Click here to skip navigation
This website uses features which update page content based on user actions. If you are using assistive technology to view web content, please ensure your settings allow for the page content to update after initial load (this is sometimes called "forms mode"). Additionally, if you are using assistive technology and would like to be notified of items via alert boxes, please follow this link to enable alert boxes for your session profile.
An official website of the United States Government.

Healthcare Reference Materials

Eligibility for Health Benefits

Federal Employees

As a Federal employee, you are eligible to elect FEHB coverage, unless your position is excluded by law or regulation. Your agency applies these rules and determines your eligibility.

Cooperative Employees

You are eligible for FEHB coverage if you are:

  • appointed by a Federal agency for service in cooperation with a non-Federal agency,
  • paid in whole or in part from non-Federal funds (such as certain employees of the Agriculture Extension Service), and
  • your position is not excluded from coverage.

Withholdings and contributions for your coverage must be made from Federally-controlled funds and must be timely paid, or the cooperating non-Federal agency must agree in writing with your agency to make and timely remit the required withholdings and contributions from non-Federal funds. The withholdings and contributions arrangement must be approved by OPM.

Agricultural Stabilization and Conservation County Committee Employees

If you are employed by a county committee established under section 8(b) of the Soil Conservation and Domestic Allotment Act, you are eligible for FEHB coverage (unless your position is excluded from coverage).

Employees Transferred to Public International Organizations

If you transfer to a public international organization under the Federal Employees International Organization Service Act, you may elect to retain your FEHB coverage. To keep your coverage, all necessary withholdings and contributions during your service with the international organization must be currently paid.

U.S. Commissioners

If you are a United States Commissioner subject to the Civil Service Retirement law or the Federal Employees Retirement law, you are eligible for FEHB coverage.

Presidential Appointee

You are eligible for FEHB coverage if you are a Presidential appointee appointed to fill an unexpired term.

Provisional Appointee

You are eligible for FEHB coverage if you are a temporary employee who receives a provisional appointment as defined in 5 CFR 316.401 and 316.403.

Acting Postmaster

You are eligible for FEHB coverage if you are an acting postmaster.

Members of Congress and Designated Congressional Staff

Members of Congress and designated congressional staff who purchase their health benefits plan via the DC SHOP with a Government contribution should contact their administrative office for information.

Back to Top

Temporary Employees

Eligibility to Enroll at Own Cost

If your position is excluded from coverage because your appointment is limited to one year or less, you will be eligible to enroll under 5 U.S.C. 8906a when you have completed one year of current continuous employment, excluding any break in service of 5 days or less. You must pay both the employee and the Government shares of the premium.

The one-year requirement may be met at the end of a one-year appointment in a single agency or it may be based on a series of shorter appointments served in one or more agencies, as long as you have not had a break in service of more than 5 days.

In many cases, a temporary appointment lasts one year. If your appointment is renewed at the end of that year, you are eligible to enroll.

Student Employees

If you are a student employee (for example, a student aide or Stay-in-School Program participant), you generally serve on temporary appointments limited to 1 year or less. You typically work part-time during the school year and full-time during summers and vacations and become eligible to participate after completing one year on the employment rolls, provided you pay the full premium cost.

Intermittent Employment

If you are an intermittent employee (you do not have a prearranged regular tour of duty), you are not eligible for coverage. Seasonal or occasional employment for one calendar year that amounted to less than 6 months of work does not meet the one year of current continuous employment requirement.

Exception

You are eligible for FEHB coverage if your appointment follows, with a break in service of no more than 3 days, a position in which you were insured.

Mixed Tour of Duty

If you work, under an appointment limited to one year or less, a mixed tour of duty (combining periods of full-time, part-time, and intermittent tours of duty during the year), you may be eligible to enroll as a temporary employee. You must be on a full-time or prearranged part-time work schedule at the beginning of the one-year period of current continuous employment and at the time you enroll under this provision. When counting the one year of current continuous employment, include any periods of intermittent service. If you change to an intermittent tour of duty after your enrollment begins, your enrollment will continue as long as you didn't have a break in service of more than three calendar days.

Back to Top

Employees Excluded from Coverage

District of Columbia Employees

You are excluded from FEHB coverage if you were first employed by the District of Columbia government on or after October 1, 1987.

