: Your employing office can give you additional details about family member eligibility including any certification or documentation that may be required for coverage. Contact your employing office for more information about covering foster child(ren),“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 TCC.

Survivor Benefits

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

Item 18. If your family member does not live with you, enter his/her home address.

Item 19. If your family member has Medicare, check which Parts

(Part A [Hospital Insurance] and/or Part B [Medical Insurance]) he/she has, including prescription drug coverage under Medicare Part D.

Item 20. If your family member has Medicare, enter his/her Medicare Beneficiary Identifier (MBI). This number is on his/her Medicare Card.

Item 21. If your family member is covered by other group insurance, such as private, state, or Medicaid, check the box and complete item 22.

Item 22. Provide the information requested on any other health insurance that covers this family member. If your family

member is covered under another FEHB plan, see instructions for item 10.

Item 23. Enter email address, if applicable, for this family member.

Item 24. Enter preferred telephone number, if applicable, for this family member.

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.

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 enroll- ment 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.

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.

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.

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Standard Form 2809

 

Revised November 2019

Part B — FEHB Plan You Are Currently Enrolled In

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

Item 1. Enter the name of the plan you are enrolled in from the front cover of the plan brochure.

Item 2. Enter your 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.

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 a 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.

Your signature in Part H authorizes deductions from your salary, annuity, or compensation to cover your cost of the enrollment you elect in this item, unless you are required to make direct payments to the employing office.

Part D — Event That Permits You To Enroll, Change, Or Cancel

Item 1. 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 that applies to you.

Following each number is a letter, which identifies a specific Qualifying Life Event (QLE); for example, the event code “1A” refers to the initial opportunity to enroll for an employee who elected to participate in premium conversion.

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 appointment began). If you are making an open season enrollment or change, enter the date on which the open season begins.

Part E — Election NOT to Enroll

Place an “X” in the box only if you are an employee and you do NOT wish to enroll in the FEHB Program. Be sure to read the information

titled Employees Who Elect Not to Enroll or Who Cancel Their Enrollment.

Part F — Cancellation of FEHB

Place an “X” in the box only if you wish to cancel your FEHB enrollment. Also enter your current plan name and enrollment code in

Part B. Be sure to read the information titled Employees Who Elect Not to Enroll or Who Cancel Their Enrollment.

Note For Parts E and F. If you are Electing Not to Enroll or Cancelling your enrollment because you are covered as a spouse or child under another FEHB enrollment, your agency must enter the enrollee’s name, Social Security number, and FEHB enrollment code in REMARKS.

Cancellation of Enrollment

Employees participating in premium conversion may cancel their FEHB enrollment only during the open season or when they experience a Qualifying Life Event. Employees who waived participation in premium conversion, annuitants, former spouses, and individuals enrolled under TCC may cancel their enrollment at any time. 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 TCC. Be sure to read the additional information below about cancelling your FEHB enrollment.

Explanation of Table of Permissible Changes in Enrollment

The tables on pages 6 through 16 illustrate when: an employee who participates in premium conversion; annuitant; former spouse; person eligible for TCC; or employee who waived participation in premium conversion may enroll or change enrollment. The tables show those permissible events that are found in the regulations at 5 CFR Parts 890 and 892.

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

1.Employees who participate in premium conversion

2.Annuitants (other than CSRS/FERS annuitants), including individuals receiving monthly compensation from the Office of Workers’ Compensation Programs

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

4.TCC enrollees

5.Employees who waived participation in premium conversion

Employees Who Elect Not to Enroll (Part E) or Who Cancel Their Enrollment (Part F)

To be eligible for an FEHB enrollment after you retire, you must retire:

Under a retirement system for Federal civilian employees, and

On an immediate annuity.

In 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), or

If fewer than 5 years, all service since your first opportunity to enroll. (Generally, your first opportunity to enroll is within 60 days after your first appointment [in your Federal career] to a position under which you are eligible to enroll under conditions that permit a Government contribution toward the enrollment.)

If you do not enroll at your first opportunity or if you cancel your enrollment, you may later enroll or reenroll only under the circumstances

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Standard Form 2809 Revised November 2019

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. 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 [under 5 U.S.C. 8906a] employees eligible for

FEHB without a Government contribution: Your decision not to enroll or to cancel your enrollment will not affect your future eligibility to continue FEHB enrollment after retirement.

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 or 36 months for eligible family members who lose coverage).

Note 2: Former spouses (Spouse Equity) and TCC enrollees who fail to pay their premiums within specified timeframes are considered to have voluntarily cancelled their enrollment.

Annuitants Who Cancel Their Enrollment

CSRS and FERS annuitants and their eligible family members should not use this form but use form RI 79-9, Health Benefits

Cancellation/Suspension Confirmation, which is available at www.opm.gov/forms/Retirement-and-Insurance-Forms, or call 1-888-767-6738.

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. Your employing office or retirement system 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 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 cancel the enrollment because you become covered under FEHB as a new spouse or employee, 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.

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 (TCC) 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.

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.

Part G — Suspension of FEHB

CSRS and FERS annuitants and their eligible family members should not use this form but use form RI 79-9, Health Benefits

Cancellation/Suspension Confirmation, which is available at www.opm.gov/forms/Retirement-and-Insurance-Forms, or call 1-888-767-6738.

Place an “X” in the box only if you are an annuitant or former spouse and wish to suspend your FEHB enrollment. Also enter your current plan name and enrollment code in Part B.

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

A Medicare Advantage plan or Medicare HMO,

Medicaid or similar State-sponsored program of medical assistance for the needy,

TRICARE (including Uniformed Services Family Health Plan or TRICARE for Life),

CHAMPVA, or

Peace Corps.

You can reenroll in the FEHB Program if your other coverage ends. If your coverage ends involuntarily, you can reenroll from 31 days before your other coverage ends through 60 days after your other coverage ends. If your coverage ends voluntarily because you disenroll, you can reenroll during the next open season.

You must submit documentation of eligibility for coverage under the non-FEHB Program to the office that maintains your enrollment. That office must enter in REMARKS the reason for your suspension.

Part H — Signature

Your agency, retirement system, or office maintaining your enrollment cannot process your request unless you complete this part.

