Form Approved: Health Benefits Election Form 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. See the Privacy Act and Public Burden Statements on page 5. 

Item 5. If you are separated but not divorced, you are still married. 

Item 7. If you have Medicare, check which Parts you have, including 

prescription drug coverage under Medicare Part D. 

Item 8. If you have Medicare, enter your Medicare Beneficiary 

Identifier (MBI). This number is on your Medicare Card.

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. 

Previous edition is not usable 

Standard Form 2809 

Revised November 2019

1
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 

99 Disabled child age 26 or older who is incapable 

of self support because of a physical or mental th disability that began before his/her 26 birthday. 

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. 

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: 

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 enrollment 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. 

Standard Form 2809 

Revised November 2019

2
 

 

 

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. 

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

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. 

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 re 

Standard Form 2809 Revised November 2019

enroll only under the circumstances

3
 

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. 

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. 

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. 

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. 

Standard Form 2809 

Revised November 2019

4
 

 

Part I - Agency or Retirement System Information  For the eligible former spouse of an enrollee, the enrollee or the

and Remarks former spouse must notify the employing office within 60 days after 

Leave this section blank as it is for agency or retirement system use only. the former spouse’s change in status; e.g., the date of the divorce. 

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. 

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.

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. 

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.

Standard Form 2809 

Revised November 2019

5
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 

May Permit Change in FEHB 

Enrollment, Designated Family 

Member or Premium Conversion 

Election

Change that May Be Permitted Premium 

Conversion Change 

that May Be 

Permitted

Time Limits in 

which Change 

May Be 

Permitted

Event

Code

Event From Not

Enrolled To

Enrolled

From Self

Only to Self

Plus One or

Self and

Family 

From One

Plan or

Option to

Another

Cancel or

Change to

Self Plus

One or Self

Only

Switch 

Designated

Family 

Member

Participate Waive When You Must

File Health Benefits

Election Form With

Your Employing

Office

1 Employee electing to receive or receiving premium conversion tax benefits

1A Initial opportunity to enroll, for 

example: 

• New employee

• Change from excluded

position 

• Temporary employee who

completes 1 year of service

and is eligible to enroll under 

5 USC 8906a

Yes N/A N/A N/A N/A Automatic 

Unless 

Waived 

Yes Within 60 days 

after becoming

eligible

1B Open Season Yes Yes Yes Yes Yes Yes Yes As announced by 

OPM

1C Change in family status that 

results in increase or decrease in 

number of eligible family 

members, for example: 

• Marriage, divorce, annulment

• Birth, adoption, acquiring

foster child or stepchild, 

issuance of court order 

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

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before the 

event.

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before the 

event.

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before the 

event.

Yes1 Yes Yes Yes Within 60 days after 

change in family 

status

1D Any change in employee’s 

employment status that could 

result in entitlement to coverage, 

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.)

Yes N/A N/A N/A No Automatic 

Unless 

Waived

Yes Within 60 days 

after employment 

status change

6
Qualifying Life Events (QLE’s) that 

May Permit Change in FEHB 

Enrollment, Designated Family 

Member or Premium Conversion 

Election

Change that May Be Permitted Premium 

Conversion Change 

that May Be 

Permitted

Time Limits in 

which Change 

May Be 

Permitted

Event

Code

Event From Not

Enrolled To

Enrolled

From Self

Only to Self

Plus One or

Self and

Family 

From One

Plan or

Option to

Another

Cancel or

Change to

Self Plus

One or Self

Only

Switch 

Designated

Family 

Member

Participate Waive When You Must

File Health Benefits

Election Form With

Your Employing

Office

1E Any change in employee’s

employment status that could

affect cost of insurance, including:

• 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 parttime career or the reverse

Yes Yes Yes Yes No Yes Yes Within 60 days 

after employment 

status change

1F Employee restored to civilian 

position after serving in uniformed 

services2.

Yes Yes Yes Yes No Yes Yes Within 60 days after 

return to civilian 

position 

1G Employee, spouse or eligible

family member:

• Begins nonpay status or 

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.)

No No No Yes No Yes Yes Within 60 days 

after employment 

status change

1H Salary of temporary employee

insufficient to make withholdings

for plan in which enrolled.