Exceptions

You are eligible for FEHB coverage if you are:

  • an employee of St. Elizabeth's Hospital, who accepts employment with the District of Columbia government following Federal employment without a break in service, as provided in Pub. L. 98-621;
  • an employee of the D.C. Control Board (District of Columbia Financial Responsibility and Management Assistance Authority), who makes an election under the Technical Corrections to Financial Responsibility and Management Assistance Act (section 153 of P. L. 104-134) to be considered a Federal employee for FEHB coverage and other benefits purposes;
  • effective August 5, 1997, the Corrections Trustee and the Pretrial Services, Defense Services, Parole, Adult Probation, and Offender Supervision Trustee and employees of these Trustees who accept employment with the District of Columbia Government within 3 days after separating from the Federal Government, as provided by P. L. 105-33; and
  • effective October 1, 1997, a judge or nonjudicial employee of the District of Columbia Courts, as provided by Pub. L. 105-33.

Noncitizens

You are excluded from FEHB coverage if you are not a citizen or national of the United States and your permanent duty station is located outside the United States and its territories and possessions.

Exception

You are eligible for FEHB coverage if you met the definition of employee on September 30, 1979, by service in an Executive agency (as defined in 5 U.S.C. 105), the United States Postal Service, or the Smithsonian Institution in the area which was then known as the Canal Zone.

TVA Employees

You are excluded from FEHB coverage if you are an employee of the Tennessee Valley Authority.

Employees of Farm Credit Administration-Supervised Corporations

You are excluded from FEHB coverage if you are an employee of a corporation supervised by the Farm Credit Administration, if private interests elect or appoint a member of the board of directors. The corporations are Regional Banks for Cooperatives, Federal Intermediate Credit Banks, Federal Land Banks, Production Credit Corporations, and the Central Bank for Cooperatives.

Temporary Employees

You are excluded from FEHB coverage if you are:

  • serving under an appointment limited to one year or less and you have not completed at least one year of current continuous employment, excluding any break in service of 5 days or less; or
  • expected to work less than 6 months in each year.

Exceptions

You are eligible for FEHB coverage if:

  • your full-time or part-time temporary appointment has a regular tour of duty and follows a position in which you were insured, with a break in service of no more than 3 days;
  • you are an acting postmaster;
  • you are a Presidential appointee appointed to fill an unexpired term;
  • you are a temporary employee who receives a provisional appointment as defined in 5 CFR 316.401 and 316.403;
  • you are employed under an OPM-approved career-related work-study program under Schedule B lasting at least one year and in pay status for at least one-third of the total period of time from the date of your first appointment to the completion of the work-study program; or
  • your appointment follows, with a break in service of no more than 3 days, a position in which you were insured.

Patient Employees

You are excluded from FEHB coverage if you are a beneficiary or patient employee in a Government hospital or home.

Employees Paid on a Contract or Fee Basis

You are excluded from FEHB coverage if you are paid on a contract or fee basis.

Exception

You are eligible for FEHB coverage when you are a:

  • United States citizen, appointed by a contract between you and the Federal employing authority which requires your personal service, and paid on the basis of units of time; or

Employees Paid on a Piecework Basis

You are excluded from FEHB coverage if you are paid on a piecework basis.

Exception

You are eligible for FEHB coverage when your work schedule provides for full-time or part-time service with a regularly scheduled tour of duty.

OPM Determination

OPM makes the final determination about whether the above categories apply to a specific employee or group of employees.

Part-time career employment or certain interim appointments are not excluded from FEHB coverage.

Back to Top

Election Procedures

Election Required

If you are eligible to enroll in the FEHB Program, you must complete an election either to enroll in a plan or not to enroll. You must do this within 60 days after you become eligible. Your employing office must remind you of the 60-day deadline and ensure that you make your election on a timely basis. If you don't make an election, you are considered to have declined coverage.

Health Benefits Election Form

Generally, you will make elections--to enroll, not to enroll, to change enrollment, or to cancel enrollment-- on the Health Benefits Election Form (SF 2809). The SF 2809 may be in either paper or electronic format. However, your employing office may allow or require you to make Open Season changes through "Employee Express" or another electronic method which does not involve an SF 2809. You should check with your employing office to see if this is available for your use.

Social Security Number

All carriers use your social security number as your identification number for enrollment purposes. Your social security number must be shown on all enrollment or disenrollment documents.

Change in Election

If you are a participant in premium conversion, once your election takes effect it is irrevocable, unless you have a Qualifying Life Event. If you want to change your election before the election period ends, you must waive premium conversion before your employing office accepts the change.

Temporary Employees

If you are a temporary employee, your employing office must establish a potential FEHB eligibility date for you. Your employing office must notify you as soon as you are eligible to enroll and give you 60 days to make an election.

