Standard Form 2809 - Health Benefits Election Form Page 11
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15QLE’s That Permit
Change Permitted
Time Limits
Enrollment or Change
From Not
From Self
From One
When You Must File Health
Event
Event
Enrolled to
Only to Self
Plan or
Benefits Election Form With
Code
Enrolled
and Family
Option to
Your Employing Office
Another
3F
Former spouse or eligible child loses FEHB coverage due
Yes
Yes
Yes
From 31 days before through 60
to termination, cancellation, or change to Self Only of the
days after date of loss of coverage.
covering enrollment.
3G
Enrolled former spouse or eligible child loses coverage under
N/A
Yes
Yes
From 31 days before through 60
another group insurance plan; for example:
days after loss of coverage.
•
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.
3H
Former spouse or eligible family member loses coverage due
N/A
Yes
Yes
During open season, unless OPM
to the discontinuance, in whole or part, of an FEHB plan.
sets a different time.
3I
Former spouse or covered family member in a Health
N/A
Yes
Yes
Upon notifying the employing
Maintenance Organization (HMO) moves or becomes
office of the move or change of
employed outside the geographic area from which the carrier
place of employment.
accepts enrollments, or if already outside this area, moves or
becomes employed further from this area.
3J
On becoming eligible for Medicare
N/A
No
Yes
At any time beginning the 30th
day before becoming eligible for
Medicare.
(This change may be made only once in a lifetime.)
3K
Former spouse’s annuity is insufficient to make FEHB with-
No
No
Yes
Retirement system will advise
holdings for plan in which enrolled.
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 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
Within 60 days after the qualifying
provisions:
event, or receiving notice of
Yes
Yes
Yes
eligibility, whichever is later.
•
Former employee
Yes
N/A
N/A
•
Former spouse
Yes
N/A
N/A
•
Child who ceases to qualify as a family
member
4B
Open Season:
As announced by OPM.
No
Yes
Yes
•
Former employee
No
Yes
Yes
•
Former spouse
No
Yes
Yes
•
Child who ceases to qualify as a family
member
4C
Change in family status (except former spouse); for example,
No
Yes
Yes
From 31 days before through 60
marriage, birth or death of family member, adoption, legal
days after event.
separation, or divorce.
4D
Change in family status of former spouse, based on addition
No
Yes
Yes
From 31 days before through 60
of family members who are eligible family members of the
days after event.
employee or annuitant.
4E
Reenrollment of a former employee, former spouse, or child
May reenroll
N/A
N/A
From 31 days before through 60
whose TCC enrollment was terminated because of other
days after the event. Enrollment is
FEHB coverage and who loses the other FEHB coverage
retroactive to the date of the loss of
before the TCC period of eligibility (18 or 36 months)
the other FEHB coverage.
expires.
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