EMPLOYEE BENEFITS MID-YEAR QUALIFYING EVENT CHANGES (Revised 12/8/2014)

Transcription

1 EMPLOYEE BENEFITS MID-YEAR QUALIFYING EVENT CHANGES (Revised 12/8/2014) The Change or Enrollment Form MUST be presented to the Insurance Department NO LATER THAN 30 DAYS after the qualifying event date. All required documentation (see below) of the qualifying event MUST be submitted WITH the appropriate Change/Enrollment Form(s) to the Insurance Department at ISC-North, Suite 136. Forms may be sent by FAX to , scanned and ed, sent thru inter-school mail, or dropped off. (If in doubt as to what type of documentation is required, call the Insurance Department. Employees whose last name begins with A K, call Laura Unger at (281) Employees whose last name begins with L Z, call Robin Rubalcava at (281) TERMINATION OF COVERAGE NOTICE: TRS-ActiveCare plans through Aetna, Scott & White, and FirstCare HMOs will not permit retroactive voluntary termination dates. Although you have 30 days from the qualifying event to present your change documents, all voluntary terminations will be effective on the last day of the month following the Insurance Department s receipt of your written documentation. Your spouse s Annual Enrollment is a qualified event for you to make election changes to your CFISD benefits. You must submit to the Insurance Department a mid-year plan Change Form (see below) and documentation. You will be able to enroll in the District s plan mid-year if your spouse s plan declares you ineligible for their plan because you are a working spouse with coverage available through your own employer. MEDICAL INSURANCE ENROLLMENT NOTICE: If you are enrolling in TRS-ACTIVECARE medical insurance because you have recently lost coverage through another plan you must submit the following within 30 days of your loss of that coverage: 1) TRS-ActiveCare Enrollment Application and Change Form. (find on the District s Insurance Department s web page at: go to Staff/HR/Insurance/click on Mid-year plan changes. 2) Your HIPAA Certificate of Creditable Coverage (COCC) (required to be sent to you by your former insurer within 15 days of your termination of coverage.) The certificate must also include the enrollment history of all dependents for whom you are requesting coverage. We cannot process your enrollment without receipt of your and your dependents COCCs. DENTAL AND VISION and Other Optional Insurance Plan Changes: You must use the TRS-ActiveCare Enrollment/Change Form to change your medical insurance coverage. Requesting a change to your MEDICAL INSURANCE coverage DOES NOT AUTOMATICALLY authorize a corresponding change to your other optional benefits. Complete and submit the attached Mid-Year Change in Status Election Form for all changes to your optional plans plus documentation that you have lost or gained the coverage. The effective date of change in coverage will be the first or last day of the month following the Insurance Department s receipt of your change form(s) and qualifying event documentations, depending on the change you wish to make.

2 WRITTEN DOCUMENTATION OF THE QUALIFYING EVENT THAT MUST BE SUBMITTED WITH THE CHANGE FORM(S) Job Change If loss of coverage is due to losing a job, we will need a COCC (Certificate of Credible Coverage) from your insurance company. If you have started a new job, we will need either a Confirmation Summary of the benefits you have enrolled in from your new employer or a COCC from your new Insurance company. NOTE: You will only be allowed to insure person(s) previously covered by other insurance who have lost their coverage due to the job change. You cannot add additional dependents until our Annual Enrollment Period (currently in the Summer for a September 1, effective date). Effective The first day of the month following the coverage termination date indicated on the above required letter or COCC. Termination The last day of the month following the Insurance Department s receipt of your Change Form and qualifying event documentation. Birth Effective 9/1/2011 Under the TRS-ActiveCare guidelines, the employee has 60 days after the newborn s date of birth to enroll the newborn for coverage. If the employee has employee and child(ren) or employee and family coverage at the time of the newborn s birth and at the time of enrollment, the employee has up to one year after the newborn s date of birth to add the newborn to coverage. Documentation required is: 1) a copy of the child s birth certificate or 2) a completed copy of the unofficial birth record with the footprints from the hospital, signed by a hospital official or physician or 3) a copy of the Verification of Birth Facts sheet signed or initialed by a hospital representative is sufficient, as long as it includes the baby s name, parents names, and date of birth. Effective Date of Coverage: Retroactive to the date of birth. Premiums are billed from the first of the month following the newborn s birth. The spouse and other eligible dependents can only be added within 30 days after the newborn s date of birth, retroactively to the date of birth. Premiums are billed for the whole month in which coverage becomes effective; premiums are not prorated. NOTE: We will also need your newborn s Social Security Number on the TRS enrollment application. Adoption A signed copy of the placement authorization from the adoption agency, Child Protective or Services, or the court. Foster Care NOTE: We will also need the child s Social Security Number. If you have not received it by the Placement time of enrollment, please forward a copy of the child s Social Security card to the Insurance Department as soon as possible. Effective Retroactive to the date of the child s placement in the employee s home.