If you are registering for someone else under a written authorization from him or her to do so, sign your name in Part H 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 TCC as his or her court-appointed guardian, sign your name in Part H and attach evidence of your court-appointed guardianship.

4

Standard Form 2809

 

Revised November 2019

Part I - Agency or Retirement System Information and Remarks

Leave this section blank as it is for agency or retirement system use only.

Electronic Enrollments

Many agencies use automated systems that allow their employees to make changes using a touch-tone telephone, or a computer instead of a form. This may be Employee Express or another automated system.

If you are not sure whether the electronic enrollment option is available to you, contact your employing office.

Dual Enrollment

No person (enrollee or family member) is entitled to receive benefits under more than one enrollment in the FEHB Program. Normally, you are not eligible to enroll if you are covered as a family member under someone else’s enrollment in the 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, or

Enable an employee who is under age 26 and covered under a parent’s enrollment and marries or becomes the parent of a child to enroll for Self Plus One or Self and Family coverage.

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. See instructions for item 10 for more information.

For the eligible former spouse of an enrollee, the enrollee or the former spouse must notify the employing office within 60 days after the former spouse’s change in status; e.g., the date of the divorce.

An individual eligible for TCC who wants to continue FEHB coverage may choose any plan, option, and type of enrollment for which he or she is eligible. The time limit for a former employee, child, or former spouse to enroll with the employing office is within 60 days after the Qualifying Life Event, or receiving notice of eligibility, whichever is later.

Effective Dates

Except for open season, most enrollments and changes of enrollment are effective on the first day of the pay period after the employing office receives this form and that follows a pay period during any part of which the employee is in pay status. 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 FEHB enrollment from Self Plus One or Self and Family to Self Only so that your spouse can enroll for Self Only, you should coordinate the effective date of your spouse’s enrollment with the effective date of your enrollment change to avoid a gap in your spouse’s coverage.

Note 2: If you are cancelling your FEHB enrollment and intend to be covered under someone else’s 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.

Temporary Continuation of Coverage (TCC)

The employing office must notify a former employee of his or her eligibility for TCC. The enrollee, child, former spouse, or their representative must notify the employing office 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 26.

Agency Distribution of SF 2809

Agencies must distribute one copy of the completed SF 2809 to each of the following, as appropriate:

Official Personnel Folder

New Carrier

Old Carrier

Payroll Office

Enrollee

Privacy Act Statement

Pursuant to 5 U.S.C. § 552a (e)(3), this Privacy Act Statement explains why OPM is requesting the information on this form. Authority: OPM is authorized to collect the information requested on this form pursuant to Title 5, U.S.C. Chapter 89 and Title 5 of the Code of Federal Regulations, Part 890 pertaining to enrollment in the Federal Employees Health Benefits (FEHB) Program. OPM is authorized to collect your Social Security Number (SSN) by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008). Purpose: The principal use of this information will be to share it 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 insurance carriers with whom you might also make a claim for payment of benefits. Your SSN and the SSNs of your covered family members may be used as individual identifiers in the FEHB Program. Routine Uses: The information you provide on this form may also be disclosed externally 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 the FEHB program. In addition, to the extent this information indicates a possible violation of civil or criminal law, it may be shared and verified with an appropriate Federal, state, or local law enforcement agency. A list of routine uses associated with this form can be found in the Privacy Act System of Records Notice (SORN), OPM/CENTRAL 1 Civil Service Retirement and Insurance, 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. In addition, failure to furnish your SSN and/or Medicare Beneficiary Identifier may result in the OPM’s inability to ensure the prompt payment of your and/or your family members’ claims for health benefits services or supplies, proper coordination with Medicare, or proper health insurance status reporting to the IRS.

Public Burden Statement

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, (3206-0160), Washington, D.C. 20415-0001. 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.

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Standard Form 2809

Revised November 2019

Federal Employees Receiving Premium Conversion Tax Benefits

Table of Permissible Changes in FEHB Enrollment and Premium Conversion Election

Premium Conversion allows employees who are eligible for FEHB the opportunity to pay for their share of FEHB premiums with pre-tax dollars. Premium conversion plans are governed by Section 125 of the Internal Revenue Code, and IRS rules govern when a participant may change his or her election outside of the annual open season. All employees who enroll in the FEHB Program automatically receive premium conversion tax benefits, unless they waive participation. When an employee experiences a Qualifying Life Event (QLE) as described below, certain changes to the employee’s FEHB coverage (including change to Self Only and cancellation) and premium conversion election may be permitted, so long as they are because of and consistent with the QLE’s. For more information about premium conversion, please visit www.opm.gov/healthcare-insurance/healthcare.

 

 

Qualifying Life Events (QLE’s) that

 

 

 

 

 

 

Change that May Be Permitted

 

 

 

 

Premium

 

 

Time Limits in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

May Permit Change in FEHB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Conversion Change

 

 

which Change

 

 

 

Enrollment, Designated Family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

that May Be

 

 

May Be

 

 

 

Member or Premium Conversion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permitted

 

 

Permitted

 

 

 

 

 

 

Election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Event

 

 

Event

 

 

From Not

 

From Self

 

From One

 

Cancel or

 

Switch

 

Participate

 

Waive

 

When You Must

 

 

Code

 

 

 

 

 

 

Enrolled To

 

Only to Self

 

Plan or

 

Change to

 

Designated

 

 

 

 

 

 

 

File Health Benefits

 

 

 

 

 

 

 

 

 

Enrolled

 

Plus One or

 

Option to

 

Self Plus

 

Family

 

 

 

 

 

 

 

Election Form With

 

 

 

 

 

 

 

 

 

 

 

 

Self and

 

Another

 

One or Self

 

Member

 

 

 

 

 

 

 

Your Employing

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

Only

 

 

 

 

 

 

 

 

 

 

Office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

Employee electing to receive or receiving premium conversion tax benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1A

 

Initial opportunity to enroll, for

 

 

Yes

 

N/A

 

N/A

 

N/A

 

N/A

 

AUTOMATIC

 

Yes

 

Within 60 days

 

 

 

 

example:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNLESS

 

 

 

 

after becoming

 

 

 

 

New employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAIVED

 

 

 

 

eligible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Change from excluded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

position

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Temporary employee who

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

completes 1 year of service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and is eligible to enroll under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5 USC 8906a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1B

 

Open Season

 

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

As announced by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1C

 

Change in family status that

 

 

Yes

 

Yes

 

Yes

 

Yes1

 

Yes

 

Yes

 

Yes

Within 60 days after

 

 

 

 

results in increase or decrease in

 

 

Employees

 

Employees

 

Employees

 

 

 

 

 

 

 

 

 

 

 

 

change in family

 

 

 

 

number of eligible family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

status

 

 

 

 

 

 

may enroll

 

may enroll

 

may enroll

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

members, for example:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or change

 

or change

 

or change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marriage, divorce, annulment

 

 

beginning

 

beginning

 

beginning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth, adoption, acquiring

 

 

31 days

 

31 days

 

31 days

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

foster child or stepchild,

 

 

before the

 

before the

 

before the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

issuance of court order

 

 

event.

