United States 

Office of Personnel Management 

The Federal Government’s Human Resources Agency

Benefits Administration Letter

Number: 12-204 Date: July 27, 2012

Subject: Federal Employees Health Benefits Program: Revision of Health 

Benefits Election Form, Standard Form 2809 

Purpose

The purpose of this letter is to notify Federal agencies and retirement systems that the 

Office of Personnel Management (OPM) has updated the Health Benefits Election Form,

Standard Form (SF) 2809. This form is used to enroll, change enrollment, decline 

enrollment or cancel enrollment in the Federal Employees Health Benefits (FEHB) 

Program. 

Availability and Use 

The online edition of the SF 2809, dated August 2011, must be downloaded from the 

OPM website at www.opm.gov/forms/pdf_fill/sf2809.pdf. The paper SF 2809 is no 

longer available for purchase from the General Services Administration. Previous 

editions of the form are not usable. 

Once the form is completed, the employing office must generate five copies and 

distribute them according to the instructions on page five of the form. 

Reasons for Revision

1. SF 2809 was updated to make it consistent with changes made to the FEHB Program 

as a result of the Affordable Care Act (Public Law 111-148) and includes updated 

eligibility information for children. This legislation extended coverage to children up 

to their 26th birthday. It also removed requirements for children to be unmarried, for 

stepchildren to live with the enrollee, and for children (except foster children) to be 

dependent on the enrollee. 

2. In an effort to reduce the number of illegal dual enrollments (i.e., when an enrollee or 

family member receives benefits under more than one FEHB enrollment), the revised 

form asks for other health insurance information in a different way. It now includes 

FEHB as a line item when requesting other insurance information for the enrollee and 

each eligible family member, and clarifies the instructions for completing this 

question. (Items 10, 20, 32, and 44).
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3. Please be aware of a new footnote, #9, in the Table of Permissible Changes in FEHB 

Enrollment and Premium Conversion Election (Table 1). It clarifies that an employee 

may change to Self Only outside of Open Season only if the Qualifying Life Event 

(QLE) caused all eligible family members 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. 

4. The revised form also requests additional information from enrollees and their 

eligible family members, including: 

Medicare Claim Number for both the enrollee and dependents. Previously, this 

number was not gathered; 

Email address for enrollee and dependents who do not live with the enrollee. 

Previously, email addresses were not gathered; and 

Preferred telephone number for enrollee and dependents who do not live with the 

enrollee. Previously, the daytime telephone number of the enrollee was 

requested. 

Who May Use SF 2809

The following individuals may use SF 2809 if they are eligible to enroll in or are 

currently enrolled in the FEHB Program: 

Employees; 

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; and 

Individuals eligible for Temporary Continuation of Coverage (TCC)

Electronic Enrollment Systems 

Electronic enrollment systems are currently being programmed to gather the new 

information. We expect that these systems will be capable of reporting the new data to 

carriers electronically by the 2012 Open Season. 

Additional Information 

If you have specific questions about the SF 2809, please contact your agency’s benefits 

officer. If you do not know who this person is, please go to http://apps.opm.gov/abo/

where you will find a list of agencies and their Headquarters Benefits Officers. 
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For more information on the FEHB Program, please visit www.opm.gov/insure/health. 

 

 Sincerely, 

John O’Brien

Director 

Healthcare and Insurance