GIC MUNICIPAL ENROLLMENT/CHANGE FORM (FORM-1MUN) Health Insurance

Transcription

1 This document contains both information and form fields. To read information, use the Down Arrow from a form field. GIC MUNICIPAL ENROLLMENT/CHANGE FORM (FORM-1MUN) Health Insurance INSURED INFORMATION Insured Contact Employment GIC-ID (usually Soc. Sec. #) Sex Date of Birth Dept. ID # or Agency/Division # M F / Name Last First MI Street City State Zip Home or Cell Phone Work Phone Date of Hire (must be completed): Name of Municipality: Country (if not USA) FOR ALL NEW ENROLLMENTS For Agency Use Only Does the employee participate in a public retirement system? Check one: Full-time Part-time Number of work hours/week: Select all that apply: New Enrollment Annual Enrollment Adding Dependent(s) Change Dropping Dependent(s) Name Change Decline GIC health insurance coverage Qualifying Status Change Marriage Birth/Adoption Divorce/Legal Separation Change in Dependent Eligibility Status Gain of Other Coverage Date of Event: / / Involuntary Loss of Other Coverage Return from FMLA or Military Leave Death of spouse/dependent Spouse s Annual Enrollment Moved out of health plan s service area HEALTH PLAN 01 Health Plan Fallon Direct (HMO) Fallon Select (HMO) Harvard Pilgrim Independence (POS) (Closed to New Members) Harvard Pilgrim Primary Choice (HMO) Cancel Health Insurance Coverage: Health New England (HMO) NHP Prime Neighborhood Health Plan (HMO) Tufts Health Plan Navigator (POS) Tufts Health Plan Spirit (HMO-type) Effective Date: UniCare State Indemnity/Basic CIC: UniCare Community Choice (PPO-type) UniCare/PLUS (PPO-type) Coverage Election Individual Family SPOUSE/DEPENDENT INFORMATION (See instructions on back) For Changes Only LAST NAME FIRST NAME MI SSN () DATE OF BIRTH SEX RELATIONSHIP FORMER SPOUSE INFORMATION If Listed Above Date of Divorce: Are you remarried? Date of your remarriage: Has your former spouse remarried? Date of former spouse s remarriage: : Street City State Zip SIGNATURE AUTHORIZATION I have read the instructions on the reverse side of this form and authorize my employer, or direct my pension authority, to deduct from my payroll or pension check the amount required for the coverage I have selected. I understand that due to IRS regulations, my health insurance coverage elections are binding for the duration of the plan year and that I may only enroll in health insurance or change my coverage elections during the plan year if I experience a qualifying status change (examples include marriage, adoption/birth of a child, death of a dependent, and involuntary loss of coverage). I understand that the GIC must receive any required documentation for health insurance changes within 60 days of the event. Signature of Applicant: Signature of Authorized Official: Date: Date: For GIC Use Only Entered Verified Political Subdivision (See over for Form-1MUN instructions) 1MUN - 3/16

2 MUNICIPAL ENROLLMENT/CHANGE FORM (FORM-1MUN) INSTRUCTIONS For an overview of your GIC benefit options, see your GIC Benefit Decision Guide mass.gov/gic/bdgs. Deadlines and Required Documentation Required Documentation: To add a spouse or dependent to coverage, documentation is required. Refer to dependent information section below for details. New Hire: Completed paperwork and required documentation must be received by your GIC Coordinator no later than your 10th calendar day of regular, benefit eligible employment. Annual Enrollment: Completed paperwork and required documentation must be received by your GIC Coordinator by the end of the Annual Enrollment period. Qualifying Status Change for Health Insurance: Municipal employees and retirees who have a qualified status change during the year can enroll in GIC health insurance or change from individual to family or family to individual coverage with proof of the family status change. Documentation of the event and the completed form must be received at the GIC within 60 days of the qualifying event. Forms received after 60 days are returned and you may re-apply during Annual Enrollment. Return from FMLA or Military Leave: If you voluntarily canceled GIC health insurance coverage at the beginning of your FMLA or military leave of absence, you can re-enroll in GIC health insurance coverage upon your return from leave. The enrollment form must be received at the GIC within 60 days of the return to work. Forms received after 60 days are returned and you may re-apply during Annual Enrollment. Work Hours and Eligibility Active municipal employees must work at least hours in a 37.5-hour workweek or 20 hours in a 40-hour workweek and must contribute to your employer s public sector retirement system. For GIC purposes, OBRA is not such a retirement system. For additional eligibility details, refer to the GIC s Regulations: mass.gov/gic/regulations. Dependent and Required Documentation In order to enroll your eligible spouse, former spouse and/or dependents in GIC health insurance, you must enter their information in the spouse/dependent box and provide a copy of a marriage certificate, birth certificate or hospital announcement letter (newborns only), separation agreement, divorce decree, certificate of appointment as legal guardian, etc., for each person you list as a dependent. If covering a former spouse, also complete the former spouse information section. Failure to provide required documentation with this enrollment/change form will result in your spouse/dependent not being covered. If you are deleting a spouse or dependent under age 19, you must provide proof of other health insurance coverage. Under federal health care reform, Social Security Numbers must be provided for each spouse/dependent to be covered under the health plan. For a newborn only, the Social Security Number can be provided at a later date. Please indicate the exact date of birth for each dependent. To cover a dependent age 19 to 26, you must also provide a completed Dependent Age 19 to 26 Enrollment and Change Form. Form and Documentation Submission Incomplete forms and insufficient required documentation may result in no coverage or a delayed effective date. Active Employees: Return completed form and documentation to your GIC Coordinator. (See over for Form-1MUN) 3/16