 

event.

 

event.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

requiring employee to provide

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

coverage for child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last child loses coverage, for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

example, child reaches age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26, disabled child becomes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

capable of self-support, child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

acquires other coverage by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

court order

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Death of spouse or eligible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

family member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1D

 

Any change in employee’s

 

 

 

Yes

 

 

N/A

 

 

N/A

 

 

N/A

 

 

No

 

 

AUTOMATIC

 

 

Yes

 

 

Within 60 days

 

 

 

 

 

employment status that could

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNLESS

 

 

 

 

 

after employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

result in entitlement to coverage,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAIVED

 

 

 

 

 

status change

 

 

 

 

 

for example:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reemployment after a break in service of more than 3 days

Return to pay status from nonpay status, or return to receiving pay sufficient to cover premium withholdings, if coverage terminated (If coverage did not terminate, see 1G.)

6

 

Qualifying Life Events (QLE’s) that

 

 

 

 

 

Change that May Be Permitted

 

 

 

 

Premium

 

 

Time Limits in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

May Permit Change in FEHB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Conversion Change

 

 

which Change

 

 

Enrollment, Designated Family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

that May Be

 

 

May Be

 

 

Member or Premium Conversion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permitted

 

 

Permitted

 

 

 

 

 

Election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Event

 

 

 

Event

 

From Not

 

From Self

 

From One

 

Cancel or

 

Switch

 

Participate

 

Waive

 

When You Must

 

Code

 

 

 

 

 

 

Enrolled To

 

Only to Self

 

Plan or

 

Change to

 

Designated

 

 

 

 

 

 

 

File Health Benefits

 

 

 

 

 

 

 

 

Enrolled

 

Plus One or

 

Option to

 

Self Plus

 

Family

 

 

 

 

 

 

 

Election Form With

 

 

 

 

 

 

 

 

 

 

 

Self and

 

Another

 

One or Self

 

Member

 

 

 

 

 

 

 

Your Employing

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

Only

 

 

 

 

 

 

 

 

 

 

Office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1E

 

 

Any change in employee’s

 

Yes

 

Yes

 

Yes

 

Yes

 

No

 

Yes

 

Yes

 

Within 60 days

 

 

 

 

employment status that could

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

after employment

 

 

 

 

affect cost of insurance, including:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

status change

 

 

 

 

Change from temporary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

appointment with eligibility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for coverage under 5 USC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8906a to appointment that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

permits receipt of government

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Change from full time to part-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

time career or the reverse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1F

 

 

Employee restored to civilian

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

No

 

 

Yes

 

 

Yes

 

 

Within 60 days after

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

return to civilian

 

 

 

 

 

position after serving in uniformed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

position

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

services

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1G

 

 

Employee, spouse or eligible

 

No

 

No

 

No

 

Yes

 

No

 

Yes

 

Yes

 

Within 60 days

 

 

 

 

family member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

after employment

 

 

 

 

Begins nonpay status or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

status change

 

 

 

 

insufficient pay3 or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ends nonpay status or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

insufficient pay if coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

continued

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If employee’s coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

terminated, see 1D.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If spouse’s or eligible family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

member’s coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

terminated, see 1M.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1H

 

 

Salary of temporary employee

 

 

N/A

 

 

No

 

 

Yes

 

 

Yes

 

 

No

 

 

Yes

 

 

Yes

 

 

Within 60 days

 

 

 

 

 

insufficient to make withholdings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

after receiving

 

 

 

 

 

for plan in which enrolled.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notice from

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employing office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1I

 

 

Employee (or covered family

 

N/A

 

Yes

 

Yes

 

N/A

 

Yes

 

No

 

No

 

Upon notifying

 

 

 

 

member) enrolled in FEHB health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employing office of

 

 

 

 

maintenance organization (HMO)

 

 

 

 

 

 

 

 

 

 

(see 1M)

 

 

 

 

(see 1M)

 

(see

 

move

 

 

 

 

moves or becomes employed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1M)

 

 

 

 

 

 

 

outside the geographic area from

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

which the FEHB carrier accepts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enrollments or, if already outside

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the area, moves further from this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

area.4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1J

 

 

Transfer from post of duty within

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Yes

 

 

Within 60 days after

 

 

 

 

 

a State of the United States or the

 

 

. Employees

 

 

Employees

 

 

Employees

 

 

 

 

 

 

 

 

 

 

 

 

 

 

arriving at new post

 

 

 

 

 

District of Columbia to post of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

may enroll

 

 

may enroll

 

 

may enroll

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

duty outside a State of the United

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or change

 

 

or change

 

 

or change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

States or District of Columbia, or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

beginning

 

 

beginning

 

 

beginning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reverse.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31 days

 

 

31 days

 

 

31 days

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

before

 

 

before

 

 

before

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

leaving the

 

 

leaving the

 

 

leaving the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

old post of

 

 

old post of

 

 

old post of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

duty.

 

 

duty.