Back to Top

Free Choice of Plans

Employing Office Responsibility

You will be given a full opportunity to make a free choice among the plans available to you. Your employing office will explain the FEHB Program to you as soon as you become eligible; give you informational material; caution you against cancellation of any private health insurance you may already have before coverage under this Program becomes effective; and urge that you study the material and decide which plan is best suited to meet your health care needs.

Materials to be Given

Your employing office will give you the following materials before, or as soon as possible after, you become eligible for FEHB coverage:

  • Guide to Federal Benefits. This booklet, which is updated each year, contains general enrollment information, lists all FEHB plans and gives your share of the premium rates, and gives the major features of each plan.
  • Health Benefits Election Form (SF 2809). You will be asked to complete and return this form, regardless of whether you elect to enroll or not to enroll in the FEHB Program.
  • Health Plan Brochures. Your employing office will allow you to review the brochures of the plans you are eligible to enroll in. Your employing office will allow you to keep the brochure of the plan you select.

Plan Selection

Only you can decide which plan is best suited for your individual needs.

Your employing office will not make comparisons between benefits offered by various plans and will not show favoritism toward a plan. They should not in any other way try to influence your final selection of a plan. However, your employing office will answer your questions about the FEHB Program.

Plans Sponsored by Unions and Employee Organizations

You may elect to enroll in a plan sponsored by a union or employee organization if you are a member of the organization or if you promptly take steps to become a member. Some employee organizations will allow your enrollment in its plan if you become an associate member (where you are enrolled in that organization only for health benefits purposes). Certain plans are open only to specific groups of employees.

Your employing office will not verify whether you are a member of the organization when it accepts your Health Benefits Election Form enrolling in the organization's plan; the organization will verify your membership when it receives your election form. However, your employing office will make sure that you understand that membership in the organization that sponsors the plan is necessary to be an enrollee in the plan.

Back to Top

Late Election

Accepting Late Elections

If, for reasons beyond your control, you were unable to make an election within the required time limits, your employing office may allow you to make a late election. You must make your election within 60 days after your employing office notified you of its decision.

Your employing office will decide whether your failure to make a timely election was beyond your control. Your error in judgment or failure to read information are not considered causes beyond your control. Some examples of cause beyond your control are:

  • You were on service elsewhere when you ordinarily would have been able to make the election.
  • You are a new employee and your employing office didn't give you information about health benefits.
  • Your employing office told you in error that you were not eligible to enroll.
  • You are an employee, formerly covered under another person's enrollment, and were belatedly informed of that coverage's termination.

Documenting Late Elections

If your employing office accepts a late election from you, it records its determination that you were unable to make the election on a timely basis for reasons beyond your control, giving the date you were notified of the determination, in the Remarks section of the Health Benefits Election Form (SF 2809). If you are electing to enroll, it is especially important that this be documented on the SF 2809 for purposes of meeting the requirements for continuing enrollment after retirement. Your employing office must state the reason for your failure to make the election on a timely basis on either the SF 2809 or on a memo attached to the Official Personnel Folder copy of the SF 2809.

Effective Date

Late elections are effective prospectively, except for belated Open Season elections, as explained in "Correction of Errors."

Election by Proxy

Your employing office may permit your representative to make an election for you with your written authorization. This may by done when you are unable to make an election on a timely basis; for example, when you will be on extended travel in a remote location, or you expect to be hospitalized during the next election opportunity. Your representative must sign his or her own name on the Health Benefits Election Form (SF 2809) and add after it "For: (your name)." Your employing office attaches the written authorization to the Official Personnel Folder copy of the SF 2809 and writes "Authorization attached" in the Remarks section.

Back to Top

Election Not to Enroll

Your Responsibility

It is your responsibility to ensure that your Health Benefits Election Form (SF 2809) correctly reflects your intentions. When you elect not to enroll you certify by your signature on the SF 2809 that you are aware:

Change in Election Not to Enroll

If you want to change your election before the election period ends, your employing office must accept the change.

Effect of Transfer on Election not to Enroll

If you transfer to another employing office without a break in service of more than 3 calendar days, your election not to enroll is also transferred and you may not enroll as a new employee of the gaining agency. If you have a break in service of more than 3 calendar days, you must elect either to enroll or not to enroll, the same as a new employee.

Employing Office Action when You do not Make an Election

If you don't make an election, your employing office will contact you before the election period ends and urge you to make an election. If you still don't make an election, you are considered to have elected not to enroll.

If you are an eligible temporary employee who doesn't enroll, your employing office will document in your Official Personnel Folder your date of eligibility, the date it sent notification of your eligibility, and the date of its follow-up contact urging you to make an election.