N/A No Yes Yes No Yes Yes Within 60 days

after receiving

notice from

employing office

1I Employee (or covered family

member) enrolled in FEHB health

maintenance organization (HMO)

moves or becomes employed

outside the geographic area from

which the FEHB carrier accepts

enrollments or, if already outside

the area, moves further from this

area.4

N/A Yes Yes N/A 

(see 1M)

Yes No

(see 1M)

No

(see 

1M)

Upon notifying 

employing office of 

move

1J Transfer from post of duty within

a State of the United States or the

District of Columbia to post of

duty outside a State of the United

States or District of Columbia, or

reverse. 

Yes 

. Employees

may enroll 

or change 

beginning 

31 days 

before 

leaving the 

old post of 

duty.

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before 

leaving the 

old post of 

duty.

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before 

leaving the 

old post of 

duty.

Yes Yes Yes Yes Within 60 days after 

arriving at new post

1K Separation from Federal 

employment when the employee or 

employee’s spouse is pregnant.

Yes Yes Yes N/A No N/A N/A During employee’s 

final pay period

7
Qualifying Life Events (QLE’s) that 

May Permit Change in FEHB 

Enrollment, Designated Family 

Member or Premium Conversion 

Election

Change that May Be Permitted Premium 

Conversion Change 

that May Be 

Permitted

Time Limits in 

which Change 

May Be 

Permitted

Event

Code

Event From Not

Enrolled To

Enrolled

From Self

Only to Self

Plus One or

Self and

Family 

From One

Plan or

Option to

Another

Cancel or

Change to

Self Plus

One or Self

Only

Switch 

Designated

Family 

Member

Participate Waive When You Must

File Health Benefits

Election Form With

Your Employing

Office

1L Employee becomes entitled to

Medicare and wants to change to

another plan or option.5 

No No Yes 

(Changes 

may be 

made 

only 

once.) 

N/A 

(see 1P)

No N/A 

(see 1P)

N/A 

(see 

1P)

Any time beginning 

on the 30th day 

before becoming 

eligible for

Medicare

1M Employee or eligible family

member loses coverage under

FEHB or another group insurance

plan including the following:

• 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 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 Statesponsored program of medical

assistance for the needy

• Loss of coverage under a nonFederal 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.)

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before the 

event.

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before the 

event.

Yes 

Employees 

may enroll 

or change 

beginning 

31 days 

before the 

event.

Yes Yes Yes Yes Within 60 days after 

loss of coverage

1N Loss of coverage under a non

Federal group health plan because

an employee moves out of the

commuting area to accept another

position and the employee’s nonFederally employed spouse

terminates employment to

accompany the employee.

Yes Yes Yes Yes Yes Yes Yes From 31 days

before the

employee leaves 

the commuting

area to 180 days

after arriving in the

new commuting

area 

1O Employee or eligible family

member loses coverage due to

discontinuance in whole or part of

FEHB plan.7

Yes Yes Yes Yes Yes Yes Yes During open season, 

unless OPM sets a 

different time

8
Qualifying Life Events (QLE’s) that 

May Permit Change in FEHB 

Enrollment, Designated Family 

Member or Premium Conversion 

Election

Change that May Be Permitted Premium 

Conversion Change 

that May Be 

Permitted

Time Limits in 

which Change 

May Be 

Permitted

Event

Code

Event From Not

Enrolled To

Enrolled

From Self

Only to Self

Plus One or

Self and

Family 

From One

Plan or

Option to

Another

Cancel or

Change to

Self Plus

One or Self

Only

Switch 

Designated

Family 

Member

Participate Waive When You Must

File Health Benefits

Election Form With

Your Employing

Office

1P Enrolled employee or eligible

family member gains coverage

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

No No No Yes9 Yes Yes Yes Within 60 days after 

QLE

1Q Change in spouse’s or eligible

family member’s coverage options

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)

No No No Yes9 Yes Yes Yes Within 60 days after 

QLE

1R Employee or eligible family 

member becomes eligible for 

assistance under Medicaid or a 

State Children’s Health Insurance 

Program (CHIP).

