Kern County Human Resources Declination of Coverage and Certificate of Other Coverage

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Kern County Human Resources Declination of Coverage and Certificate of Other Coverage As an eligible employee of Kern County I understand I have the option of accepting employee health benefits for

1 Kern County Human Resources Declination of Coverage and Certificate of Other Coverage As an eligible employee of Kern County I understand I have the option of accepting employee health benefits for myself, and my eligible dependents. My option covers the medical, prescription drug, dental and vision benefits, combined. I am not entitled to accept certain health benefits and decline others. BY COMPLETING THIS DOCUMENT I AM DECLINING ALL COVERAGE ON MYSELF, AND MY ELIGIBLE DEPENDENTS, (IF ANY), AS DESCRIBED IN THE APPLICABLE PLAN DOCUMENTS. I UNDERSTAND TO DECLINE COVERAGE I MUST CERTIFY THAT I HAVE COVERAGE UNDER ANOTHER EMPLOYER S GROUP PLAN. IF I LOSE THAT COVERAGE, I MUST NOTIFY KERN COUNTY HUMAN RESOURCES - HEALTH BENEFITS WITHIN 30 DAYS. I understand the ONLY circumstances under which I can apply for Kern County coverage in the future are: 1. During open enrollment, or 2. Within 30 days of loss of coverage under another employer s health benefits plan(s) as a result of: a. Loss of qualifying employment; or b. Loss of eligibility for other employer s health benefit plan(s); c. Involuntary termination of the other employer s health benefits plan; or d. Death of or divorce from spouse who covered me under their employer s health benefits plan; or e. Death of domestic partner or termination of the domestic partnership, when the domestic partner covered me under their employer s health benefits plan. Further, I understand that children who are not enrolled in the County health plan before reaching the age of 26 through one of the following events, will never be permitted to be enrolled in the County health plan: 1. Enrolled at the employee s initial opportunity to enroll, defined in the eligibility policy as the employee s initial hire date; or 2. Enrolled during a subsequent open enrollment period before reaching the age of 26; or 3. Enrolled as a result of a permitting event before reaching the age of 26. OTHER EMPLOYER SPONSORED HEALTH INSURANCE INFORMATION Name of Employer providing health benefits coverage Subscriber s Name Customer Service No.: Insurance Company Name: Identification No.: Group No.: EMPLOYEE CERTIFICATION I certify by under penalty of perjury under the laws of the State of California by signing below that: the coverage indicated on this form is now in effect and I decline Kern County health plan coverage for myself and any eligible dependents, which includes medical, drug, dental and vision benefits. I will notify Kern County H R - Health Benefits within 30 days if any of the provided information changes. I am the Active Employee eligible for Kern County Health Benefits. Employee s Name: Employee ID No.: Employee s Signature: Date: TO BE COMPLETED BY HEALTH BENEFITS Date of Hire Plan Code Effective Date:

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Kern County HR County Administrative Office 1115 Truxtun Avenue, 1st Floor, Bakersfield, CA 93301 Telephone (661) 868-3182 Fax (661) 868-3110 Ryan J. Alsop County Administrative Officer Devin W.