 

 

duty.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1K

 

 

Separation from Federal

 

Yes

 

Yes

 

Yes

 

N/A

 

No

 

N/A

 

N/A

During employee’s

 

 

 

 

employment when the employee or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

final pay period

 

 

 

 

employee’s spouse is pregnant.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

Qualifying Life Events (QLE’s) that

 

 

 

 

Change that May Be Permitted

 

 

Premium

 

 

Time Limits in

 

 

 

 

 

 

 

 

 

 

 

 

 

May Permit Change in FEHB

 

 

 

 

 

 

 

 

 

 

 

 

 

Conversion Change

 

 

which Change

 

 

Enrollment, Designated Family

 

 

 

 

 

 

 

 

 

 

 

 

 

that May Be

 

 

May Be

 

 

Member or Premium Conversion

 

 

 

 

 

 

 

 

 

 

 

 

 

Permitted

 

 

Permitted

 

 

 

 

 

Election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Event

 

 

Event

 

From Not

 

From Self

 

From One

 

Cancel or

Switch

 

Participate

 

Waive

 

When You Must

 

Code

 

 

 

 

 

Enrolled To

 

Only to Self

 

Plan or

 

Change to

Designated

 

 

 

 

 

 

 

File Health Benefits

 

 

 

 

 

 

 

Enrolled

 

Plus One or

 

Option to

 

Self Plus

Family

 

 

 

 

 

 

 

Election Form With

 

 

 

 

 

 

 

 

 

Self and

 

Another

 

One or Self

Member

 

 

 

 

 

 

 

Your Employing

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

Only

 

 

 

 

 

 

 

 

Office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1L

 

 

Employee becomes entitled to

 

 

No

 

No

 

Yes

 

 

N/A

 

No

 

N/A

 

 

N/A

 

 

Any time beginning

 

 

 

 

 

Medicare and wants to change to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

on the 30th day

 

 

 

 

 

another plan or option.5

 

 

 

 

 

 

(Changes

 

 

(see 1P)

 

 

 

(see 1P)

 

 

(see

 

 

before becoming

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

eligible for

 

 

 

 

 

 

 

 

 

 

 

 

may be

 

 

 

 

 

 

 

 

 

1P)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare

 

 

 

 

 

 

 

 

 

 

 

 

made

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

once.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1M

 

 

Employee or eligible family

 

Yes

 

Yes

 

Yes

 

Yes

Yes

 

Yes

 

Yes

 

Within 60 days after

 

 

 

 

member loses coverage under

 

Employees

 

Employees

 

Employees

 

 

 

 

 

 

 

 

 

 

 

loss of coverage

 

 

 

 

FEHB or another group insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

may enroll

 

may enroll

 

may enroll

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

plan including the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or change

 

or change

 

or change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loss of coverage under

 

beginning

 

beginning

 

beginning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

another FEHB enrollment due

 

31 days

 

31 days

 

31 days

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to termination, cancellation, or

 

before the

 

before the

 

before the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

change to Self Plus One or

 

event.

 

event.

 

event.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self Only of the covering

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loss of coverage due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

termination of membership in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employee organization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sponsoring the FEHB plan6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loss of coverage under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

another federally-sponsored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

health benefits program,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

including: TRICARE,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare, Indian Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loss of coverage under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid or similar State-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sponsored program of medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

assistance for the needy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loss of coverage under a non-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal health plan, including

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

foreign, state or local

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

government, private sector

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loss of coverage due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

change in worksite or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

residence (Employees in an

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEHB HMO, also see 1I.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1N

 

 

Loss of coverage under a non

 

 

Yes

 

Yes

 

Yes

 

 

Yes

 

Yes

 

Yes

 

 

Yes

 

 

From 31 days

 

 

 

 

 

Federal group health plan because

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

before the

 

 

 

 

 

an employee moves out of the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employee leaves

 

 

 

 

 

commuting area to accept another

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the commuting

 

 

 

 

 

position and the employee’s non-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

area to 180 days

 

 

 

 

 

Federally employed spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

after arriving in the

 

 

 

 

 

terminates employment to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

new commuting

 

 

 

 

 

accompany the employee.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

area

 

 

1O

 

 

Employee or eligible family

 

Yes

 

Yes

 

Yes

 

Yes

Yes

 

Yes

 

Yes

 

During open season,

 

 

 

 

member loses coverage due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

unless OPM sets a

 

 

 

 

discontinuance in whole or part of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

different time

 

 

 

 

FEHB plan.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

 

Qualifying Life Events (QLE’s) that

 

 

 

Change that May Be Permitted

 

 

Premium

 

 

Time Limits in

 

 

 

 

 

 

 

 

 

 

 

 

May Permit Change in FEHB

 

 

 

 

 

 

 

 

Conversion Change

 

 

which Change

 

 

Enrollment, Designated Family

 

 

 

 

 

 

 

 

that May Be

 

 

May Be

 

 

Member or Premium Conversion

 

 

 

 

 

 

 

 

Permitted

 

 

Permitted

 

 

 

 

Election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Event

 

Event

From Not

 

From Self

From One

Cancel or

Switch

 

Participate

Waive

 

When You Must

 

Code

 

 

 

Enrolled To

 

Only to Self

Plan or

Change to

Designated

 

 

 

 

 

File Health Benefits

 

 

 

 

 

Enrolled

 

Plus One or

Option to

Self Plus

Family

 

 

 

 

 

Election Form With

 

 

 

 

 

 

 

Self and

Another

One or Self

Member

 

 

 

 

 

Your Employing

 

 

 

 

 

 

 

Family

 

Only

 

 

 

 

 

 

Office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1P

 

Enrolled employee or eligible

 

No

 

No

No

Yes9

Yes

 

Yes

Yes

 

 

Within 60 days after

 

 

 

 

family member gains coverage

 

 

 

 

 

 

 

 

 

 

 

 

QLE

 

 

 

 

under FEHB or another group

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

insurance plan, including the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare (Employees who

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

become eligible for Medicare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and want to change plans or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

options, see 1L.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRICARE for Life, due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enrollment in Medicare.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRICARE due to change in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employment status, including:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) entry into active military

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

service, (2) retirement from

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reserve military service under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chapter 67, title 10.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health insurance acquired due

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to change of worksite or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

residence that affects

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

eligibility for coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health insurance acquired due

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to spouse’s or eligible family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

member’s change in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employment status (includes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

state, local, or foreign

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

government or private sector

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employment).8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1Q

 

Change in spouse’s or eligible

No

 

No

No

Yes9

Yes

 

Yes

Yes

 

Within 60 days after

 

 

 

family member’s coverage options

 

 

 

 

 

 

 

 

 

 

 

QLE

 

 

 

under a health plan, for example:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer starts or stops

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

offering a different type of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

coverage (If no other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

coverage is available, also see

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1M.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Change in cost of coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO adds a geographic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

service area that now makes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

spouse eligible to enroll in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

that HMO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO removes a geographic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

area that makes spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ineligible for coverage under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

that HMO, but other plans or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

options are available (If no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other coverage is available,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

see 1M)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1R

 

Employee or eligible family

 

Yes

 

Yes

Yes

Yes9

Yes

 

Yes

Yes

 

 

Within 60 days

 

 

 

 

member becomes eligible for

 

 

 

 

 

 

 

 

 

 

 

 

after the date the

 

 

 

 

assistance under Medicaid or a

 

 

 

 

 

 

 

 

 

 

 

 

employee or

 

 

 

 

State Children’s Health Insurance

 

 

 

 

 

 

 

 

 

 

 

 

family member

 

 

 

 

Program (CHIP).

