RI 79-9 is the Health Benefits Cancellation/Suspension Confirmation, a form from the U.S. Office of Personnel Management (OPM), Retirement Eligibility and Services. It goes to CSRS and FERS annuitants, survivor annuitants and former spouse annuitants who asked OPM to cancel or suspend their Federal Employees Health Benefits Program (FEHBP) enrollment. OPM will not process the request until you sign, date and return it. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; OPM publishes the original PDF at opm.gov.
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What is RI 79-9?
Health Benefits Cancellation/Suspension Confirmation (RI 79-9) is the OPM form on which a CSRS or FERS annuitant, survivor annuitant or former spouse annuitant confirms a request to cancel or suspend Federal Employees Health Benefits Program (FEHBP) enrollment and states that they understand the effect on future eligibility.
The form is sent to the annuitant after the request is made, with the annuitant's name, address and claim number printed at the top. OPM says it will not process the request until the signed and dated form comes back. The annuitant checks only one block:
- Block A: cancelling to be covered under a family member's FEHBP enrollment.
- Block B: cancelling for any other reason.
- Block C: suspending because of enrollment in a Medicare Advantage health plan.
- Block D: suspending to use TRICARE, TRICARE for Life, Peace Corps or CHAMPVA.
- Block E: suspending because of eligibility for Medicaid or a similar state-sponsored program of medical assistance for the needy.
Blocks A and B, on the front, are cancellations. Blocks C, D and E, on the reverse, are suspensions. The form also points to the Affordable Care Act (ACA) requirement that individuals maintain minimum essential coverage (MEC). It states that previous editions are not usable.
Who needs to file RI 79-9?
The form is for CSRS and FERS annuitants, survivor annuitants and former spouse annuitants who have asked OPM to cancel or suspend their FEHBP enrollment. It is printed with the annuitant's name, address and claim number.
Which block you check depends on your situation:
- Block A: you are cancelling because you will be covered under a family member's FEHBP enrollment.
- Block B: you are cancelling for any other reason.
- Block C: you are enrolled in a Medicare Advantage health plan. Medicare Parts A and B alone do not qualify, and the form says you cannot suspend if you are covered only by Part A and/or B.
- Block D: you are eligible for TRICARE, TRICARE for Life (enrollees over age 65 with Medicare Parts A and B), Peace Corps or CHAMPVA.
- Block E: you are eligible for Medicaid or a similar state-sponsored program of medical assistance for the needy.
Check only the one block that applies. The form warns that many annuitants who cancel will not be able to reenroll, so read both sides first. It names no one else who may sign for you.
When to file RI 79-9
Return RI 79-9 after you have asked OPM to cancel or suspend your FEHBP enrollment; OPM will not act on the request until it receives the form signed and dated.
Timing then depends on the block:
- Block B: the cancellation takes effect at the end of the month in which OPM receives the signed and dated form.
- Block A: OPM coordinates the effective date with the start of your coverage under your spouse's enrollment.
- Blocks C and E: if OPM receives the form and documentation from 31 days before to 31 days after the effective date of your new coverage, the suspension takes effect at the close of business the day before that coverage begins. Otherwise it takes effect at the end of the month in which OPM receives the documentation.
- Block D: you write the suspension effective date yourself, and OPM cannot change it once the request is processed.
The form sets no other due date.
Documents you need
- Block A, spouse is a Federal employee: a copy of the spouse's SF 2809, Health Benefits Registration Form, showing the change to a family enrollment.
- Block A, spouse is an annuitant: no document, but enter your spouse's name and annuity claim number on the form.
- Block C: documentation showing the effective date of your Medicare Advantage health plan coverage.
- Block D: evidence of eligibility for TRICARE, TRICARE for Life, Peace Corps or CHAMPVA, such as a copy of your Uniformed Services Identification (I.D.) card.
- Block D, over age 65 (TRICARE for Life): a copy of your Medicare card showing enrollment in both Medicare Parts A and B, in addition to the Uniformed Services I.D. card.
- Block D, CHAMPVA: a copy of your CHAMPVA Authorization Card (A-card).
- Block E: evidence of eligibility for Medicaid or a similar state-sponsored program, such as an enrollment card or eligibility letter that shows the coverage effective date.
- Blocks C, D and E, involuntary loss of that coverage later: evidence of the involuntary loss when you ask to re-enroll.
How to fill out RI 79-9
Check the printed header details
At the top, confirm the name, date, address and claim number (CS) that OPM printed for you. Read the front and back of the form before you choose anything.
Choose only one block
Check the one block, A through E, that matches your situation. Blocks A and B cancel your FEHBP enrollment; blocks C, D and E suspend it.
Complete block A if it applies
If you are cancelling to be covered under a family member's enrollment, enter your spouse's name (last, first, middle) and claim number when your spouse is an annuitant. If your spouse is a Federal employee, enclose a copy of the spouse's SF 2809.