Yes Yes Yes Yes9 Yes Yes Yes Within 60 days

after the date the

employee or

family member

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 

Enrollment or Change Change that May Be Permitted Time Limits 

Event 

Code Event 

From Not 

Enrolled to 

Enrolled 

From Self 

Only to Self 

Plus One or 

Self 

and Family 

From 

One 

Plan or 

Option 

to 

Another 

Switch 

Designated 

Family 

Member 

When You Must File Health 

Benefits Election Form With 

Your Employing Office 

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 

death of family member, adoption, or divorce. 

No Yes Yes Yes From 31 days before through 60 

days after the event. 

2C Reenrollment of annuitant who suspended FEHB 

enrollment to enroll in a Medicare Advantage plan, 

Medicaid or similar State-sponsored program, or to use 

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. 

May Reenroll N/A N/A No From 31 days before through 60 

days after involuntary loss of 

coverage. 

2D Reenrollment of annuitant who suspended FEHB 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. 

May Reenroll N/A N/A No During open season. 

2E Restoration of annuity or compensation (OWCP) 

payments, for example: 

• Disability annuitant who was enrolled in FEHB, and 

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 immediately before survivor annuity terminated because of 

marriage and whose survivor annuity is restored. 

Yes N/A N/A No Within 60 days after the retirement system or OWCP mails a 

notice of insurance eligibility. 

2F Annuitant or eligible family member loses FEHB 

coverage due to termination, cancellation, or change to 

Self Plus One or Self Only of the covering enrollment. 

Yes Yes Yes Yes From 31 days before through 60 

days after date of loss of coverage. 

11
QLE’s That Permit 

Enrollment or Change Change that May Be Permitted Time Limits 

Event 

Code Event 

From Not 

Enrolled to 

Enrolled 

From Self 

Only to Self 

Plus One or 

Self 

and Family 

From 

One 

Plan or 

Option 

to 

Another 

Switch 

Designated 

Family 

Member 

When You Must File Health 

Benefits Election Form With 

Your Employing Office 

2G Annuitant or eligible family member loses coverage 

under another group insurance plan, for example: 

 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. 

No Yes Yes Yes From 31 days before through 60 

days after loss of coverage. 

2H Annuitant or eligible family member loses coverage due 

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

N/A Yes Yes Yes During open season, unless 

OPM sets a different time. 

2I Annuitant or covered family member in a Health 

Maintenance Organization (HMO) moves or becomes 

employed outside the geographic area from which the 

carrier accepts enrollments, or if already outside this area, 

moves or becomes employed further from this area. 

N/A Yes Yes Yes Upon notifying the employing 

office of the move or change of 

place of employment. 

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 

31 days or more in a uniformed service. 

N/A Yes Yes No Within 60 days after separation 

from the uniformed service. 

2L On becoming eligible for Medicare. 

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

N/A No Yes No At any time beginning on the 

30th day before becoming eligible for Medicare. 

2M Annuitant’s annuity is insufficient to make withholdings 

for plan in which enrolled. 

N/A No Yes No Employing office will advise 

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 

eligible to enroll under the authority of the Civil Service 

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

amended, the Intelligence Authorization Act of 1986 

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

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

Yes N/A N/A N/A Generally, must apply within 

60 days after dissolution of 

marriage. However, if a retiring 

employee elects to provide a 

former spouse annuity or 

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 

members who are also eligible family members of the 

employee or annuitant. 

No Yes Yes Yes From 31 days before through 60 

days after change in family 

status. 

3D Reenrollment of former spouse who suspended FEHB 

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 later involuntarily loses this 

coverage under one of these programs. 

May reenroll N/A N/A No From 31 days before through 60 

days after involuntary loss of 

coverage. 

12
QLE’s That Permit 

Enrollment or Change Change that May Be Permitted Time Limits 

Event 

Code Event 

From Not 

Enrolled to 

Enrolled 

From Self 

Only to Self 

Plus One or 

Self 

and Family 

From 

One 

Plan or 

Option to 

Another 

Switch 

Designated 

Family 

Member 

When You Must File Health 

Benefits Election Form With 

Your Employing Office 

3E Reenrollment of former spouse who suspended FEHB 

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. 

May reenroll N/A N/A No During open season. 

3F Former spouse or eligible child loses FEHB coverage 

due to termination, cancellation, or change to Self Only 

of the covering enrollment. 

Yes Yes Yes Yes From 31 days before through 60 

days after date of loss of coverage. 