 

 

 

 

 

 

 

 

 

 

 

 

becomes eligible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for assistance.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

(If you are a United States Postal Service employee, these rules may be different. Consult your employing office or information provided by your agency.)

1.Employees may change to Self Only outside of open season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment. Employees may change to Self Plus One outside ofOpen Season only if the QLE causes only one family member to be eligible under the FEHB enrollment. Employees may cancel enrollment outside of open season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage.

2.Employees who enter active military service are given the opportunity to terminate coverage. Termination for this reason does not count against the employee for purposes of meeting the requirements for continuing coverage after retirement. Additional information on the FEHB coverage of employees who return from active military service is available in the Frequently Asked Questions section of the FEHB website at www.opm.gov/healthcare-insurance/healthcare.

3.Employees who begin nonpay status or insufficient pay must be given an opportunity to elect to continue or terminate coverage. A termination differs from a cancellation as it allows conversion to nongroup coverage and does not count against the employee for purposes of meeting the requirements for continuing coverage after retirement.

4.This code reflects the FEHB regulation that gives employees enrolled in an FEHB HMO who change from Self Only or Self Plus One to Self and Family or from one plan or option to another a different timeframe than that allowed under 1M. For change to Self-Only or Self Plus One, cancellation, or change in premium conversion status, see 1M.

5.This code reflects the FEHB regulation that gives employees enrolled in FEHB a one-time opportunity to change plans or options under a different timeframe than that allowed by 1P. For change to Self Only or Self Plus One, cancellation, or change in premium conversion status, see 1P.

6.If employee’s membership terminates (e.g., for failure to pay membership dues), the employee organization will notify the agency to terminate the enrollment.

7.Employee’s failure to select another FEHB plan is deemed a cancellation for purposes of meeting the requirements for continuing coverage after retirement.

8.Under IRS rules, this includes start/stop of employment or nonpay status, strike or lockout, and change in worksite.

9.Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage. Employees may change to Self Plus One outside of Open Season only if the QLE caused all but one eligible family member to acquire other health insurance coverage. Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage.

10

Tables of Permissible Changes in FEHB Enrollment for Individuals Who Are Not Participating

in Premium Conversion

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

Change that May Be Permitted

Time Limits

 

Enrollment or Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From Self

From

Switch

 

 

 

From Not

Only to Self

One

When You Must File Health

Event

 

Designated

Event

Enrolled to

Plus One or

Plan or

Benefits Election Form With

Code

Family

 

Enrolled

Self

Option

Your Employing Office

 

 

Member

 

 

 

and Family

to

 

 

 

 

 

 

 

 

 

 

Another

 

 

 

 

 

 

 

 

 

2

Annuitant (Includes Compensationers)

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

 

2A

Open Season

No

Yes

Yes

Yes

As announced by OPM.

 

 

 

 

 

 

 

2B

Change in family status; for example: marriage, birth or

No

Yes

Yes

Yes

From 31 days before through 60

 

death of family member, adoption, or divorce.

 

 

 

 

days after the event.

2C

Reenrollment of annuitant who suspended FEHB

May Reenroll

N/A

N/A

No

From 31 days before through 60

 

enrollment to enroll in a Medicare Advantage plan,

 

 

 

 

days after involuntary loss of

 

Medicaid or similar State-sponsored program, or to use

 

 

 

 

coverage.

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

2D

Reenrollment of annuitant who suspended FEHB enroll-

May Reenroll

N/A

N/A

No

During open season.

 

ment 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.

 

 

 

 

 

2E

Restoration of annuity or compensation (OWCP)

Yes

N/A

N/A

No

Within 60 days after the retire-

 

payments, for example:

 

 

 

 

ment system or OWCP mails a

 

Disability annuitant who was enrolled in FEHB, and

 

 

 

 

notice of insurance eligibility.

 

whose annuity terminated due to restoration of earning

 

 

 

 

 

 

capacity or recovery from disability, and whose

 

 

 

 

 

 

annuity is restored;

 

 

 

 

 

 

Compensationer whose compensation terminated

 

 

 

 

 

 

because of recovery from injury or disease and whose

 

 

 

 

 

 

compensation is restored due to a recurrence of

 

 

 

 

 

 

medical condition;

 

 

 

 

 

 

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 immedi-

 

 

 

 

 

 

ately before survivor annuity terminated because of

 

 

 

 

 

 

marriage and whose survivor annuity is restored.

 

 

 

 

 

2F

Annuitant or eligible family member loses FEHB

Yes

Yes

Yes

Yes

From 31 days before through 60

 

coverage due to termination, cancellation, or change to

 

 

 

 

days after date of loss of cover-

 

Self Plus One or Self Only of the covering enrollment.

 

 

 

 

age.

 

 

 

 

 

 

 

11

 

QLE’s That Permit

Change that May Be Permitted

Time Limits

 

Enrollment or Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From Self

From

Switch

 

 

 

From Not

Only to Self

One

When You Must File Health

Event

 

Designated

Event

Enrolled to

Plus One or

Plan or

Benefits Election Form With

Code

Family

 

Enrolled

Self

Option

Your Employing Office

 

 

Member

 

 

 

and Family

to

 

 

 

 

 

 

 

 

 

 

Another

 

 

 

 

 

 

 

 

 

2G

Annuitant or eligible family member loses coverage

No

Yes

Yes

Yes

From 31 days before through 60

 

under another group insurance plan, for example:

 

 

 

 

days after loss of coverage.

