Dear State of Florida Retiree:

Transcription

1 Peple First Service Center P.O. Bx 6830 Tallahassee, FL Tel: Fax: TTY: Dear State f Flrida Retiree: Cngratulatins n yur retirement! As a new retiree, yu need t be aware f State Grup Insurance benefit ptins available t yu. Please read each sectin carefully. Sectin A: Summary f ptins t cntinue yur current cverage Health cntinue thrugh COBRA fr up t 18 mnths r elect retiree cverage Basic life chse either the $2,500 r the $10,000 benefit (ptinal life is nt available) Dental and visin cntinue thrugh COBRA fr up t 18 mnths Other supplemental plans cntact yur insurance cmpany abut cnverting yur plicy r buying an individual plan Health savings accunt make cntributins until enrlled in Medicare, but the state will n lnger make cntributins Healthcare flexible spending accunt cntinue thrugh the grace perid f the fllwing plan year if yu pay the balance and cmplete the frm Dependent care flexible spending accunt ends with yur last emplyee payrll deductin, but yu can file claims incurred befre yur terminatin date Sectin B: Infrmatin yu shuld receive in the mail If yu are enrlled in the plan at the time f yur retirement, then yu shuld receive tw packets by mail: 1. COBRA rights infrmatin packet: Health: Federal law (COBRA) prvides that insured emplyees and their cvered dependent(s) may cntinue emplyer grup health cverage fr up t 18 mnths frm the date emplyment ends r until they becme cvered under anther grup plan, whichever is first. Take nte f enrllment deadlines in the COBRA package. Supplemental dental and visin: The enrllment frms in yur COBRA infrmatin packet have infrmatin abut yur current state grup dental and/r visin plans (if any). Yu can nly cntinue yur dental and/r visin plans under COBRA fr up t 18 mnths. 2. Retiree enrllment packet (enclsed with this letter): Yur persnalized benefits statement: Shws yur current insurance cverage with the state. Please carefully review this statement and the imprtant messages. Dependent Eligibility Certificatin Frm: Yu must cmplete this frm if yu cver dependents. Insert New Retiree Cver Letter

2 Sectin C: When cverage ends Yur emplyee insurance plans autmatically end the last day f the mnth fllwing yur terminatin date; fr example, if yur terminatin date is June 7, yur cverage ends July 31. If yur last pay warrant will nt cver the remaining premium balance, please submit check, mney rder r cashier s check t the Peple First Service Center. Flexible spending accunts autmatically end the day f yur terminatin. Only expenses incurred befre yur last payrll deductin are eligible fr reimbursement. File by April 15. Retiree health and life and COBRA dental and visin autmatically cancel if yu send n payment by the last day f the cverage mnth. If yur cverage cancels fr any reasn, yu will nt be allwed t jin the State Grup Insurance health and/r life plans at a later date as a retiree. Sectin D: T cntinue yur cverage if yu currently have insurance benefits 1. Make smart chices: Yu must make State Grup health and life insurance electins thrugh Peple First within 60 days f yur emplyment terminatin. If yu d nt, yu will nt be able t enrll at a later time as a retiree. New Retiree Health and Life Insurance Electin Frm: Use t cntinue r end yur cverage. Yu must enrll within 60 days f yur last day f wrk if yu are currently enrlled in health and/r life insurance. Yu must als send the apprpriate premium payments t remain cvered. Review yur enclsed benefits statement t see yur cverage ptins. Upn retirement, yu can change frm family t individual cverage, but yu can nly change plans if yu have an apprpriate qualifying event, such as mving ut f a Health Maintenance Organizatin (HMO) service area. Yu re allwed t make any changes t plans yu are enrlled in during pen enrllment. Cntact the insurance carriers directly t cnvert yur supplemental pretax plicies r t buy an individual plan. G t mybenefits.myflrida.cm fr cntact infrmatin. Call Peple First at TTY users call fr help. If yu and yur spuse are bth State f Flrida retirees with n eligible dependents, think abut changing yur level f cverage frm family t tw individual plicies. This may be cheaper than the family plan. When yur spuse is a State f Flrida emplyee: Health insurance: If yu are listed as a dependent under yur spuse s health plan, d nthing. If yur spuse is listed as yur dependent, yu shuld bth call Peple First t have yur spuse enrll in emplyee cverage and add yu as a dependent. As lng as yu maintain cntinuus cverage, yu will be able t enrll in retiree health insurance later when yur spuse retires r ends state emplyment. Life insurance: Yur spuse shuld enrll in spuse life cverage. This cverage prvides a higher benefit at a lwer mnthly premium than retiree life insurance. As lng as yu maintain cntinuus cverage, yu will be able t enrll in retiree life insurance later when yur spuse retires r ends state emplyment. Insert New Retiree Cver Letter