Back to Top

Initial Decision and Reconsideration

Initial Decision

Your employing office has the responsibility for determining whether you are eligible to enroll or change your enrollment in the FEHB Program or in the premium conversion plan. Its initial decision that you can not enroll is given in writing and will inform you of the right to an independent level of review (reconsideration) by the appropriate agency office. The written initial decision will include the address of the office making reconsideration decisions, the time limit for requesting reconsideration, and a statement that you should include a copy of the initial decision with your reconsideration request.

See "Opportunities to Enroll or Change Enrollment" for the events that allow enrollment or changes in enrollment and the time frames within which changes may be made.

Reconsideration Right

You have the right to ask your employing office to reconsider its initial decision denying FEHB enrollment or the opportunity to change your enrollment, or your participation in the premium conversioin plan. The reconsideration determines whether your employing office properly applied law and regulations in making its initial decision. This reconsideration is your final level of administrative review for enrollment decisions under the FEHB Program.

Who Does the Reconsideration?

The office that makes the reconsideration decision must be at either a higher level or in a different office than the office that made the initial decision. Employing offices that make initial decisions must be made aware of the identity of the agency office making reconsideration decisions because they must include that information with the initial decision.

How to Request Reconsideration

You must request reconsideration in writing. The request must include:

  • Your name and address
  • Your date of birth
  • Your Social Security Number
  • The reason(s) for the request
  • A copy of the initial decision.

Time Limit

You must request reconsideration within 30 calendar days from the date of the initial decision. Exception: you must request reconsideration of a carrier's disenrollment decision within 60 calendar days after the date of a carrier's disenrollment notice.

This time limit may be extended when you show that you were not notified of the time limit and were not otherwise aware of it or that you were unable to make the request within the time limit for reasons beyond your control.

Final Decision

The reconsidering office will issue a final decision. This decision will be in writing and fully state the findings. Initial decisions that comply with law and regulations cannot be overturned by reconsideration.

Example 1

Henry lists parents who live with and are dependent on him as family members under his family enrollment. His employing office denies coverage of his parents. This initial decision cannot be overturned by reconsideration because the FEHB law does not provide for coverage of an employee's parents.

Example 2

John marries. Three months later he requests a change of enrollment from Self Only to Self and Family based on the marriage. The employing office denies his request because the time frame for making a change due to marriage is 31 days before to 60 days after the marriage. This initial decision cannot be overturned because the time frame is a regulatory requirement.

(If John claimed that he didn't make the change timely for reasons beyond his control, his employing office could allow a late election on that basis either at the initial decision level or at the reconsideration level.)

Effective Date of Reconsideration Enrollment

If on reconsideration your employing office decides that you should have been allowed to enroll or change enrollment, it accepts a Health Benefits Election Form (SF 2809) from you making the change. Generally, changes made upon reconsideration are effective prospectively. Under FEHB regulations, the change is normally effective on the first day of the first pay period beginning after the employing office receives the SF 2809.

In some cases, the law or regulations provide for retroactive effective dates, so your employing office doesn't need to decide whether a retroactive effective date is appropriate.

When the late election was the result of an administrative error, you may request that your employing office make the change retroactive to an earlier date, generally the date it would have been effective if you had been able to make a timely election.

If on reconsideration your employing office decides that you are entitled to continued enrollment in a plan from which you were disenrolled by the carrier, the disenrollment is void and coverage is reinstated retroactively.

Back to Top

Correction of Errors

Employing Office

Your employing office can make corrections of administrative errors regarding eligibility to enroll or changes in enrollment at any time. Your employing office may retroactively correct an enrollment code error if you report the error by the end of the second pay period after you received written documentation showing the error (for example, a pay statement or enrollment change confirmation).

When retroactive corrections are made, your employing office must determine whether the proper amount of health benefits deductions were made from your pay. Your employing office must submit any uncollected deductions and Government contributions to OPM for deposit in the Employees Health Benefits Fund.

Exception: If the administrative error was made before January 1, 1995, your employing office does not have the authority to make a retroactive correction. Instead, you must request a retroactive correction from OPM, Retirement and Insurance Service, Healthcare and Insurance, P.O. Box 436, Washington, D.C. 20044.

OPM

OPM can order correction of an administrative error after reviewing evidence that it would be against equity and good conscience not to do so. A request for review should be sent to OPM, Healthcare and Insurance, P.O. Box 436, Washington, D.C. 20044.

Impaired Relationship

OPM may order a change in your enrollment from a particular HMO when you can show that you cannot receive adequate medical care because you (or a family member) and your HMO's health care providers have a seriously impaired relationship. You should submit your request and documentation of the impaired relationship to OPM, Healthcare and Insurance, P.O. Box 436, Washington, DC 20044.