 

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

N/A

Yes

Yes

Yes

During open season, unless

 

to the discontinuance, in whole or part, of an FEHB plan.

 

 

 

 

OPM sets a different time.

 

 

 

 

 

 

 

2I

Annuitant or covered family member in a Health

N/A

Yes

Yes

Yes

Upon notifying the employing

 

Maintenance Organization (HMO) moves or becomes

 

 

 

 

office of the move or change of

 

employed outside the geographic area from which the

 

 

 

 

place of employment.

 

carrier accepts enrollments, or if already outside this area,

 

 

 

 

 

 

moves or becomes employed further from this area.

 

 

 

 

 

2J

Employee in an overseas post of duty retires or dies.

No

Yes

Yes

Yes

Within 60 days after retirement

 

 

 

 

 

 

or death.

 

 

 

 

 

 

 

2K

An enrolled annuitant separates from duty after serving

N/A

Yes

Yes

No

Within 60 days after separation

 

31 days or more in a uniformed service.

 

 

 

 

from the uniformed service.

2L

On becoming eligible for Medicare.

N/A

No

Yes

No

At any time beginning on the

 

 

 

 

 

 

30th day before becoming eligi-

 

(This change may be made only once in a lifetime.)

 

 

 

 

ble for Medicare.

 

 

 

 

 

 

 

2M

Annuitant’s annuity is insufficient to make withholdings

N/A

No

Yes

No

Employing office will advise

 

for plan in which enrolled.

 

 

 

 

annuitant of the options.

3

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

 

employee or annuitant.

 

 

 

 

 

 

 

 

 

 

 

 

3A

Initial opportunity to enroll. Former spouse must be

Yes

N/A

N/A

N/A

Generally, must apply within

 

eligible to enroll under the authority of the Civil Service

 

 

 

 

60 days after dissolution of

 

Retirement Spouse Equity Act of 1984 (P.L. 98-615), as

 

 

 

 

marriage. However, if a retiring

 

amended, the Intelligence Authorization Act of 1986

 

 

 

 

employee elects to provide a

 

(P.L. 99-569), or the Foreign Relations Authorization

 

 

 

 

former spouse annuity or

 

Act, Fiscal Years 1988 and 1989 (P.L. 100-204).

 

 

 

 

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 employing office

 

 

 

 

 

 

establishes eligibility.

3B

Open Season.

No

Yes

Yes

Yes

As announced by OPM.

 

 

 

 

 

 

 

3C

Change in family status based on addition of family

No

Yes

Yes

Yes

From 31 days before through 60

 

members who are also eligible family members of the

 

 

 

 

days after change in family

 

employee or annuitant.

 

 

 

 

status.

3D

Reenrollment of former spouse who suspended FEHB

May reenroll

N/A

N/A

No

From 31 days before through 60

 

enrollment to enroll in a Medicare Advantage plan,

 

 

 

 

days after involuntary loss of

 

Medicaid, or similar State-sponsored program, or to

 

 

 

 

coverage.

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12

 

 

QLE’s That Permit

Change that May Be Permitted

Time Limits

 

 

Enrollment or Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From Self

From

Switch

 

 

 

 

From Not

Only to Self

When You Must File Health

Event

 

 

One

Designated

 

Event

Enrolled to

Plus One or

Benefits Election Form With

Code

 

Plan or

Family

 

 

Enrolled

Self

Your Employing Office

 

 

 

Option to

Member

 

 

 

 

and Family

 

 

 

 

 

Another

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3E

Reenrollment of former spouse who suspended FEHB

May reenroll

N/A

N/A

No

During open season.

 

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.

 

 

 

 

 

3F

Former spouse or eligible child loses FEHB coverage

Yes

Yes

Yes

Yes

From 31 days before through 60

 

due to termination, cancellation, or change to Self Only

 

 

 

 

days after date of loss of cover-

 

of the covering enrollment.

 

 

 

 

age.

 

 

 

 

 

 

 

3G

Enrolled former spouse or eligible child loses coverage

N/A

Yes

Yes

Yes

From 31 days before through 60

 

under another group insurance plan, for example:

 

 

 

 

days after loss of coverage.

 

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 3D and 3E);

 

 

 

 

 

 

Loss of coverage under a non-Federal health plan.

 

 

 

 

 

3H

Former spouse or eligible family member loses coverage

N/A

Yes

Yes

Yes

During open season, unless

 

due to the discontinuance, in whole or part, of an FEHB

 

 

 

 

OPM sets a different time.

 

plan.

 

 

 

 

 

 

 

 

 

 

 

 

3I

Former spouse or covered family member in a Health

N/A

Yes

Yes

Yes

Upon notifying the employing

 

Maintenance Organization (HMO) moves or becomes

 

 

 

 

office of the move or change of

 

employed outside the geographic area from which the

 

 

 

 

place of employment.

 

carrier accepts enrollments, or if already outside this

 

 

 

 

 

 

area, moves or becomes employed further from this area.

 

 

 

 

 

3J

On becoming eligible for Medicare

N/A

No

Yes

No

At any time beginning the 30th

 

 

 

 

 

 

 

day before becoming eligible for

 

(This change may be made only once in a lifetime.)

 

 

 

 

Medicare.

 

 

 

 

 

 

 

 

 

 

 

 

 

3K

Former spouse’s annuity is insufficient to make FEHB

No

No

Yes

No

Retirement system will advise

 

withholdings for plan in which enrolled.

 

 

 

 

former spouse of options.

4

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

 

employee or annuitant.

 

 

 

 

 

 

 

 

 

 

 

 

4A

Opportunity to enroll for continued coverage under TCC

 

 

 

 

Within 60 days after the qualify-

 

provisions:

 

 

 

 

ing event, or receiving notice of

 

Former employee

Yes

Yes

Yes

N/A

eligibility, whichever is later.

 

Yes

N/A

N/A

 

 

 

 

Former spouse

 

 

 

Yes

N/A

N/A

 

 

 

Child who ceases to qualify as a family

 

 

 

 

 

 

 

 

 

 

member

 

 

 

 

 

4B

Open Season:

No

Yes

Yes

Yes

As announced by OPM.

