SF 2809 - Health Benefits Election Form

SF-2809 is the Health Benefits Election Form used to enroll in, change, or cancel coverage under the Federal Employees Health Benefits (FEHB) Program administered by the U.S. Office of Personnel Management (OPM). FEHB PROGRAM OVERVIEW: The FEHB Program is the largest employer-sponsored health insurance program in the world, covering over 8 million federal employees, retirees, and their dependents. It offers a wide variety of health plan options including Fee-for-Service plans, Health Maintenance Organizations (HMOs), Consumer-Driven Health Plans (CDHPs), and High Deductible Health Plans (HDHPs). ELIGIBILITY CATEGORIES: - Federal employees in positions that convey FEHB eligibility - Annuitants (retired federal employees) who meet enrollment requirements - Survivor annuitants - Former spouses who meet eligibility requirements - Temporary Continuation of Coverage (TCC) enrollees - Employees on Leave Without Pay (LWOP) COVERAGE TYPES: - Self Only: Covers only the enrollee - Self Plus One: Covers the enrollee and one designated eligible family member - Self and Family: Covers the enrollee and all eligible family members Note: Self Plus One may cost more than Self and Family for some plans - always compare premiums ELIGIBLE FAMILY MEMBERS: - Spouse (including same-sex spouse legally married in any jurisdiction) - Children under age 26 (natural, adopted, stepchildren, foster children, children for whom the enrollee is legal guardian) - Children age 26 or older who are incapable of self-support due to mental or physical disability that existed before age 26 ENROLLMENT OPPORTUNITIES: 1. Initial Opportunity: New employees have 60 days from date of appointment to enroll 2. Open Season: Annual period (typically mid-November to mid-December) when all eligible persons can enroll, change plans, change coverage type, or cancel 3. Qualifying Life Events (QLEs): Specific events that permit enrollment changes outside Open Season within 60 days of the event QUALIFYING LIFE EVENTS (Event Codes): Family Status Changes: - Marriage - Birth or adoption of child - Acquisition of foster child or stepchild - Legal separation/divorce/annulment - Death of spouse or dependent family member Employment Changes: - Return to pay status from non-pay status exceeding 365 days - Restoration from uniformed services - Transfer from non-eligible to eligible position - Change from part-time to full-time or vice versa Loss of Coverage Events: - Loss of coverage under another FEHB enrollment - Moving outside HMO service area - Loss of coverage under Medicare, Medicaid, TRICARE, or CHAMPVA - Loss of coverage under non-federal employer group plan PREMIUM CONVERSION (PRE-TAX PREMIUMS): Federal employees automatically participate in premium conversion, meaning FEHB premiums are deducted from pay before taxes are calculated. This provides approximately 25-35% tax savings. Employees may waive premium conversion to maintain flexibility to drop coverage without a QLE, but this means paying premiums with after-tax dollars. COORDINATION WITH MEDICARE: Enrollees eligible for Medicare can choose to have both FEHB and Medicare coverage. When both coverages exist: - Medicare typically pays first (primary) - FEHB pays second (secondary) for remaining costs Medicare Part A (Hospital) is premium-free for most; Part B (Medical) requires monthly premium RELATIONSHIP CODES (for Family Members): 01 - Spouse 03 - Natural child 04 - Adopted child 05 - Stepchild 06 - Foster child 07 - Child of domestic partner 14 - Incapacitated child over 26 CANCELLATION VS. SUSPENSION: - Cancellation: Terminates FEHB coverage entirely. Employees cannot reenroll until next Open Season or QLE. Annuitants may be unable to reenroll. - Suspension: Available only to annuitants and former spouses. Allows temporary suspension for coverage under CHAMPVA or Medicare. Enrollee may reenroll later under certain conditions. IMPORTANT DEADLINES: - All enrollment actions must be made within 60 days of a qualifying event - Forms must be submitted to employing agency (employees) or retirement system (annuitants) - Coverage effective dates vary based on the type of enrollment action FRAUD WARNING: False statements on this form are punishable by fine up to $10,000, imprisonment up to 5 years, or both under 18 U.S.C. 1001.

Enrollee name:

Date of birth:

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

1. Plan name

2. Enrollment code

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

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 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 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 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.

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.)

Part H - Signature

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

13. Name of family member (last, first, middle initial)	14. Social Security Number	15. Date of birth (mm/dd/yyyy)	16. Sex M F	17. Relationship code
18. Address (if different from enrollee)
19. If this family member is covered by Medicare, check all that apply. A B D	20. Medicare Beneficiary Identifier		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 FEHB Other Name of other insurance: Policy Number: 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.
23. Email address (if applicable)			24. Preferred telephone number (if applicable)

25. Name of family member (last, first, middle initial)	26. Social Security Number	27. Date of birth (mm/dd/yyyy)	28. Sex M F	29. Relationship code
30. Address (if different from enrollee)
31. If this family member is covered by Medicare, check all that apply. A B D	32. Medicare Beneficiary Identifier		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 FEHB Other Name of other insurance: Policy Number: 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.
35. Email address (if applicable)			36. Preferred telephone number (if applicable)

37. Name of family member (last, first, middle initial)	38. Social Security Number	39. Date of birth (mm/dd/yyyy)	40. Sex M F	41. Relationship code
42. Address (if different from enrollee)
43. If this family member is covered by Medicare, check all that apply. A B D	44. Medicare Beneficiary Identifier		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 FEHB Other Name of other insurance: Policy Number: 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.
47. Email address (if applicable)			48. Preferred telephone number (if applicable)