Back to Top

Processing Elections

Generally, the responsibility for processing health benefits actions is divided between the personnel and payroll offices.

References in this section to Standard Forms 2809 and 2810 apply to the August 1992 and June 1995 editions respectively.

Prompt Action on Elections

Your personnel and payroll offices must process your election within one week after their receipt. This is very important to protect your eligibility for benefits (especially when you are enrolling in an HMO), to keep health plan carriers fully informed of the status of its enrollments, and to avoid retroactive adjustments in withholding and contributions.

Health Benefits Forms

Health benefits actions are taken on either the Health Benefits Election Form (SF 2809) or the Notice of Change in Health Benefits Enrollment (SF 2810). Each of these forms contains instructions explaining its use.

Remarks

Both the SF 2809 and SF 2810 contain space for remarks. Your employing office will use this space to give information needed to support any action that is not apparent from the completed form. For example, to show that as a new employee, you are enrolling on a timely basis, your employing office will note "Appointed (date)", or "Converted to eligible type of appointment (date)". It should not include information that is not relevant to your health benefits, such as the reason for separation, or title and grade of your position.

Special entries in the Remarks section are required if you are a temporary continuation of coverage (TCC) enrollee or a temporary employee eligible under 5 U.S.C. 8906(a).

SF 2809

The Health Benefits Election Form (SF 2809) is used to enroll, to decline enrollment, to change your enrollment, or to cancel your enrollment. The SF 2809 may be in either paper or electronic format. Whenever the use of the SF 2809 is discussed in this section, it refers to either the paper or electronic format.

Employing Office Review of SF 2809

Upon its receipt of your Health Benefits Election Form (SF 2809), your employing office will:

  • note in part I the date it received the completed form;
  • make sure that you are eligible to enroll;
  • check that you are not already covered as a family member under another FEHB enrollment;
  • review the form for completeness, consistency, signature, accuracy, and legality of the action, and check all copies for legibility;
  • discuss with you any inconsistencies or situations not permitted by the law or regulations (e.g., not filed within the required time limits; enrollment in a plan not serving your area; name of plan and enrollment code do not agree; code number indicating Self Only enrollment when family members are listed; listing of persons not eligible for family coverage.) If you are enrolling in an employee organization plan, your employing office must accept your enrollment but also advise you that you must become a member of the organization, if you are not already a member;
  • obtain a medical certificate from you if you have listed a child age 26 or over as a family member. Your employing office will record its determination of capability for self-support in the Remarks section on all copies of the form (e.g.,"[name] is incapable of self-support--permanent" or "certificate expires on [date])", and will attach the documentation to the Official Personnel Folder copy of SF 2809 (in a sealed envelope if preferred). If coverage is approved for a limited period of time, your employing office will prepare a follow-up notice to remind you in writing, at least 60 days before the certificate expires, that it must be renewed. If your employing office doesn't approve coverage, it will remove the child's name from the listing of family members;
  • if you are a temporary employee enrolling under 5 U.S.C. 8906a, enter in the Remarks section: "Temporary employee eligible under 5 U.S.C. 8906a; must pay the full premium amount with no Government contribution.";
  • if you have properly completed the SF 2809 and you are eligible to enroll, enter in part I the effective date of your enrollment, payroll office number (or the agency location code, if different from the payroll office number), and the name, title, address, signature, and telephone number of the authorized agency official. These entries may be made by rubber stamp, overprint, or facsimile signature;
  • file a copy on the right or permanent side of the Official Personnel Folder (or its equivalent);
  • send the new carrier and payroll office copies of SF 2809 to the payroll office for transmission to the carrier and for posting to the payroll records, respectively. (If it prefers, your employing office may send all copies except the enrollee copy to the payroll office for its action and later return of the Official Personnel Folder copy for filing.) It will discard the old carrier copy if it is a new enrollment;
  • give you the enrollee copy, so you can use it as proof of enrollment until the carrier sends you an identification card.

Processing an Election not to Enroll

Your employing office will process your election not to enroll in the FEHB Program by following the applicable instructions under "Employing Office Review of SF 2809," except that the carrier copies should be destroyed.

Processing an Election Change

Your employing office will process your election change as outlined in "Employing Office Review of SF 2809" and take these additional steps:

  • if you are changing from one option or type of enrollment to another in the same plan, your employing office will use the new carrier copy of SF 2809 to notify your carrier of the change. It will discard the old carrier copy;
  • if you are changing plans, your employing office will use the new carrier copy of SF 2809 to notify the gaining carrier, and the old carrier copy to notify the losing carrier;
  • if you are changing plans, the correct transmittal document report number must be entered on each carrier's copy.