 

Former employee

 

 

No

Yes

Yes

 

 

 

 

Former spouse

 

 

 

No

Yes

Yes

 

 

 

Child who ceases to qualify as a family

 

 

 

 

 

 

 

 

 

 

member

 

 

 

 

 

4C

Change in family status (except former spouse); for

No

Yes

Yes

Yes

From 31 days before through 60

 

example, marriage, birth or death of family member,

 

 

 

 

days after event.

 

adoption, or divorce.

 

 

 

 

 

 

 

 

 

 

 

 

 

13

 

QLE’s That Permit

Change that May Be Permitted

Time Limits

 

Enrollment or Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From Self

From

Switch

 

 

 

From Not

Only to Self

One

When You Must File Health

Event

 

Designated

Event

Enrolled to

Plus One or

Plan or

Benefits Election Form With

Code

Family

 

Enrolled

Self and

Option

Your Employing Office

 

 

Member

 

 

 

Family

to

 

 

 

 

 

 

 

 

 

 

Another

 

 

 

 

 

 

 

 

 

4D

Change in family status of former spouse, based on

No

Yes

Yes

Yes

From 31 days before through 60

 

addition of family members who are eligible family

 

 

 

 

days after event.

 

members of the employee or annuitant.

 

 

 

 

 

4E

Reenrollment of a former employee, former spouse, or

May reenroll

N/A

N/A

No

From 31 days before through 60

 

child whose TCC enrollment was terminated because of

 

 

 

 

days after the event. Enrollment

 

other FEHB coverage and who loses the other FEHB

 

 

 

 

is retroactive to the date of the

 

coverage before the TCC period of eligibility (18 or 36

 

 

 

 

loss of the other FEHB cover-

 

months) expires.

 

 

 

 

age.

 

 

 

 

 

 

 

4F

Enrollee or eligible family member loses coverage

No

Yes

Yes

Yes

From 31 days before through 60

 

under FEHB or another group insurance plan, for

 

 

 

 

days after loss of coverage.

 

example:

 

 

 

 

 

 

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.

 

 

 

 

 

4G

Enrollee or eligible family member loses coverage due

N/A

Yes

Yes

Yes

During open season, unless

 

to the discontinuance, in whole or part, of an FEHB

 

 

 

 

OPM sets a different time.

 

plan.

 

 

 

 

 

 

 

 

 

 

 

 

4H

Enrollee or covered family member in a Health

N/A

Yes

Yes

No

Upon notifying the employing

 

Maintenance Organization (HMO) moves or becomes

 

 

 

 

office of the move or change of

 

employed outside the geographic area from which the

 

 

 

 

place of employment.

 

carrier accepts enrollments, or if already outside this

 

 

 

 

 

 

area, moves or becomes employed further from this

 

 

 

 

 

 

area.

 

 

 

 

 

4I

On becoming eligible for Medicare.

N/A

No

Yes

No

At any time beginning on the

 

 

 

 

 

 

30th day before becoming eligi-

 

(This change may be made only once in a lifetime.)

 

 

 

 

ble for Medicare.

 

 

 

 

 

 

 

 

 

 

 

 

 

5

Employees Who Are Not Participating In Premium Conversion

 

 

 

 

5A

Initial opportunity to enroll.

Yes

N/A

N/A

N/A

Within 60 days after becoming

 

 

 

 

 

 

eligible.

 

 

 

 

 

 

 

5B

Open Season.

Yes

Yes

Yes

Yes

As announced by OPM.

5C

Change in family status; for example: marriage, birth or

Yes

Yes

Yes

Yes

From 31 days before through 60

 

death of family member, adoption, or divorce

 

 

 

 

days after event.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14

 

QLE’s That Permit

Change that May Be Permitted

Time Limits

 

Enrollment or Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From Self

From

Switch

 

 

 

From Not

Only to Self

One

When You Must File Health

Event

 

Designated

Event

Enrolled to

Plus One or

Plan or

Benefits Election Form With

Code

Family

 

Enrolled

Self and

Option

Your Employing Office

 

 

Member

 

 

 

Family

to

 

 

 

 

 

 

 

 

 

 

Another

 

 

 

 

 

 

 

 

 

5D

Change in employment status, for example:

Yes

Yes

Yes

No

Within 60 days of employment

 

Reemployment after a break in service of more than 3

 

 

 

 

status change.

 

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;

 

 

 

 

 

 

Change to or from part-time career employment.

 

 

 

 

 

5E

Separation from Federal employment when the

Yes

Yes

Yes

No

Enrollment or change must

 

employee or employee’s spouse is pregnant.

 

 

 

 

occur during final pay period of

 

 

 

 

 

 

employment.

5F

Transfer from a post of duty within the United States to

Yes

Yes

Yes

Yes

From 31 days before leaving old

 

a post of duty outside the United States, or reverse.

 

 

 

 

post through 60 days after arriv-

 

 

 

 

 

 

ing at new post.

5G

Employee or eligible family member loses coverage

Yes

Yes

Yes

Yes

From 31 days before through 60

 

under FEHB or another group insurance plan, for

 

 

 

 

days after loss of coverage.

 

example:

 

 

 

 

 

 

Loss of coverage under another FEHB enrollment

 

 

 

 

 

 

due to termination, cancellation, or change to Self

 

 

 

 

 

 

Plus One or 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

 

 

 

 

 

 

plan;

 

 

 

 

 

 

Loss of coverage under Medicaid or similar

 

 

 

 

 

 

State-sponsored program;

 

 

 

 

 

 

Loss of coverage under a non-Federal health plan.

 

 

 

 

 

5H

Enrollee or eligible family member loses coverage due

N/A

Yes

Yes

Yes

During open season, unless

 

to the discontinuance, in whole or part, of an FEHB

 

 

 

 

OPM sets a different time.

 

plan.

 

 

 

 

 

5I

Loss of coverage under a non-Federal group health plan

Yes

Yes

Yes

Yes

From 31 days before the

 

because an employee moves out of the commuting area

 

 

 

 

employee leaves the commuting

 

to accept another position and the employee’s

 

 

 

 

area through 180 days after

 

non-federally employed spouse terminates employment

 

 

 

 

arriving in the new commuting

 

to accompany the employee.

 

 

 

 

area.

