Civil Service Federal Employees Federal Employees Federal Employees

Retirement Group Life Health Benefits Retirement

System Insurance Program System

 United States

Office of 

Personnel Management

The Federal Government’s Human Resources Agency

Retirement and Insurance Service

Benefits Administration Letter

 

Number: 99-215 Date: October 14, 1999

Subject: Federal Employees Health Benefits (FEHB) Program: Revision of SF 2809

(Health Benefits Election Form)

Date of Revision The revised form is dated July 1999.

Purpose of We revised the form to conform to the 1997 changes to FEHB regulations

Revision that simplified and clarified the opportunities to enroll and change

enrollment.

The revised SF 2809, Employee Health Benefits Election Form, will be

used by employees, former employees and former dependents eligible to

enroll under the Temporary Continuation of Coverage or Spouse Equity

provisions of FEHB law.

We also created a new form, Annuitant/OWCP Health Benefits Election

Form (SF 2809-1) for use by annuitants of other retirement systems for

Federal employees and compensationers. We have provided additional

information on this form in Benefits Administration Letter 99-216.

Previous Editions Previous editions of SF 2809 are not usable.

When Available The revised SF 2809 will be available at the beginning of October from the

General Services Administration’s Federal Supply Service using the normal

FEDSTRIP/MILSTRIP procedures as specified by your agency’s

procurement or acquisition office. (FEDSTRIP/MILSTRIP is the ordering

procedure used by agencies to procure items from the GSA Federal Supply

Depot.)

The revised SF 2809 will soon be available on the OPM FEHB website at

www.opm.gov/insure.
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Stock Number and The National Stock Number for SF 2809 is 7540-01-231-6227. The cost

Cost is $15.62 per hundred. . 

Transition Help As you know, the old SF 2809 used numbers to designate the events that

permitted enrollment or change of enrollment. The revised form uses a

code consisting of a number and a letter so that the events could be

grouped by category of enrollee as they are in the regulations. The number

signifies the category of enrollee, and the letter signifies the event. The

enrollee categories are:

1 - Employee

2 - Annuitant (not shown on SF 2809)

3 - Former Spouse

4 - Temporary Continuation of Coverage

We believe these new event codes will make it easier for enrollees to find

the event applicable to their specific situation. To ease the transition for

agencies, we have attached two versions of a chart that translates the old

event number from the 1992 SF 2809 into the new event code.

The first chart lists the events from the August 1992 SF 2809 and shows

both the old and new event codes. The second chart provides a further

breakdown of the new codes by category of enrollee. For example, an

open season change that was previously event #1 would now be 1B for

employees, 2A for annuitants, 3B for former spouses, and 4B for TCC

enrollees. 

The 1997 regulations created several new events for which there is no old

event number; therefore these new events are not shown on the attached

charts. For example, an employee’s initial opportunity to enroll is event

1A.

In addition, the 1997 regulations combined several of the old events, so

that old event numbers 5, 6, 7, 11, 12, 15, 16, 17 and 20 are now event F

or G under the new enrollee categories. Charts #1 and #2 give complete

information on old and new codes and associated events.
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If you need assistance in understanding the new SF 2809, please call our

Information Staff on (202) 606-0191. You may also send Email about the

new SF 2809 to Barbara Myers at bdmyers@opm.gov.

Abby L. Block, Chief

Insurance Policy

 and Information Division

Attachments
Chart #1

4

Event Old

Code

New Code

Open season 1 1B, 2A, 3B, 4B

Marital status change 2 1C, 2B, 4C

Other family status change 3 1C, 2B, 3C, 4C, 4D

Move from HMO area 4 1J, 2I, 3I, 4H

Membership in employee organization terminates 5 1G, 2G, 3G, 4F

Employee, annuitant, or former spouse loses other FEHB

coverage for reasons other than cancellation or change to

self only;