3G Enrolled former spouse or eligible child loses coverage 

under another group insurance plan, for example: 

 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. 

N/A Yes Yes Yes From 31 days before through 60 

days after loss of coverage. 

3H Former spouse or eligible family member loses coverage 

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

plan. 

N/A Yes Yes Yes During open season, unless 

OPM sets a different time. 

3I Former spouse or covered family member in a Health 

Maintenance Organization (HMO) moves or becomes 

employed outside the geographic area from which the 

carrier accepts enrollments, or if already outside this 

area, moves or becomes employed further from this area. 

N/A Yes Yes Yes Upon notifying the employing 

office of the move or change of 

place of employment. 

3J On becoming eligible for Medicare 

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

N/A No Yes No At any time beginning the 30th 

day before becoming eligible for 

Medicare. 

3K Former spouse’s annuity is insufficient to make FEHB 

withholdings for plan in which enrolled. 

No No Yes No Retirement system will advise 

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 

provisions: 

 Former employee 

 Former spouse 

 Child who ceases to qualify as a family 

member 

Yes 

Yes 

Yes 

Yes 

N/A 

N/A 

Yes 

N/A 

N/A 

N/A 

Within 60 days after the qualifying event, or receiving notice of 

eligibility, whichever is later. 

4B Open Season: 

 Former employee 

 Former spouse 

 Child who ceases to qualify as a family 

member 

No 

No 

No 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

As announced by OPM. 

4C Change in family status (except former spouse); for 

example, marriage, birth or death of family member, 

adoption, or divorce. 

No Yes Yes Yes From 31 days before through 60 

days after event. 

13
QLE’s That Permit 

Enrollment or Change Change that May Be Permitted Time Limits 

Event 

Code Event 

From Not 

Enrolled to 

Enrolled 

From Self 

Only to Self 

Plus One or 

Self and 

Family 

From 

One 

Plan or 

Option 

to 

Another 

Switch 

Designated 

Family 

Member 

When You Must File Health 

Benefits Election Form With 

Your Employing Office 

4D Change in family status of former spouse, based on 

addition of family members who are eligible family 

members of the employee or annuitant. 

No Yes Yes Yes From 31 days before through 60 

days after event. 

4E Reenrollment of a former employee, former spouse, or 

child whose TCC enrollment was terminated because of 

other FEHB coverage and who loses the other FEHB 

coverage before the TCC period of eligibility (18 or 36 

months) expires. 

May reenroll N/A N/A No From 31 days before through 60 

days after the event. Enrollment 

is retroactive to the date of the 

loss of the other FEHB coverage. 

4F Enrollee or eligible family member loses coverage 

under FEHB or another group insurance plan, for 

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. 

No Yes Yes Yes From 31 days before through 60 

days after loss of coverage. 

4G Enrollee or eligible family member loses coverage due 

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

plan. 

N/A Yes Yes Yes During open season, unless 

OPM sets a different time. 

4H Enrollee or covered family member in a Health 

Maintenance Organization (HMO) moves or becomes 

employed outside the geographic area from which the 

carrier accepts enrollments, or if already outside this 

area, moves or becomes employed further from this 

area. 

N/A Yes Yes No Upon notifying the employing 

office of the move or change of 

place of employment. 

4I On becoming eligible for Medicare. 

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

N/A No Yes No At any time beginning on the 

30th day before becoming eligible 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 

death of family member, adoption, or divorce 

Yes Yes Yes Yes From 31 days before through 60 

days after event. 

14
QLE’s That Permit 

Enrollment or Change Change that May Be Permitted Time Limits 

Event 

Code Event 

From Not 

Enrolled to 

Enrolled 

From Self 

Only to Self 

Plus One or 

Self and 

Family 

From 

One 

Plan or 

Option 

to 

Another 

Switch 

Designated 

Family 

Member 

When You Must File Health 

Benefits Election Form With 

Your Employing Office 

5D Change in employment status, for example: 

 Reemployment after a break in service of more than 3 

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. 

Yes Yes Yes No Within 60 days of employment 

status change. 

5E Separation from Federal employment when the 

employee or employee’s spouse is pregnant. 

Yes Yes Yes No Enrollment or change must 

occur during final pay period of 

employment. 