Complete block B if it applies
Check block B to cancel for reasons other than the one in block A. Understand that you will not be able to reenroll in FEHBP.
Sign the cancellation certification
For block A or B, sign the certification on the front, add your daytime telephone number with area code, and enter the date.
Complete block C for Medicare Advantage
On the reverse, check block C only if you are enrolled in a Medicare Advantage health plan, and enclose documentation showing its effective date.
Complete block D with the effective date
Check block D for TRICARE, TRICARE for Life, Peace Corps or CHAMPVA and write the suspension effective date on the blank line. Enclose the eligibility evidence the form lists.
Complete block E for Medicaid
Check block E if you are eligible for Medicaid or a similar state-sponsored program, and enclose an enrollment card or eligibility letter showing the effective date.
Sign the suspension certification
For blocks C, D or E, sign the certification on the reverse, enter your daytime telephone number with area code and the date, confirming you enclosed the appropriate documentation.
Review and download the completed PDF
Check that only one block is marked, the effective date (block D) and spouse details (block A) are filled in, and the right side is signed. Download or print the completed PDF from FillingPDF and send it with your documentation as described under How to submit.
How to submit RI 79-9
You can return the signed RI 79-9 to OPM or fax it. The form names no other channel.
- Fax: send the completed form to 202-606-1640.
- Return to OPM: the letterhead identifies the sender as the Office of Personnel Management, Retirement Eligibility and Services, 1900 E Street NW - Room 2416, Washington, DC 20415-0001. The form does not print a separate return address, so use the address on your own correspondence from OPM if unsure.
- Questions: call OPM at 1-888-767-6738.
Send the supporting documentation for your block with the form: a copy of the spouse's SF 2809 for block A when the spouse is a Federal employee, proof of Medicare Advantage coverage dates for block C, proof of eligibility for block D, or proof of Medicaid eligibility for block E. Sign and date the certification on the side that applies to you.
FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Checking more than one block; the form says to check only the one block that applies to you.
- Checking block B without understanding that you will never again be eligible to enroll in FEHBP, and that you and covered family lose the free 31-day extension of coverage.
- Requesting a suspension under block C with Medicare Parts A and/or B only; the form says that is not a Medicare Advantage health plan and does not qualify.
- Sending blocks C, D or E without the required documentation of the new coverage or eligibility.
- Returning the form unsigned or undated; OPM will not process the request until it is signed, dated and returned.
- Entering a block D effective date carelessly; once OPM processes the request, the date cannot be changed.
- Leaving out the spouse's SF 2809 under block A when the spouse is a Federal employee, or the spouse's name and claim number when the spouse is an annuitant.
- Using a previous edition of the form; the form states that previous editions are not usable.
- Signing only one side: the cancellation certification is on the front and the suspension certification is on the reverse.
Frequently asked questions
What is RI 79-9 used for?
RI 79-9 is the OPM form that confirms your request to cancel or suspend FEHBP enrollment. Annuitants check one block, sign and date it, and return it. OPM will not process the cancellation or suspension until it receives the signed, dated form.
What is the difference between cancelling and suspending FEHBP coverage?
Blocks A and B cancel your enrollment; blocks C, D and E suspend it. After a block B cancellation you cannot reenroll. After a suspension you may re-enroll during an annual open season, or after an involuntary loss of the other coverage within the form's time window.
Can I fax RI 79-9 to OPM?
Yes. The form says you may fax the completed form to 202-606-1640. For questions, call OPM at 1-888-767-6738. Include the documentation your block requires, since blocks C, D and E need evidence of the new coverage or eligibility.
Can I reenroll in FEHBP after I cancel with RI 79-9?
It depends on the block. Under block A you can resume your own enrollment if your coverage as a family member on your spouse's enrollment ends. Under block B you will not be eligible to reenroll, and you and covered family lose the free 31-day extension of coverage.
Can I suspend FEHBP if I only have Medicare Parts A and B?
No. The form says you cannot suspend your FEHBP enrollment if you are covered by Medicare Parts A and/or B only. Block C requires enrollment in a Medicare Advantage health plan, with documentation of its effective date.
What documents do I send with RI 79-9?
It depends on the block. Block A with a Federal employee spouse needs a copy of the spouse's SF 2809. Block C needs proof of Medicare Advantage coverage dates, block D needs eligibility evidence, and block E needs a Medicaid enrollment card or eligibility letter.
How do I re-enroll after an involuntary loss of coverage?
For blocks C, D and E, you can re-enroll effective the day after your coverage ends, with evidence of the involuntary loss. OPM must receive your request from 31 days before to 60 days after your coverage ends; otherwise wait for open season.
Can I fill out RI 79-9 online?
You can fill out the RI 79-9 PDF online on FillingPDF and download or print it. FillingPDF is independent of OPM and does not file the form; you return it to OPM by fax or the other means described under How to submit.
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