SF 2810

Your employing office uses the Notice of Change in Health Benefits Enrollment form (SF 2810) to record certain changes in an enrollment not requiring your signature. It is used for an enrollment termination (but not a cancellation), reinstatement, change in payroll office, and a name change. In case of an enrollment termination, the back of the original (enrollee) copy of the SF 2810 serves as your official notice of the 31-day extension of coverage and conversion right. The back of the form also explains other rights you may have (continuation of enrollment on transfer, retirement, death, or entitlement to compensation under the Federal Employees' Compensation law).

Temporary Employee's Change in Employment Status

If your employment status changes from a temporary employee enrolled under 5 U.S.C. 8906a to a position in which you become eligible to receive the Government contribution, your employing office will document the change on the Notice of Change in Health Benefits Enrollment (SF 2810). The SF 2810 documents the change in premium withholding and when your enrollment begins to count toward the requirement for continuation after retirement. (You may change your enrollment if you wish.)

Your employing office will complete parts A, G, and H of the SF 2810, and enter the following remark in Part G: "Employee has been converted/appointed to a position in which (he)(she) participates in a retirement system and is eligible for the Government contribution to the premium."

Name Change

If your name changes but your enrollment does not, your employing office must report it to your carrier. Your employing office prepares a Notice of Change in Health Benefits Enrollment (SF 2810) and notes in the Remarks section the reason and date of the change (e.g., "Employee married [date])."

Reinstatement of Enrollment

When your enrollment is reinstated, your employing office will complete parts A, D, and H of Notice of Change in Health Benefits Enrollment (SF 2810). It will note in the Remarks section the event permitting reinstatement (e.g., "Returned from military service", "Employee reinstated", or "Correction of erroneous termination of enrollment").

Your employing office will send you the enrollee copy, file a copy on the right side of the Official Personnel Folder, and send the carrier and payroll office copies to the payroll office for transmission to the carrier and posting to the payroll records, respectively.

Back to Top

Transfer Between Payroll Offices

Continued Coverage

Your enrollment and coverage continue without change when you transfer from one payroll office to another without a break in service of more than 3 days. Your employing office will promptly take action to transfer your enrollment. See "When You Transfer to a Different Payroll Office (Daily Proration Rule)" for information on each payroll office's responsibility for withholdings and contributions.

Gaining Employing Office Actions

Your gaining employing office will perform a record check on SF 75 before you enter on duty to establish your current enrollment status, enrollment code number, and Social Security number.

When you enter on duty, your employing office will:

  • review SF 75 with you to confirm its accuracy. It will inform you of any opportunities you may have at that time to change your enrollment (e.g., if you moved out of your HMO's service area);
  • complete a Notice of Change in Health Benefits Enrollment (SF 2810), including parts C and H, transferring the enrollment to the gaining employing office;
  • give you the enrollee copy of the new SF 2810. It will keep a file copy for your Official Personnel Folder, and send the carrier and payroll office copies to the payroll office for transmission to the carrier and posting to the payroll records, respectively;
  • verify the transfer-in action on the basis of the health benefits documents located in your Official Personnel Folder. If the action was correct, it will file a copy of SF 2810 on the right side of the Official Personnel Folder (or its equivalent). If the action was not correct, it will correct the error. (If the losing office erroneously terminated your enrollment, the gaining employing office will use part D to show a reinstatement of the enrollment rather than part C to show a transfer in.)

Mass Transfers

When you are part of a group of 25 or more employees enrolled in the same plan to be transferred on the same day from one payroll office to another payroll office, your employing office doesn't need to prepare a separate transfer-in Notice of Change in Health Benefits Enrollment (SF 2810) for each of you. The gaining employing office may make a list of all the employees involved in the transfer and attach several copies to only one SF 2810 documenting the mass transfer in. It will post the change in payroll office number on the latest SF 2809 in each of your Official Personnel Folders so that the payroll office number is up to date.

The gaining employing office will prepare the list in three columns, with column 1 for the employee's name, column 2 for the Social Security Number, and column 3 for the enrollment code number.

Back to Top

Voiding Health Benefits Actions

When Voiding is Appropriate

Voiding is appropriate only when an incorrect health benefits action must be withdrawn and your enrollment status must revert to what it was before the incorrect action was taken. Voiding has the effect of removing the incorrect action as though it never occurred.