 

 

 

 

 

 

 

5J

Employee or covered family member in a Health

N/A

Yes

Yes

Yes

Upon notifying the employing

 

Maintenance Organization (HMO) moves or becomes

 

 

 

 

office of the move or change of

 

employed outside the geographic area from which the

 

 

 

 

place of employment.

 

carrier accepts enrollments, or if already outside the

 

 

 

 

 

 

area, moves or becomes employed further from this

 

 

 

 

 

 

area.

 

 

 

 

 

 

 

 

 

 

 

 

15

 

QLE’s That Permit

Change that May Be Permitted

Time Limits

 

Enrollment or Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From Self

From

Switch

 

 

 

From Not

Only to Self

One

When You Must File Health

Event

 

Designated

Event

Enrolled to

Plus One or

Plan or

Benefits Election Form With

Code

Family

 

Enrolled

Self

Option

Your Employing Office

 

 

Member

 

 

 

and Family

to

 

 

 

 

 

 

 

 

 

 

Another

 

 

 

 

 

 

 

 

 

5K

On becoming eligible for Medicare

N/A

No

N/A

No

At any time beginning on the

 

 

 

 

 

 

30th day before becoming

 

(This change may be made only once in a lifetime.)

 

 

 

 

eligible for Medicare.

5L

Temporary employee completes one year of continuous

Yes

N/A

N/A

No

Within 60 days after becoming

 

service in accordance with 5 U.S.C. Section 8906a.

 

 

 

 

eligible.

 

 

 

 

 

 

 

5M

Salary of temporary employee insufficient to make

N/A

No

Yes

No

Within 60 days after receiving

 

withholdings for plan in which enrolled.

 

 

 

 

notice from employing office.

5N

Employee or eligible family member becomes eligible for

Yes

Yes

Yes

Yes

Within 60 days after the date the

 

assistance under Medicaid or a State Children’s Health

 

 

 

 

employee or family member

 

Insurance Program (CHIP).

 

 

 

 

becomes eligible for assistance.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16

Form Approved: OMB No. 3206-0160

Federal Employees Health Benefits Program

HEALTH BENEFITS ELECTION FORM

Part A - Enrollee and Family Member Information (for additional family members use a separate sheet and attach)

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

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Home mailing address (including ZIP Code)

 

 

7.

If you are covered by Medicare,

8.

Medicare

 

Beneficiary Identifier

 

 

 

 

 

 

 

 

 

 

 

check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

B

 

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Are you covered by insurance other than Medicare?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes, indicate in item 10 below.

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Indicate the type(s) of other insurance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRICARE

 

Other

Name of other insurance:

______________________________________________

 

Policy Number: _____________________

 

 

FEHB 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 10 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

Address (if different from enrollee)

 

 

19.

If this family member is covered

20.

 

Medicare Beneficiary Identifier

 

 

 

 

 

 

 

 

 

by Medicare, check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

B

 

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

Is this

family member covered by

insurance other than Medicare?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes, indicate in item 22 below.

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

Indicate the type(s) of other insurance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRICARE

 

Other

Name of other insurance:

______________________________________________

 

Policy Number: _____________________

 

 

FEHB 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 10 on page 1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.

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

24.

Preferred telephone number (if applicable, enter preferred phone number of

 

 

 

 

 

 

 

 

 

your spouse or adult child)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

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

 

26. Social Security Number

27.

Date of birth (mm/dd/yyyy)

 

28.

 

Sex

 

 

 

 

29.

Relationship code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30.

Address (if different from enrollee)

 

 

31.

If this family member is covered

32.

 

Medicare

 

Beneficiary Identifier

 

 

 

 

 

 

 

 

 

by Medicare, check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

B

 

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33.

Is this

family member covered by

insurance other than Medicare?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes, indicate in item 34 below.

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34.

Indicate the type(s) of other insurance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRICARE

 

Other

Name of other insurance:

______________________________________________

 

Policy Number: _____________________

 

 

FEHB 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 10 on page 1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35.

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

36.

Preferred telephone number (if applicable, enter preferred phone number of

 

 

 

 

 

 

 

 

 

your spouse or adult child)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

37.

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

 

38. Social Security Number

39.

Date of birth (mm/dd/yyyy)

 

40.

 

Sex

 

 

 

 

41.

Relationship code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42.

Address (if different from enrollee)

 

 

43.

If this family member is covered

44.

 

Medicare

 

Beneficiary Identifier

 

 

 

 

 

 

 

 

 

by Medicare, check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

B

 

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

45.

Is this

family member covered by

insurance other than Medicare?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes, indicate in item 46 below.

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

46.

Indicate the type(s) of other insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRICARE

 

Other

Name of other insurance:

______________________________________________

 

Policy Number: _____________________

 

 

 

 

 

 

FEHB 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 10 on page 1.

 

 

 

 

 

 

 

47.

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

48.

Preferred telephone number (if applicable, enter preferred phone number of

 

 

 

 

 

 

 

 

 

 

your spouse or adult child)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Continued on the reverse)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Standard Form 2809

 

U.S. Office of Personnel Management

 

 

For agency distribution of copies, see page 5 of the instructions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised November 2019

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enrollee name: _________________________________________________________ Date of birth: ____________________________

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

1. Plan name

2. Enrollment code

 

 

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 6)

1. Event code

2. Date of event

 

 

Part F - Cancellation of FEHB

I CANCEL my enrollment.

My signature in Part H certifies that I have read and understand the information on page 3 regarding cancellation of enrollment.

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

1. Plan name

2. Enrollment code

 

 

Part E - Election NOT to Enroll (Employees Only)

I do NOT want to enroll in the FEHB Program.

My signature in Part H certifies that I have read and understand the information on page 3 regarding this election.

Part G - Suspension of FEHB (Annuitants/Former Spouses Only)

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the information on page 4 regarding suspension of enrollment.

Part H - Signature

WARNING: Any intentionally false statement in 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)

 

 

Part I -To be completed by agency or retirement system

REMARKS

1. Date received (mm/dd/yyyy)

2. Effective date of action (mm/dd/yyyy)

3. Personnel telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

4.

Name and address of agency or retirement system

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Authorizing official (please print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Signature of authorized agency official

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Payroll office number

 

 

 

8. Payroll office contact (please print)

9.

Payroll telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

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