3 Marriage To add your new spouse and/or newly acquired stepchildren: Either a copy of the marriage certificate or a copy of the signed marriage license. A letter or church sacramental certificate signed by the wedding official can also be used for documentation. Effective The first day of the month following the date of marriage. To terminate your own coverage: Same as above PLUS documentation (Confirmation Summary) from your new spouse s plan (medical and/or dental and/or vision) that you have been enrolled or a COCC from his new Insurance company. Termination The last day of the month following the Insurance Department s receipt of your Change Form and qualifying event documentation. Divorce To terminate your former spouse s coverage: Copy of the first and Judge s signature page of your certified divorce decree signed by the judge. Termination Last day of the month following the Insurance Department s receipt of your Change Form and qualifying event documentation. NOTE: Do not wait for a copy from your attorney s office. You have only 30 days from the date of your divorce to make your plan changes. You are advised to purchase a certified copy of your decree from the courthouse as soon as it is available (usually 1-2 weeks after your court date.) (Please provide your former spouse s current address. We are required by law to send him/her a COBRA extension of coverage notice and his or her HIPAA Certificate of Creditable Coverage.) To enroll in coverage: Same as above PLUS documentation (letter from your former spouse s company showing termination due to divorce or HIPAA Certificate of Credible Coverage they are required to send to you within 15 days of your termination of coverage.) Effective The first day of the month following the date your former spouse s plan terminated your coverage because of the divorce. Death To terminate the deceased s coverage: Either a copy of the death certificate or the obituary. Termination The last day of the month following the death. Do not delay in removing a deceased dependent from your plan. All claims incurred by the dependent will be paid based on the date the medical service was received; not when the claim is presented to the insurance company for payment. To enroll in coverage: Same as above PLUS documentation (letter from spouse s company or COCC that your deceased spouse s plan has terminated your coverage because of his/her death. Effective The first day of the month following the date your spouse s plan terminated your coverage because of his death. Age Ineligibility Effective on the dependent child s 26 th birthday: Cy-Fair automatically terminates all coverage for dependents reaching their 26 th birthday. (Please provide the terminating dependent s current address under the dependent screen in our Benefits Connect system. We are required to send him/her a COBRA extension of coverage notice and his or her HIPAA Certificate of Coverage.) To enroll in coverage: Submit the change form along with a COCC (Certificate of Credible Coverage from your former insurance company) along with a copy of your birth certificate or drivers license. Effective The first day of the month following your loss of coverage. Termination Last day of the month following the dependent s 26 th birthday. Please do not send your mid-year plan paperwork to the Insurance Department until it is complete with the following: Change Forms Required Documentation of Qualifying Event HIPAA COCC (Certificate of Creditable Coverage) Your paperwork will be returned to you if it is incomplete.

