U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

Federal Employees Health Benefits Program

This is to advise you that the Health Benefits Election Form, Standard Form (SF) 2809 has been revised. The October 2004 edition supersedes all previous editions of this form and makes obsolete the Annuitant/OWCP Health Benefits Election Form, SF 2809-1. This form will be available to Federal agencies before the upcoming open season.

We informed agencies to begin using the revised SF 2809 this upcoming open season which begins November 8. We expect that most agencies will do so. You may receive enrollment information on the previous edition of the SF 2809. Please process these forms as well, so that enrollees will receive their ID cards and benefits in a timely manner. You should contact the enrollees for any information included on the revised form that you need.

SF 2809 Users

The following individuals may use the SF 2809 if they are eligible to enroll or are currently enrolled in the FEHB Program:

• Employees, including temporary employees eligible under 5 U.S.C. 8906a.
• Annuitants (other than Civil Service Retirement System (CSRS) and Federal Employees Retirement System (FERS) annuitants), including individuals receiving monthly compensation from the Office of Workers' Compensation Programs (OWCP).
• Former spouses eligible under the Spouse Equity provisions of the FEHB law or similar statures.
• Individuals eligible for temporary continuation of coverage (TCC), including:
  • Former employees (who separated from service);
  • Children who lose FEHB coverage; and
  • Former spouses who are not eligible under the Spouse Equity provisions of the FEHB law.

Significant Changes to the SF 2809

A New Table of Permissible Changes

We have included a new table for those employees who are participating in premium conversion. There are now five Tables of Permissible Changes in Enrollment that are organized by enrollee category. Each category is designated by a number that identifies the enrollee group, as follows:

Table 1: Employees who participate in premium conversion;

Table 2: Annuitants (other than Civil Service Retirement System (CSRS) and Federal Employees Retirement System (FERS) annuitants), including individuals receiving monthly compensation from the Office of Workers' Compensation Programs;

Table 3: Former spouses eligible under the Spouse Equity provisions of the FEHB law or similar statutes;

Table 4: Individuals eligible for coverage under the TCC provisions of the FEHB law; and

Table 5: Employees who do not participate in premium conversion.

If your enrollment system collects data from the 2-character event code field in Part D, Item 1, you will need to add the information from Table 1. This table lists qualifying life events for employees participating in premium conversion. Prior to premium conversion, the previous Table 1 (July 1999 SF 2809) applied to all employees. We have redesignated this as Table 5 for employees who are not participating in premium conversion.

HIPAA Compliance

The SF 2809 is now consistent with the electronic FEHB enrollment format that you currently receive. This electronic format corresponds to the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standard for enrollment and disenrollment in a health plan.

The changes to the SF 2809 include:

• New family relationship codes,
• Other insurance information, including Medicare and TRICARE, requested for all family members, and
• Family members' addresses when different from the enrollee.

Please be aware that these fields may be blank in some of the electronic SF 2809 transmissions. We recently became aware that some agencies may not have made these changes to their FEHB enrollment change input systems.

If you have already updated your enrollment system to maintain this data, no changes to your system should be necessary. If you have not updated your enrollment system, please make these changes as quickly as possible. We ask that you continue processing all enrollment information to avoid disruption or delay in services.

Combined with the SF 2809-1

The revised SF 2809 now includes information from the SF 2809-1 in order to maintain only one Health Benefits Election Form for all enrollee categories. We have added a section for annuitants and former spouses to suspend their FEHB enrollment because they are covered by a Medicare Advantage plan, Medicaid or similar State-sponsored program of medical assistance for the needy, TRICARE (including Uniformed Services Family Health Plan or TRICARE-for-Life), or CHAMPVA.

Suspensions are a form of cancellation and will appear as a 'Stop' action on the electronic SF 2809 transmission. Currently, the enrollees do not receive the 31-day temporary extension of coverage and conversion opportunity. Enrollees who suspend may return to FEHB coverage under certain circumstances if their other coverage ends.

If you have any further questions about this form, please contact your contract specialist.

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