Procedure

To void an action, your employing office marks "VOID" in bold letters on the Official Personnel Folder and payroll office copies of the form on which the incorrect action was taken (either the SF 2809 or SF 2810), and explains the action in the Remarks section. Additional remarks are required when an erroneous enrollment is voided.

If your employing office had sent the carrier's copy of the form, it will send the voided payroll office copy to the carrier with the next regular transmittal. If the action being voided is a change in plan, it will send a copy of the voided SF 2809 to both the old and new carrier. Your employing office will keep a copy in your Official Personnel Folder (OPF). If a copy had not been sent to the carrier, it will destroy all but one copy to be retained in your OPF.

Back to Top

Correction of Information on Forms

Your employing office must correct and report to your carrier erroneous information given on the Health Benefits Election Form (SF 2809) or Notice of Change in Health Benefits Enrollment form (SF 2810) that would affect your entitlement to benefits. Significant errors include errors in your name, enrollment code, Social Security number, the effective date of a health benefits action, or a listing of family members when there are none.

Your employing office will make a correction on SF 2809 or SF 2810 (depending on which of these forms contains the erroneous information), and clearly label the form "CORRECTION." The corrected form must give your name, Social Security number, and other identifying data. The form may show only the specific item(s) being corrected, or your employing office may substitute another complete corrected form for the one previously submitted. Your employing office will send the corrected form to your carrier with the next regular transmittal. If the erroneous information was sent to both the old and the new carriers, each will be sent a corrected form.

Back to Top

Reporting Enrollment and Changes in Enrollment to Carriers

Delegation of Authority

Title 6 of the General Accounting Office Manual for Guidance of Federal Agencies, which provides principles and standards for payroll office operations, delegates to OPM the authority to prescribe the principles and standards for payroll transactions for the FEHB Program.

Timely Processing of Transmittals to Carriers

On at least a weekly basis, your payroll office will send copies of Health Benefits Election forms (SF 2809) and Notice of Change in Health Benefits Enrollment forms (SF 2810) to the appropriate carrier with the transmittal document. Your payroll office cannot accumulate health benefits forms for longer than one week.

Verification

Before transmitting a copy of a health benefits form to a carrier, your payroll office must verify that the payroll action required by the form can be taken (e.g., that you were in pay status during the pay period before the effective date, if it is a requirement for that action). A copy of the form can be released to the carrier before payroll action is completed to adjust the health benefits control or to note the individual pay record.

Preparing Transmittal Report

Your payroll office will prepare an original and two copies of the transmittal report. It will send the original and one copy to the carrier with the carrier copies of Health Benefits Election forms (SF 2809) and Notice of Change in Health Benefits Enrollment forms (SF 2810). It will hold the second copy until the carrier returns a certified copy.

Carrier addresses for fee-for-service plans and HMOs are provided to payroll offices by OPM before the start of each annual Open Season. The carrier code is the first two characters of the carrier's enrollment code number.

Payroll Office Number

Each agency payroll office that reports FEHB withholdings and contributions uses a unique eight digit identification number. The first two digits represent the agency (assigned by the U.S. Treasury Department) and the last six digits identify the payroll office within the agency. Agency headquarters must notify OPM of any establishment of or change in payroll office number.

The payroll office number must be provided on every health benefits form (SF 2809, 2810, and transmittal document). In most cases, the agency office that maintains the Retirement and Insurance Transfer System (RITS) also maintains the FEHB enrollment. When different offices are responsible for maintaining RITS and FEHB enrollment, OPM maintains a payroll office directory, containing the addresses and phone numbers of agency offices that prepare RITS and FEHB enrollment information. It is important that agencies promptly report changes to OPM so this directory is kept current. Carriers must also be notified of changes so they can update their records. This is done in the same way as a mass transfer.

Report Number

Your payroll office must enter a report number on each Transmittal Report that it prepares. The first two digits designate the calendar year and the remaining digits run in numerical sequence, starting with number 1. Thus, 99-1 is the number of the first transmittal sent on or after January 1, 1999; 99-2 is the number of the second transmittal in that year, etc. A new series starting with number 1 begins each calendar year.

Your payroll office will enter the transmittal report number in the appropriate space on each Health Benefits Election Form (SF 2809) and Notice of Change in Health Benefits Enrollment form (SF 2810) sent with that transmittal and on the corresponding payroll office copies.

Transmittal

Your payroll office will show the number of Health Benefits Election Forms (SF 2809) and Notice of Change in Health Benefits Enrollment forms (SF 2810) sent with that transmittal to carrier in the space provided.