4 Enrollment Application and Change Form ELIGIBILTY: Are you an active employee and making monthly contributions to TRS? Yes If no, are you regularly scheduled to work 10 or more hours per week? Yes SECTION 1: ENROLLMENT/CHANGE TRANSACTION TYPE Annual Enrollment New Employee Add Dependent Special Enrollment No No For New Employee (check one): Effective on Actively at Work Effective 1 st day of month following Special Enrollment Event / / Change Only: Name Address Plan/Coverage Decline Coverage: Yes (Complete Section 6) N/A Effective Date of Change/Cancel / / Marriage Court Order Birth/Adoption Loss of Coverage Other: Cancel Employee Death Loss of Eligibility Retirement/Terminated Non-Payment Other: Cancel Dependent Divorce Death Loss of Eligibility Dropped Coverage Other: (If no to both, you are not eligible for TRS-ActiveCare coverage) For District Use Only TRS District # Actively at Work Effective/Change Employer Approval: Were you covered by another district? Yes No If so, which: SECTION 2: EMPLOYEE INFORMATION Last Name: First Name: MI: Social Security #: Mailing Address: City: State: Zip: Home Phone Number: Cell Phone Number: Date of Birth: Sex: M F Language: English Spanish Ethnicity: Do you have a disability affecting your ability to communicate or read? Yes (Please complete Section 8) No Is the Employee Covered By Other Insurance? Yes Carrier/Plan: No Is the Employee Covered by Medicare? Yes Part A Part B Part C Part D Effective: No Reason for Medicare Coverage: Entitlement Age Disability End Stage Renal Disease (ESRD) SECTION 3: COVERAGE SELECTION (Please select a Plan of Coverage and Coverage Type) PPO Selection: ActiveCare 1-HD ActiveCare Select ActiveCare 2 HMO Selection: FirstCare Scott & White Health Plan Valley Baptist Health Plan Coverage Type Selected: Employee Only Employee + Spouse Employee + Child(ren) Employee + Family SECTION 4: DEPENDENT INFORMATION (Use additional form for additional dependents) SPOUSE Last Name: First Name: MI: City: State: Zip: Phone Number: Sex: M F Date of Birth: Social Security #: CHILD Last Name: First Name: MI: Date of Birth: Social Security #: Sex: M F CHILD Last Name: First Name: MI: Date of Birth: Social Security #: Sex: M F PLEASE CONTINUE ON NEXT PAGE

5 CHILD Last Name: First Name: MI: Date of Birth: Social Security #: Sex: M F CHILD Last Name: First Name: MI: Date of Birth: Social Security #: Sex: M F: SECTION 5: DISABLED DEPENDENTS OVER AGE 26 Dependent Child s Statement of Disability Attached Please note that a Dependent Child s Statement of Disability form is required for coverage of a disabled child over age 26. See your Benefits Administrator for the form, which must be completed in full and submitted to your Benefits Administrator. SECTION 6: DECLINATION OF COVERAGE This is to certify that the available coverage has been explained to me. I have been given the opportunity to apply for the coverage available to me and my dependents and have voluntarily elected to decline the coverage as elected below. Name: SSN: Employee Reason: Other Coverage Other: Name: Spouse Reason: Other Coverage Other: SECTION 7: COVERAGE CONDITIONS I am employed by the Employer named in this Enrollment Application and Change Form. I am eligible to participate in the coverage(s) offered by the TRS-ActiveCare program which is administered by Aetna, with HMO benefits provided by SHA, L.L.C. dba FirstCare, Scott and White Health Plan, and Valley Baptist Insurance - Company dba Valley Baptist Health Plans. On behalf of myself and any dependents listed on their Enrollment Application and Change Form, I apply for those coverage(s) for which I am eligible. o If I am enrolling a grandchild in Section 4, I certify that my household is the grandchild s primary residence and the grandchild is my dependent for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect. o If I am enrolling a child as an other Child in Section 4, I certify that my household is the child s primary residence, that I provide at least 50% of the child support, that neither of the children s natural parents reside in my household, and that I have the legal right to make decisions regarding the child s medical care. Only those coverage(s) and amount for which I am eligible will be available to me. I understand that if this Enrollment Application and Change Form is accepted, the coverage(s) will become effective in accordance with the provisions or the TRS-ActiveCare program. I understand that by enrolling for coverage with Employer named in the Enrollment Application and Change Form that any TRS-ActiveCare coverage I previously elected under another TRS-ActiveCare participating district/entity will be terminated under TRS Rules. I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). I agree that my Employer acts as my agent. All notices given to my Employer are binding upon me. I also agree that my participation in the coverage(s) is subject to any future amendments. I understand that by declining TRS-ActiveCare coverage now or by terminating TRS-ActiveCare coverage during the plan year, I am not eligible to re-enroll in TRS-ActiveCare until the next plan year, unless I experience a special enrollment event. I state that the information given on the Enrollment Application and Change Form is true and correct. I understand and agree that any incorrect statements material to the risk and knowingly made by me will invalidate my coverage(s). Applicant Signature: SECTION 8: SPECIAL NOTES REGARDING MY ENROLLMENT (Please indicate any special information regarding my enrollment for Aetna, Caremark or my selected HMO)

