United States 

Office of 

Personnel Management

The Federal Government’s Human Resources Agency 

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: 

o	 Former employees (who separated from service); 

o	 Children who lose FEHB coverage; and 

o	 Former spouses who are not eligible under the Spouse Equity provisions of FEHB 

law. 

Civil Service Federal Employees’ Federal Employees Federal Employees Long Term 

Retirement Group Life Health Benefits Retirement Care Insurance 

System Insurance Program Program System Program 
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. 

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 

2 
• 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 Programs 

Attachment 

3