3 This document contains both information and form fields. To read information, use the Down Arrow from a form field. GIC MUNICIPAL EMPLOYMENT STATUS CHANGE FORM (FORM-1AMUN) INSURED INFORMATION Insured Contact Employment GIC-ID (usually Soc. Sec. #) Date of Birth Dept. ID # or Agency/Division # / Name Last First MI Street City State Zip Home or Cell Phone Date of Hire: Work Phone Sex M Number of work hours/week: F Country (if not USA) Name of Municipality employed or retiring from: TRANSFERS AND TERMINATION 01 Effective Date (for GIC use only) Transfer from Transfer to Name of Agency/GIC Municipality Last Day of Work: Name of Agency/GIC Municipality Hire Date: Termination of Service Coverage (if elected) Termination reason Last Day of Work: n 39-week Layoff Coverage n Deferred Retiree n COBRA (must complete COBRA application) n Conversion (contact carrier for application) SCHOOL DEPARTMENT TERMINATION Employees who leave employment at the end of the school year only: Termination Date: Premiums Paid Through: RETIREMENT 01 Date Retired: Effective Date (for GIC use only) Health Insurance Election (If enrolling for first time, also complete Form-RS) Medicare Eligibility check if applicable and attach copy of Medicare Claim Card(s): Insured Spouse Enrollment materials will be mailed to the Medicare-eligible members. Cancel Health Insurance Non-Medicare Plan Election for insured and/or spouse not eligible for Medicare: Keep current health plan Change Non-Medicare Plan election to Plan name: GIC Retiree Dental (Only if municipality participates) I wish to enroll in GIC Retiree Dental and have attached the completed GIC Municipal Retiree Dental Enrollment and Change Form I do not wish to enroll in the GIC Retiree Dental at this time SIGNATURE AUTHORIZATION I have read the instructions on the reverse side of this form and authorize my employer, or direct my pension authority, to deduct from my payroll or pension check the amount required for the coverage I have selected. I understand that due to IRS regulations, my health insurance coverage elections are binding for the duration of the plan year and that I may only enroll in health insurance or change my coverage elections during the plan year if I experience a qualifying status change (examples include marriage, adoption/birth of a child, death of a dependent, and involuntary loss of other coverage). I understand that the GIC must receive any required documentation within 60 days of the event. Signature of Applicant: Signature of Authorized Official: Date: Date: For GIC Use Only Entered Verified Political Subdivision (See over for Form-1AMUN instructions) 1AMUN - 3/16