3 Kern County HR County Administrative Office 1115 Truxtun Avenue, 1st Floor, Bakersfield, CA Telephone (661) Fax (661) Ryan J. Alsop County Administrative Officer Devin W. Brown Chief Human Resources Officer Important Notices As required by law, certain notices and documents are provided to all newly hired employees who are eligible for health benefits. Your Medical Plan Enrollment/Declination Packet contains these notices. Copies of these notices are available online at (see Polices & Notices ) or print copies can be requested by calling (661) COBRA COBRA is a federal law passed in 1986 (Public Law , title X) that requires most employers to offer continuation of health coverage at group rates in certain instances where coverage might otherwise end. HIPAA The Health Insurance Portability and Accountability Act (HIPAA - Public Law ) was enacted in The law provides comprehensive federal protection for the privacy of health information. In general, it states that a covered entity may not use or disclose an individual s healthcare information without permission except for treatment, payment or healthcare operations. Women s Health and Cancer Rights Act The Women s Health and Cancer Rights Act of 1998 requires all employer sponsored health plans that cover mastectomies to also cover related reconstructive surgery. Health Care Reform In March of 2010 the Patient Protection and Affordable Care Act (HR 3590) and The Health Care and Education Reconciliation Act of 2010 (HR 4827), collectively known as Health Care Reform, were signed into law. Among other things, Health Care Reform extended coverage to adult children through their 26 th birthday and eliminated lifetime maximums on certain covered benefits. Because the County s plans are considered to be grandfathered plans, certain provisions of the Act may not apply at this time. Medicare and Prescription Drug Coverage Starting January 1, 2006, prescription drug coverage was extended to everyone with Medicare coverage. The County has determined that prescription drug coverage offered to employees is creditable drug coverage. Health Insurance MarketPlace Coverage Options and Your Health Coverage The federal Affordable Care Act (ACA), often called health care reform, will require that most Americans have health insurance starting January 1, Acknowledgment By signing below, I indicate that I understand I must complete the attached page indicating the address for any dependent I enroll who does not live at my address, to be used for initial COBRA notice purposes. By signing below, I indicate that I have read and understood the documents/notices described above. I have been given copies of the following policies and/or documents: 1) COBRA Notification. 2) HIPAA Privacy Policy 3) Women s Health and Cancer Rights Act Notice 4) Health Care Reform (Extension of coverage, grandfathered plan, OB-GYN, Lifetime limits) 5) Medicare and Prescription Drug Coverage Notice 6) Medicaid and the Children Health Insurance Program (CHIP) 7) Health Insurance MarketPlace Coverage Options and Your Health Coverage Signature Date: This signed acknowledgment must be turned in with your health benefits enrollment or declination form.

4 COBRA Address Notification Form If you have a dependent that is covered by the group health plan whose legal residence is not yours (dependent child covered by court order, living with an ex-spouse, etc.), you are required to provide us with the proper address so an initial COBRA notice can be sent to them as well. Thank you for your assistance. This information must be provided to Kern County Human Resources Health Benefits upon commencement of coverage under the group health plan.

5 Voluntary Benefits Acknowledgment I, (please print name), understand that all of the voluntary benefits listed on this page are available to me as a newly hired employee of the County: Deferred Compensation I understand that Kern County s Deferred Compensation plan is available to me as an employee of the County. Depending on my bargaining unit, I may be entitled to a 6% salary match paid by the County if I begin contributing to Deferred Compensation. If so, I will forfeit the match if I do not enroll. I acknowledge that I was provided information and an enrollment form and I understand I should contact the Treasurer/Tax Collector s office if I have questions about Deferred Compensation or to turn in my Deferred Compensation enrollment form. For more information call (661) or visit Voluntary Insurance Products**: Short-term Disability Insurance Long-term Disability Insurance Cancer Plan Group Term Life Insurance Universal Life Insurance Accident Plan Hospital Indemnity Plan Prepaid Legal Plan Critical Illness Plan ** I understand that some of these benefits are offered on a guaranteed issue basis (no health questions) only when I am a newly hired employee and may not be offered again that way in the future. I may elect to enroll in products from Chimienti & Associates by enrolling on-line at or calling 1 (877) Additional insurance products are available through Walter Mortenson and Associates (661) and Mills & Marling (661) Depending on my bargaining unit, I may have County-paid life insurance or other insurance products offered through my union. Kern County Human Resources Health Benefits can answer questions about County-paid insurance at (661) Flexible Spending Accounts (FSAs): Dependent Care FSA (maximum $5, per calendar year) Unreimbursed Medical FSA (maximum $2, per calendar year) I understand that I may elect to enroll in the County s pre-tax Kern$Flex Plans (IRS Section 125) flexible spending accounts on-line at If I do not have access to the internet, I may contact Kern County Human Resources Health Benefits at (661) for assistance. I have read, understood, and I acknowledge the information on this page. I am aware that if I elect to enroll in any of the above options, I must enroll or contact the respective plan administrator listed above by the enrollment date due (within one month of my date of hire). Signature Date

Kern County Human Resources

Kern County Human Resources Health Benefits Enrollment Form This form is to be used by probationary/permanent new hire employees who are eligible for the below medical, dental and vision coverage Medical,