Retirement and Insurance Service Benefits Administration Letter
Number: |
04-405 |
Date: October 15, 2004 |
Subject: |
Federal Employees Health Benefits Program: Revision of Health Benefits Election Form, Standard Form 2809
|
PURPOSE
This is to advise Federal agencies and retirement systems that the Health Benefits Election Form, Standard Form (SF) 2809 has been revised and is currently available. The October 2004 edition supersedes all previous editions of this form and makes obsolete the Annuitant/OWCP Health Benefits Election Form, SF 2809-1.
SF 2809 Users
The following individuals may use the SF 2809 if they are eligible to enroll in 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 FEHB law or similar statutes.
- 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 FEHB law.
Ordering Information
The SF 2809 can be ordered from the General Services Administration's (GSA) Federal Supply Service using the normal FEDSTRIP/MILSTRIP procedures. Ordering information is provided below.
Form Number |
Title of Form |
National Stock No. |
Estimated Cost |
SF 2809 |
Health Benefits Election Form |
7540-01-231-6227 |
$28.62 per 100 |
The SF 2809 can also be accessed from our web site at www.opm.gov.
If your employees have access to Employee Express or another electronic FEHB enrollment system, you should keep this in mind when deciding how many forms to order.
Significant Changes to the SF 2809
A New Table of Permissible Changes
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 CSRS/FERS annuitants), including individuals receiving monthly compensation from the Office of Workers' Compensation Programs;
Table 3: Former spouses eligible for coverage under the Spouse Equity provisions of the FEHB law;
Table 4:Individuals eligible for coverage under the temporary continuation of coverage (TCC) provisions of the FEHB law;
Table 5: Employees who do NOT participate in premium conversion. Employees who do NOT participate in premium conversion.
HIPAA Compliance
The SF 2809 is now consistent with the electronic FEHB enrollment format that 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 member's address when different from the enrollee.
Combined with the SF 2809-1
The 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.
Additional Information
If your agency currently submits FEHB enrollments electronically, this new form should not require any changes in your submissions. If you have any further questions about this form, please call our information staff on (202) 606-0745. You may also send an e-mail about this issue to fehb@opm.gov.
|
Frank D. Titus
Assistant Director
for Insurance Services
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Attachments
Download the Letter as a PDF File 
40 KB