6 CYPRESS-FAIRBANKS INDEPENDENT SCHOOL DISTRICT Mid-Year Change in Status Election Form for Optional Benefit Plans Change Effective (Please print) LAST NAME: FIRST NAME MIDDLE I EMPLOYEE NUMBER SOCIAL SECURITY NUMBER CAMPUS WORK PHONE MAILING ADDRESS (PO BOX): CITY ST ZIP HOME/ CELL PHONE Indicate the Status Change Event Below Required Documentation MUST be submitted with Change Form X Change in Status Event: Beginning or end of employment of spouse/dependent Birth of a child / Adoption or Placement for adoption or foster care of child Marriage Divorce Death Change from Full Time to Part Time employment or Part Time to Full Time employment: Self Spouse Dependent FT>PT PT>FT Ineligibility of dependent child (26 th birthday) Court Order Date Received: Medicare Enrollment: Self Spouse Dependent Medicaid/CHIP Enrollment Self Spouse Dependent Significant change in health coverage due to spouse s or dependent s employment Explain: X CHANGE MY PLANS INDICATED BELOW BY ADDING OR DROPPING THE FOLLOWING DEPENDENTS Optional Life Insurance Employee Amount $ Spouse Amount: $ $10,000 Child under 26 Cancel All Emp + 2 or more Assurant Dental Indemnity Plan Emp Only Emp + 1 Dependent dependents Cancel All Heritage DHMO Dental Plan Emp Only Emp + 1 Dependent Emp + 2 or more Dependents Cancel All MSofA Dent-All Plan (discount plan) A,B,C Plans Emp Only Emp + Dependents Cancel All QCD of America Dental Plan Emp Only Emp + 1 Dependent Emp + 2 or more dependents Cancel All Guardian Vision Plan Emp Only Emp + Spouse Emp + Child(ren) Emp + Family Cancel All Humana Cancer& Specified Disease Plan 1 Parent Family 2 Parent Family Cancel All Assurant Disability Insurance (Cancel or reduction of monthly benefit Reduce Monthly ONLY) Cancel: Benefit to: $ Cancel All List of Dependents (List ONLY those dependents affected by the change. Last Name, First Name MI Date of Birth Sex ADD Male Spouse Child Child DROP ADD DROP ADD DROP Female Address City State ZIP Last Name, First Name MI Date of Birth Sex Male Female Address City State ZIP Last Name, First Name MI Date of Birth Sex Male Female Address City State Zip Social Security Number Social Security Number Social Security Number I state that the information given on this Enrollment/Change Form is true and correct. I understand that any incorrect statements relevant to the risk and knowingly made by me will invalidate my coverage(s). I authorize the necessary payroll deductions by my employer. Employee s Signature Mail to the CFISD Insurance Department at ISC-North, Suite 136 or FAX to (281) /2014 Date