Carrier Enrollment Records

OPM does not require a specific enrollment records system for carriers. Carriers must maintain their records in a way that allows for easy determination of the number and identity of enrollees served by individual payroll offices for control and statistical reporting and for reconciliations.

Back to Top

Reconciliation

OPM requires the quarterly reconciliation of carrier enrollment records with agency personnel and payroll records. These reconciliations are critical to ensure that enrollees receive the health benefits to which they are entitled.

Joint Payroll Office-Carrier Reconciliations

Each payroll office will reconcile the names and numbers of enrollees in a particular plan with the carrier's records through the National Finance Center (NFC). OPM urges payroll offices and carriers to fully cooperate to maintain accurate and up-to-date enrollment files.

Each payroll office and carrier is required to submit an electronic listing of those enrolled in a FEHB health plan to the NFC on a quarterly basis. The data submitted is to be "as of" March 1, June 1, September 1, or December 1, or as close to those dates as the closest pay period allows. The data is to be submitted in a format designed by NFC and approved by OPM. The social security number is the principal identifying number and must be submitted by all parties. NFC will conduct a computer match of records submitted by payroll offices versus records submitted by carriers and identify discrepancies. These discrepancies are then posted on a secure website known as the Centralized Enrollment Reconciliation Clearinghouse, or CLER for short. Payroll offices are then to resolve the discrepancies with the carriers. Carriers may also contact payroll offices to request resolution of specific discrepancies.

For those enrollments that are reported to CLER only by the carriers, the carriers may use the FEHB Disenrollment Procedures to unilaterally resolve these discrepancies.

The carrier must keep the reconciliation results and work papers for inspection by OPM and the General Accounting Office.

Use of Social Security Numbers in Reconciling Enrollments

Your carrier is required to use your Social Security number to reconcile enrollments. Social Security numbers must be clearly shown on any Health Benefits Election forms (SF 2809) and Notice of Change in Health Benefits Enrollment forms (SF 2810) processed and forwarded to the carriers. Social Security numbers must be available for use in the reconciliation process either within the payroll office or during the joint payroll office-carrier reconciliations.

If you object to giving your carrier your Social Security number, your employing office may make special provisions to accommodate your wishes. However, it may be difficult for the carrier to pay your claims or provide services without using your Social Security number as an identifier.

Disenrollment

When a carrier can not reconcile its records of your enrollment with the employing office's enrollment records, or when it does not receive the necessary documentation from the employing office to resolve the discrepancy within 31 days from its request, the carrier may proceed with your disenrollment.

The carrier must provide you with written notice that the employing office of record does not show you as enrolled in the carrier's plan and that you will be disenrolled 31 calendar days after the date of the notice unless you can provide documentation of your enrollment. This documentation may include:

  • a copy of the Health Benefits Enrollment Form (SF 2809) or a letter confirming an electronic transaction;
  • a Notice of Change in Health Benefits Enrollment (SF 2810) (or the equivalent electronic submission) transferring your enrollment;
  • copies of earnings and leave statements or annuity statements showing withholdings for the plan; or
  • a document or other credible information from your employing office stating that you are entitled to continued enrollment in the plan and that premiums are being paid.

After receiving your documentation, the carrier must notify you and your employing office of its decision on your information. If the carrier does not receive documentation of your enrollment within 31 calendar days from its notice, you will be disenrolled from its plan, without further notice.

You may request that your employing office reconsider the carrier's disenrollment decision. Your reconsideration request must be filed within 60 calendar days of the date of the carrier's disenrollment notice. Your employing office must notify the carrier when it receives such a request.

If, at any time after disenrollment, your employing office or OPM determines that you should be enrolled under another coverage provision, or if the carrier receives appropriate documentation showing that you should be enrolled, the disenrollment is void and coverage is reinstated retroactively.

Other Disenrollment Actions

A carrier also has the right to disenroll:

  • an individual with a Self Only enrollment when it receives reliable information that the person has died;
  • a child survivor annuitant with a Self Only enrollment when he/she reaches age 26, unless the carrier's records indicate that the child is incapable of self-support due to a physical or mental disability;
  • an enrollee who notifies the carrier that he/she has separated from Federal employment and is no longer eligible for FEHB enrollment.

Notice of disenrollment must be provided to a child survivor annuitant or a former employee. The notice must be provided to the child survivor annuitant prior to the disenrollment date.

A child survivor annuitant has the right to request that the retirement system reconsider the disenrollment decision.

If, at any time after disenrollment, the employing office or OPM determines that coverage should be extended under another coverage provision, or if the carrier receives appropriate documentation of the enrollment, the disenrollment is void and coverage is reinstated retroactively.

Back to Top

Control Panel