C. I am suspending my Federal Employees Health Benefits Program (FEHBP) enrollment because I am enrolled
in a Medicare Advantage health plan. Please note: Medicare Parts A and B are not the same as a Medicare Advantage
health plan. You CANNOT suspend your FEHBP enrollment if you are covered by Medicare Parts A and/or B only. Any
Questions: Call Medicare at 1-800-633-4227.
These Medicare Advantage health plans are Health Maintenance Organizations or Fee-For-Service plans approved
by the Centers for Medicare and Medicaid Services (CMS). If you are enrolled in a Medicare supplemental plan and
are not sure if it qualifies as a Medicare Advantage health plan, call Medicare at the number shown above. To
suspend your FEHBP coverage for this reason, you must give us documentation that shows the effective date of your
Medicare Advantage health plan coverage. If we receive this form within 31 days before to 31 days after the effective
date of your Medicare Advantage health plan enrollment, we will suspend your FEHBP coverage at the close of
business the day before your Medicare Advantage health plan enrollment begins. Otherwise, we will suspend your
FEHBP coverage at the end of the month in which we receive your documentation.
D. I am suspending my FEHBP enrollment to use TRICARE, TRICARE for Life (enrollees over age 65 with
Medicare Parts A and B), Peace Corps, or CHAMPVA. Please suspend my FEHBP enrollment effective
_______________________________. (Carefully consider the effective date of your suspension. Once we
process your request, we are not able to change the effective date.)
To suspend your FEHBP coverage for this reason, you must give us evidence of your eligibility for TRICARE,
TRICARE for Life, Peace Corps, or CHAMPVA. Please send us a copy of your Uniformed Services Identification
(I.D.) card and if over age 65, you must also send us a copy of your Medicare card showing enrollment in both
Medicare Parts A and B (required for TRICARE for Life). To document your eligibility for CHAMPVA, please send us
a copy of your CHAMPVA Authorization Card (A-card). Please tell us the date you want to suspend your FEHBP to
use TRICARE, TRICARE for Life, Peace Corps, or CHAMPVA. Special note: If we receive this signed form and the
eligibility documentation within 31 days before to 31 days after the date you designate above, we will suspend your
FEHBP coverage on that date. Otherwise, we will suspend your FEHBP coverage at the end of the month in which
we receive your documentation.
E. I am suspending my FEHBP enrollment because I am eligible for coverage under Medicaid or a similar
state-sponsored program of medical assistance for the needy.
To suspend your FEHBP coverage for this reason, you must give us evidence of your eligibility for Medicaid or a
similar state-sponsored program of medical assistance for the needy. You may send us a copy of an enrollment card
or a letter of eligibility which shows the effective date of your Medicaid or similar state-sponsored program coverage.
If we receive this signed form and documentation within 31 days before to 31 days after the effective date of your
Medicaid or similar state-sponsored enrollment, we will suspend your FEHBP coverage at the close of business the
day before your Medicaid or state-sponsored program coverage begins. Otherwise, we will suspend your FEHBP
coverage at the end of the month in which we receive your documentation.
The following information applies to blocks C, D and E.
Reenrollment: You may voluntarily reenroll in the FEHBP during an annual open season. We will send you an open
season package each year with instructions on how to reenroll. If you don't want to reenroll, disregard your open
season material.
If you involuntarily lose your coverage under one of the programs mentioned above, you can reenroll in the FEHBP
effective the day after your coverage ends. You must provide evidence of your involuntary loss of coverage. Your
request to reenroll must be received at the Office of Personnel Management (OPM) within the period beginning 31
days before and ending 60 days after your coverage ends. Otherwise, you must wait until open season to reenroll.
I certify that I have read and understand the information on suspending FEHBP coverage. I have checked the block relating to my
suspension, and I have enclosed the appropriate documentation.
Signature
Daytime Telephone No. (including area code)
Date
Reverse of RI 79-9
Revised August 2014
