All Self-Pay Participants Open Enrollment Oct. 1 to Oct. 31, 2018
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1 All Self-Pay Participants Open ment Oct. 1 to Oct. 31, 2018 Office use only Approved by: Approved date: Effective date: See the Summary Plan Description for more information on benefits at Submit completed form to BenefitHelp Solutions, PO Box 40548, Portland, OR or Fax to or Keep a copy of your benefit forms for your records. Any alteration of this form may result in it being ineffective. I am enrolling as c Retiree Note: you cannot add a plan or dependents during open enrollment. Do not participate in HEM. c Cobra Note: you can enroll in full or part-time plans. Do not participate in HEM. c Self-Pay OLCC Agent, Post Doc, Blind Business Enterprise, Foster Parent and Nurse. Note: you can only enroll in full-time plans. Do not participate in HEM. Contact information (You must complete all fields) PEBB benefit number (P########), OR#, University ID or Lottery ID Last name First name Middle Agency c M c F Contact address c Check if new address Apartment # City State ZIP Residence ZIP code Work ZIP code Work Personal (optional) Date of birth () Work phone Home phone (optional) Are you Medicare eligible? c No c Yes This may affect enrollment (retirees only). Are you serving or did you ever serve in the military? c No c Yes Do you authorize PEBB to send your name and address to Oregon Department of Veteran s affairs (ODVA) for the purpose of receiving benefit information? c No c Yes Page 1 of 5 PEBB Self-Pay (09/2018)
2 Family coverage (List all eligible family members you want to provide coverage for in Attach additional dependent sheet if necessary. Please see OARs Division 15 concerning eligible dependents at: Spouse/Domestic Partner Last name First name Middle Relationship c Spouse c Partner If you listed a Domestic Partner, mark the type of Domestic Partnership (Affidavits need to be to your payroll/hr by Nov. 7, 2018 or enrollments will not take place.) c Registered Certificate of Domestic Partnership (Copy not required) You have a registered certificate issued by an Oregon county clerk to you and your same sex partner. c PEBB Domestic Partner Affidavit is a partnership between an eligible employee and an individual of the opposite sex, or same sex without a Certificate of Registered Domestic Partnership. Eligible dependent children (List the eligible children you want to provide coverage for in Attach a separate sheet if necessary. Required affidavits and appropriate legal documents for child by affidavit or grandchild need to be to your payroll/hr by Nov. 7, 2018 or enrollments will not take place. Please see OARs Division 15 concerning eligible dependents at: Page 2 of 5 PEBB Self-Pay (09/2018)
3 Page 3 of 5 PEBB Self-Pay (09/2018)
4 Medical plans/dental plans (Some plans have specific service areas and may not be available to you, be sure to review plan availability for your area.) Medical Full time Part time Dental Full time Part time Kaiser Deductible (Kaiser vision included with full time plan) Kaiser HMO (Kaiser vision included with full time plan) c c Kaiser Permanente c c c c Delta (MODA) Premier c c Moda Summit c c Delta (MODA) PPO c N/A Moda Synergy c c Willamette Dental c N/A PEBB Statewide PPO c c Providence Choice c c c I Decline all Dental Plan ment Vision plan VSP Basic Plan VSP Plus Includes the Basic Plan and PLUS additional benefits I Decline all VSP ment Tobacco use (If you enroll in a Medical plan and do not complete this Section a tobacco surcharge ($25.00 per participant and $25.00 for spouse/partner enrolled in medical) will be added to your monthly premium.) Check one box: I currently use tobacco and, my spouse/domestic partner currently does not use tobacco. ($25) I currently do not use tobacco, and my spouse/domestic partner currently uses tobacco. ($25) Both my spouse/domestic partner and I currently use tobacco. ($50) Both my spouse/domestic partner and I currently do not use tobacco. ($0) I currently use tobacco and do not have a spouse/domestic partner covered in PEBB. ($25) I currently do not use tobacco and do not have a spouse/domestic partner covered in PEBB. ($0) I do not enroll in PEBB medical plans. My or c My spouse s or domestic partners provider advised not to quit using tobacco (Medical Waiver). ($0) Page 4 of 5 PEBB Self-Pay (09/2018)
5 Other spousal/partner employer group coverage (If you enroll in a medical plan and cover a spouse or partner you need to complete this section or a surcharge will be added to your monthly premium.) When your spouse or domestic partner is enrolled in your PEBB medical coverage and has access to medical coverage from their employer s sponsored group plan (i.e., a non- State of Oregon) but does not enroll for it, $50 will be added to your monthly PEBB premium. Check one box: My spouse/domestic partner has PEBB coverage as an eligible employee (Includes a spouse who enrolls in Opt Out). ($0) My spouse/domestic partner has other employer group coverage available and enrolls for that coverage. ($0) F F My spouse/domestic partner has other-employer group overage available, but does not enroll in that coverage and is enrolled in PEBB coverage. ($50) My spouse/domestic partner does not have other-employer group coverage available. ($0) I do not cover a spouse or domestic partner in a PEBB medical plan. ($0) Participant signature and authorization I declare that the individuals listed on this form and I are eligible for the coverage requested. I understand the benefit elections made on this application are in effect for as long as I continue to meet PEBB s eligibility requirements, or until I elect to change them subject to the provisions of PEBB s plan. I have read the benefit materials and I understand the limitations and qualifications of the PEBB benefits program. If necessary, I authorize premium payments deducted from my pay. I understand that: A person knowingly makes a false statement in connection with an application for any benefit may be subject to imprisonment and fines. Knowingly making a false statement may subject me to termination of enrollment, denial of future enrollment, or civil damages. If I fail to report a change that made an enrolled family member ineligible, PEBB may consider my omission an intentional misrepresentation of a fact material to my enrollment. In that case, PEBB may terminate the family member s coverage retroactively, pursuant to PEBB rules. You must submit a midyear change form to your benefit office within 30 days of the date when an individual you provide coverage for is no longer PEBB eligible. If your notice is late, you and your qualified beneficiaries may lose the right to elect COBRA. This form supersedes all forms and submissions I previously made for PEBB coverage for individuals named. I certify under penalty of the State of Oregon laws that the foregoing is true and accurate to the best of my knowledge and belief. I declare the dependents listed and I are eligible for the coverages requested per PEBB Administrative Rule (OAR) Division 15. I understand that they are subject to penalty for false claims. Participant signature Date Submit completed form to BenefitHelp Solutions, PO Box 40548, Portland, OR or Fax to or Keep a copy of your benefit forms for your records. Any alteration of this form may result in it being ineffective. Page 5 of 5 PEBB Self-Pay (09/2018)
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