5F Transfer from a post of duty within the United States to 

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

Yes Yes Yes Yes From 31 days before leaving old 

post through 60 days after arriving at new post. 

5G Employee or eligible family member loses coverage 

under FEHB or another group insurance plan, for 

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. 

Yes Yes Yes Yes From 31 days before through 60 

days after loss of coverage. 

5H Enrollee or eligible family member loses coverage due 

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

plan. 

N/A Yes Yes Yes During open season, unless 

OPM sets a different time. 

5I Loss of coverage under a non-Federal group health plan 

because an employee moves out of the commuting area 

to accept another position and the employee’s 

non-federally employed spouse terminates employment 

to accompany the employee. 

Yes Yes Yes Yes From 31 days before the 

employee leaves the commuting 

area through 180 days after 

arriving in the new commuting 

area. 

5J Employee or covered family member in a Health 

Maintenance Organization (HMO) moves or becomes 

employed outside the geographic area from which the 

carrier accepts enrollments, or if already outside the 

area, moves or becomes employed further from this 

area. 

N/A Yes Yes Yes Upon notifying the employing 

office of the move or change of 

place of employment. 

15
QLE’s That Permit 

Enrollment or Change Change that May Be Permitted Time Limits 

Event 

Code Event 

From Not 

Enrolled to 

Enrolled 

From Self 

Only to Self 

Plus One or 

Self 

and Family 

From 

One 

Plan or 

Option 

to 

Another 

Switch 

Designated 

Family 

Member 

When You Must File Health 

Benefits Election Form With 

Your Employing Office 

5K On becoming eligible for Medicare 

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

N/A No N/A No At any time beginning on the 

30th day before becoming 

eligible for Medicare. 

5L Temporary employee completes one year of continuous 

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

Yes N/A N/A No Within 60 days after becoming 

eligible. 

5M Salary of temporary employee insufficient to make 

withholdings for plan in which enrolled. 

N/A No Yes No Within 60 days after receiving 

notice from employing office. 

5N Employee or eligible family member becomes eligible for 

assistance under Medicaid or a State Children’s Health 

Insurance Program (CHIP). 

Yes Yes Yes Yes Within 60 days after the date the 

employee or family member 

becomes eligible for assistance. 

16
Form Approved: 

OMB No. 3206-0160 

Federal Employees Health Benefits Election Form Health Benefits Program 

7. If you are covered by Medicare, 8. Medicare Beneficiary Identifier check all that apply. 

6. Home mailing address (including ZIP Code)

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 

M F 

5. Are you married? 

Yes No 

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. 

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

19. If this family member is covered by Medicare, check all that apply. 

21. Is this family member covered by insurance other than Medicare? 

11. Email address 

18. Address (if different from enrollee) 

14. Social Security Number 15. Date of birth (mm/dd/yyyy) 16. Sex 

M F 

17. Relationship code 

A B 

20. Medicare Beneficiary Identifier 

D 

Yes, indicate in item 22 below. No 

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

12. Preferred telephone number 

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. 

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

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

31. If this family member is covered by Medicare, check all that apply. 

33. Is this family member covered by insurance other than Medicare? 

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

your spouse or adult child)

30. Address (if different from enrollee) 

26. Social Security Number 27. Date of birth (mm/dd/yyyy) 28. Sex 

M F 

29. Relationship code 

A B 

32. Medicare Beneficiary Identifier 

D 

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. 

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

43. If this family member is covered by Medicare, check all that apply. 

45. Is this family member covered by insurance other than Medicare? 

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)

42. Address (if different from enrollee) 

38. Social Security Number 39. Date of birth (mm/dd/yyyy) 40. Sex 

M F 

41. Relationship code 

A B 

44. Medicare Beneficiary Identifier 

D 

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 Revised November 2019 For agency distribution of copies, see page 5 of the instructions.
Enrollee name: _________________________________________________________ Date of birth: ____________________________ 

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 6) Part E - Election NOT to Enroll (Employees Only) 

Part F - Cancellation of FEHB 

I CANCEL my enrollment. 

1. Event code 2. Date of event 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. 

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. 

Part H - Signature 

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

Plan name 2. Enrollment code

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

1. 1. Plan name 2. Enrollment code 

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 

( ) 

Standard Form 2809 

Reverse of revised November 2019

Previous edition is not usable