Part G - Suspension of FEHB (Annuitants/Former Spouses Only) I SUSPEND my enrollment. For information on how to enroll in a health plan as an employee of a tribe, tribal organization or Urban Indian organization, please … There are tools available to evaluate provider options, select your 2020 plan, and submit changes to OPM. For FEHB Medical Plans: Choose a medical plan. Which plan did you select? Subpart F - Transfers From Retired Federal Employees Health Benefits Program (§§ 890.601 - 890.605) Subpart G [Reserved] Subpart H - Benefits for Former Spouses (§§ 890.801 - 890.808) Subpart I - Limit on Inpatient Hospital Charges, Physician Charges, and FEHB Benefit Payments (§§ 890.901 - … - FEHB three-digit enrollment code and YY/MM/DD with no spaces between the enrollment code and the date. These rates do not apply to all enrollees. I CANCEL my enrollment Place an "X" in the box if the enrollee wishes to cancel FEHB enrollment. Each plan’s FEHB brochure is the official statement of benefits. Are you an active federal employee? Part F - Cancelation of FEHB. Make note of the corresponding Federal Employees Health Benefits (FEHB) Program enrollment code: If you are in a special enrollment category, please refer to the FEHB Program website or contact the agency or Tribal Employer which maintains your health benefits enrollment. If you want to enroll in or change your medical plan, please record the appropriate enrollment code for your selected plan option and family status below. A data entry example for Enrollment code 104 and date of 6/24/09 would be 104090624. Enrollment code Bi-weekly Category 1 Bi-weekly Category 2; Self (131) $51.02: $44.11: Self + 1 (133) $109.68: $94.83: Self & Family (132) $120.65: $104.31: These rates do not apply to all enrollees. For information on how to enroll in a health plan as a Federal employee, visit the Healthcare Enrollment page or view Enrollment Form (SF2809). Note: Signature in Part H certifies that they have read and understand the information on page 3 regarding cancelation of enrollment. What is the enrollment code for that plan? If you are in a special enrollment category, contact the agency or Tribal employer that manages your health benefits enrollment. New hires have 60 days to choose benefits; Have the answers to the following questions ready: Will you be enrolling yourself only or you and your family? Annuitants (Retirees) Annuitants can change plans online at FEHB Open Season Online. Code Explanation From Through; 104: BLUE CROSS AND BLUE SHIELD SERVICE BENEF--SELF ONLY: 01/01/2002 Present 105: BLUE CROSS AND BLUE SHIELD SERVICE BENEF--SELF AND FAMILY: 01/01/2002 Present 106: BLUE CROSS AND BLUE SHIELD SERVICE BENEF --SELF PLUS ONE: 01/01/2016 Present 111 - The correct date will only be reflected in PPS’ history once a subsequent personnel action is processed. After that, contact your agency’s personnel office to make your medical plan selection. GEHA Standard to Blue Cross Blue Shield Basic Plan Comparison – 2021; Changing Enrollment. Enrollment Codes and Rates 2021. Code Explanation From Through; ZZY: DECLINED ENROLLMENT: 09/01/1986 Present ZZZ: NOT ELIGIBLE: 09/01/1986 Present EA2: CAPITAL HEALTH PLAN --SELF AND FAMILY: 09/01/1986 Present ZZX: PENDING: 09/01/1986 Present EA1: CAPITAL HEALTH PLAN --SELF ONLY Confirm your desired family status (Self Only, Self Plus One or Self & Family) and the plan of your choice. The Federal Employees Health Benefits (FEHB) Open Season for selecting our 2020 healthcare plans runs from November 11 th through December 9 th this year. Before making your final enrollment decision, always refer to the individual FEHB brochures. 2. Example for enrollment code 104 and date of 6/24/09 would be 104090624 agency s. 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