Employee loses other federally sponsored coverage

6 1G, 2F, 3F

Employee, annuitant or former spouse loses other FEHB

coverage due to change to self only

7 1G, 2F, 3F

Employee transfers to or from overseas post of duty 8 1F

Employee returns to active civilian duty;

Annuitant separates from military service

9 1D, 2K

Plan stops participating in FEHB program 10 1H, 2H, 3H, 4G

Spouse’s self only enrollment terminates 11 1G, 2F

Employee loses coverage under parent’s non-Federal plan 12 1G

Employee retires from overseas post of duty 13 2J

Enrollee becomes eligible for Medicare 14 1K, 2L, 3J, 4I

Enrollee’s child loses other FEHB coverage 15 1G, 2G, 3F, 4F

Employee or family member loses Medicaid coverage 16 1G, 3G, 4F

Employee, annuitant or former spouse loses other FEHB

coverage due to cancellation

17 1G, 2F, 3F
Chart #1

5

Event Old

Code

New Code

Employee changes from full-time to part-time career

employment

18 1D

Employee or spouses loses coverage under spouse’s nonFederal health plan when spouse terminates employment to

accompany employee who is reassigned out of commuting

area

19 1I

Loss of coverage under non-Federal health plan 20 1G, 2G, 3G, 4F

Former spouse enrolls under Spouse Equity Act 21 3A

Temporary employee completes one year of service in

accordance with 5 U.S.C. 8906a

22 1L

Temporary employee, eligible under 5 U.S.C. 8906a,

changes to nontemporary appointment

23 1D

Employee is separated from service and eligible for TCC 24 4A

Enrollee’s child ceases to be an unmarried dependent child 25 4A
Chart #2

6

Event Old

Code

New Code

Employee Annuitant Former

Spouse

TCC

Open season 1 1B 2A 3B 4B

Marital status change 2 1C 2B 4C

Other family status change 3 1C 2B 3C 4C, 4D

Move from HMO area 4 1J 2I 3I 4H

Membership in employee organization

terminates

5 1G 2G 3G 4F

Employee, annuitant, or former spouse loses

other FEHB coverage for reasons other than

cancellation or change to self only;

Employee loses other federally sponsored

coverage

6 1G 2F 3F

Employee, annuitant or former spouse loses

other FEHB coverage due to change to self

only

7 1G 2F 3F

Employee transfers to or from overseas post of

duty

8 1F

Employee returns to active civilian duty;

Annuitant separates from military service

9 1D 2K

Plan stops participating in FEHB program 10 1H 2H 3H 4G

Spouse’s self only enrollment terminates 11 1G 2F
Chart #2

7

Event Old

Code

New Code

Employee Annuitant Former

Spouse

TCC

Employee loses coverage under parent’s nonFederal plan12 1G

Employee retires from overseas post of duty 13 2J

Enrollee becomes eligible for Medicare 14 1K 2L 3J 4I

Enrollee’s child loses other FEHB coverage 15 1G 2G 3F 4F

Employee or family member loses Medicaid

coverage

16 1G 3G 4F

Employee, annuitant or former spouse loses

other FEHB coverage due to cancellation

17 1G 2F 3F

Employee changes from full-time to part-time

career employment

18 1D

Employee or spouses loses coverage under

spouse’s non-Federal health plan when spouse

terminates employment to accompany

employee who is reassigned out of commuting

area

19 1I

Loss of coverage under non-Federal health

plan

20 1G 2G 3G 4F

Former spouse enrolls under Spouse Equity

Act

21 3A

Employee Annuitant Former TCC
Chart #2

8

Event Old

Code

New Code

Spouse

Temporary employee completes one year of

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

22 1L

Temporary employee, eligible under 5 U.S.C.

8906a, changes to nontemporary appointment

23 1D

Employee is separated from service and

eligible for TCC

24 4A

Enrollee’s child ceases to be an unmarried

dependent child

25 4A