4 GIC MUNICIPAL EMPLOYMENT STATUS CHANGE FORM (FORM-1AMUN) INSTRUCTIONS Use this Form-1AMUN for all employment status changes including retirement. If enrolling in GIC health insurance coverage for the first time at retirement, you must also complete and return Form-RS. For GIC retiree benefits, see the GIC Benefit Decision Guide mass.gov/gic/bdgs. Transfers and Terminations Because GIC premiums are paid a month in advance, coverage terminates at the end of the following month after you leave a state agency or GIC participating municipality (for example, if you leave June 10, your coverage will end July 31). If you are hired by a state agency, authority, or participating municipality before the coverage end date, you are considered a transfer and will not be subject to the 60-day waiting period. You must remain in the same health plan. For other GIC benefits, the same rule applies. If you are hired after the coverage end date, you are subject to the 60-day new hire waiting period. If an employee is terminating state service, he/she may continue GIC health coverage and must indicate the option elected. Please put the termination reason (e.g., resigned or laid off). School department employees who are ending employment at the end of the school year and have prepaid their health insurance premiums through the summer must complete the school department termination section. Retirement If you and/or your covered spouse are age 65 or over, and eligible for Medicare Part A for free, you (and your covered spouse, if applicable) must enroll in Medicare Parts A and B to continue coverage with the GIC. If one of you (or other family members) is under age 65, the non-medicare member(s) will be covered under a non- Medicare plan until he/she becomes eligible for Medicare coverage. Enrollment materials will be mailed to the Medicare-eligible members. The following are your Medicare/non-Medicare health plan combination choices: Non-Medicare Plan Fallon Health Direct Care Fallon Health Select Care Harvard Pilgrim Independence Plan (Closed to New Members) Harvard Pilgrim Primary Choice Plan Health New England Tufts Health Plan Navigator Tufts Health Plan Navigator Tufts Health Plan Spirit Tufts Health Plan Spirit UniCare State Indemnity Plan/Basic UniCare State Indemnity Plan/Community Choice UniCare State Indemnity Plan/PLUS Medicare Plan Fallon Senior Plan Fallon Senior Plan Harvard Pilgrim Medicare Enhance Harvard Pilgrim Medicare Enhance Health New England MedPlus Tufts Health Plan Medicare Complement Tufts Health Plan Medicare Preferred Tufts Health Plan Medicare Complement Tufts Health Plan Medicare Preferred GIC Retiree Dental For participating municipalities, the GIC Municipal Retiree Dental form is on the GIC s website mass.gov/gic/forms. Form and Document Submission Active Employees and Employees Who Are Retiring: Return completed form and documentation to your GIC Coordinator. (See over for Form-1AMUN) 3/16

5 DEPENDENT AGE 19 TO 26 ENROLLMENT/CHANGE FORM FEDERAL HEALTH CARE REFORM (ACA) Use this form to enroll your dependent age 19 to 26 for the first time or to report your dependent s age 19 to 26 status change. Upon receipt of a complete application, the GIC will determine coverage eligibility and effective date. For new insureds, coverage for the dependent age 19 to 26 will begin on the new insured s effective date. Dependents of existing GIC enrollees who are already over age 19 must have a qualifying event to enroll during the year or may apply during the GIC s Annual Enrollment. Incomplete applications will be returned. PLEASE USE ONE FORM FOR EACH DEPENDENT AGE 19 TO 26. I am applying for coverage or reporting a status change for my dependent age 19 to 26. The GIC may require proof of relationship for the dependent you plan to cover and will contact you for any documents, if necessary. Name of Insured Social Security # / / Telephone # PLEASE COMPLETE ONLY ONE SECTION BELOW City State Zip SECTION A ENROLL YOUR DEPENDENT SECTION B CHANGE DEPENDENT STATUS A) ENROLLMENT DEPENDENT AGE 19 TO 26 Use this section to enroll your dependent Name of Dependent Age City State Zip Social Security # / / Dependent s Date of Birth / / Relationship to Insured Check here if your dependent is a full-time student attending an accredited institution outside your health plan s service area and provide school name and address below: (Check with your health plan for benefits available to full-time students that are attending school outside the service area.) Name of School School (That is outside health plan s service area) You must contact the GIC when your dependent is no longer a full-time student to continue coverage to age 26. B) CHANGE OF DEPENDENT S AGE 19 TO 26 STATUS Use this section to report dependent address and full-time student status changes Name of Dependent Age Social Security # / / City State Zip Dependent s Date of Birth / / Relationship to Insured Dependent Change New : Dependent is no longer a full-time student as of. (Date) SIGNATURE Please sign and date below I understand that if my dependent is not a full-time student he/she must reside in my health plan s service area. If you are not sure, the GIC health plan service areas are listed in the GIC Benefit Decision Guide (available on our website, or you may contact your health plan directly. If your dependent does not live in your health plan s service area and is not a full-time student, you must change health plans. The UniCare Indemnity Plan Basic is the only nationwide plan. Under the pains and penalties of perjury, I attest that all statements I have made on this form are true. I understand that if I misrepresent or provide false or incomplete information on this form my GIC coverage may be terminated (possibly retroactively), in addition to other legal remedies and financial consequences, at the GIC s discretion. Signature of Insured Date Revised 3/15 Return to: Group Insurance Commission, PO Box 8747, Boston, MA GIC USE ONLY APPROVED Effective Date Expiration Date DENIED