3 2. Cmplete the enclsed New Retiree Health and Life Insurance Electin Frm t cntinue cverage as a retiree. If yu call Peple First and make yur chices ver the phne, yu dn t need t cmplete the frm. Mail and fax infrmatin are n the frm. 3. Pay the required premium payments fr each mnth f cverage. Yu have tw ptins t pay: Have the premium deducted n a pst tax basis each mnth frm yur Flrida Retirement System (FRS) mnthly pensin benefit. Yur benefit must be sufficient t cver the premium. Call the Divisin f Retirement at t find ut when yur mnthly pensin payment will begin; Tallahassee residents call Then call Peple First t set up the deductin. Yu must send payments t Peple First until yur deductins start. Call Peple First if yu are a retiree under an ptinal retirement plan r if yur FRS mnthly pensin payment, including the Health Insurance Subsidy, will nt cver yur mnthly health and life insurance premium deductins. Be sure yur mailing address is crrect and Peple First will send yu payment cupns. Send a persnal check, mney rder, r cashier s check. Write yur Peple First ID number n yur payment, made payable t Divisin f State Grup Insurance and send it t: Peple First Service Center PO Bx Orland, FL Yu can pay up t six mnths in advance, but yu must pay by the 10 th f the mnth fr the next mnth s cverage; fr example, payments fr July cverage are due t Peple First by June 10. If yur payment is nt received by the 10 th, yur cverage will be suspended fr the next mnth and yu will nt be eligible fr services until the full payment is received. If yur payment is nt received by the last day f the mnth in suspensin, yur cverage will be cancelled and yu will nt be able t re enrll. 4. Submit yur applicatin fr the Health Insurance Subsidy. The health insurance subsidy is an emplyee benefit f the FRS. (Investment Plan members are eligible fr the HIS benefit nly if they meet certain requirements.) Retirees wh carry qualified health insurance receive a mnthly supplemental payment based n years f service. If yu are an FRS pensin plan retiree, the Divisin f Retirement Payrll Sectin will send the HIS 1 frm t yu in yur retiree packet. If yu are cntinuing yur State Grup Health Insurance as a retiree r if yu are a cvered dependent under yur spuse s State Grup Health Insurance plan, cmplete the HIS 1 frm and send r fax it t: Peple First Service Center Fax: PO Bx 6830 Tallahassee, FL Peple First will prcess this frm t certify t FRS that yu have State Grup Health Insurance cverage and return it t the Divisin f Retirement. If yur retiree health insurance cverage will be thrugh a private vendr r Medicare, fllw the instructins fr submissin n the HIS 1 frm. Insert New Retiree Cver Letter

4 Peple First can nly certify State Grup Health Insurance cverage. G t dms.myflrida.cm/retirement t learn mre. 5. If yu are enrlled in a healthcare flexible spending accunt and have mney remaining in yur FSA, yu can cntinue yur benefit under COBRA thrugh the grace perid (March 15 f the fllwing plan year). T avid frfeiting yur mney, cmplete and submit the Cntinuing Yur Healthcare FSA When Emplyment Ends frm, lcated at mybenefits.myflrida.cm in the Frms and Publicatins sectin. This frm gives yu the ptin f paying the balance f yur accunt n a pretax basis frm yur sick r annual leave payut, r yu can pay by persnal check n a pst tax basis. Once yu make the electin, yu will have until March 15 t incur claims and April 15 f the fllwing plan year t file claims. Sectin E: Medicare Fr specific infrmatin abut Medicare, including eligibility and cverage, visit r call 800 Medicare ( ). TTY users call General Medicare infrmatin: Part A is hspitalizatin cverage free t eligible Medicare beneficiaries. Part B is medical cverage that requires a mnthly premium (taken frm yur Scial Security check r paid by persnal check). Part C (Medicare Advantage Plan) is a type f Medicare health plan ffered by a private cmpany that cntracts with Medicare t prvide yu with all yur Part A and Part B benefits and ften includes prescriptin drug cverage. Yu must be enrlled in Medicare Part B and yu may als be required t send a mnthly premium t the insurance cmpany. Part D is prescriptin drug cverage that may require a mnthly premium (taken frm yur Scial Security check r paid by persnal check). Medicare Supplement (Medigap) Plans sld by private cmpanies can help pay sme f the health care csts Medicare desn't cver, like cpayments, cinsurance, and deductibles. Sme Medigap plicies als ffer cverage fr services that Medicare desn't cver. Yu may purchase Part B, Part C, Part D r Medigap plans n the private market. If yu chse t d s, yu shuld cancel yur state grup health insurance plan. Remember, nce yu cancel, yu cannt enrll at a later time. Yu are eligible fr Medicare (either at retirement r after retiring) and keeping state grup health insurance: Crdinating medical cverage: When Medicare Part A r Part B pays, yur state grup health insurance pays secndary. When Medicare des nt pay, yur state grup health insurance pays primary fr cvered benefits and services (just like when yu were an emplyee). Flrida Blue administers the natinwide PPO secndary plan; Aetna, AvMed, and UnitedHealthcare administer the HMO secndary plans in their respective service areas. If yu fail t enrll in Medicare Part B: Yu will have significant ut f pcket expenses fr Part B eligible services because yu will be required t pay the prtin (apprximately 80 percent) that Medicare wuld have paid. If yu chse t cntinue yur state grup health Insert New Retiree Cver Letter

5 insurance cverage nce yu re eligible fr Medicare, elect yur Medicare Part B cverage. Althugh Medicare des nt require yu t purchase Part B, it is in yur financial interest t d s. This cverage prvisin als applies t Medicare eligible dependents n yur plan. Creditable Cverage fr Medicare Part D: Fr prescriptin drug cverage, yur state grup health insurance pays primary fr mst prescriptin drugs. Cvered medicatins, cpays and the netwrk remain the same as when yu were an emplyee. If yu are enrlled in the state grup secndary health insurance, d nt enrll in a separate Medicare Part D plan. The state s prescriptin drug cverage is as gd as r better than Medicare Part D and is currently apprved by Medicare as creditable cverage. Medicare (Retiree) Advantage Plan: Capital Health Plan ffers this plan t state retirees in their respective HMO service area. T becme a member, yu must be enrlled in Medicare Parts A and B, cmplete Capital Health Plan s applicatin and receive apprval befre yur retiree health cverage becmes effective. Medicare Advantage Plans d nt allw retractive enrllment and claims can nly be paid if yu are apprved fr the plan. Medical and prescriptin drug cverage are included. Enrlling in Medicare: Once yu are eligible fr Medicare Part A and Part B due t age (65) r disability and n lnger wrking, yu shuld cntact the Scial Security Administratin (SSA) abut yur Medicare benefits. Enrllment in Medicare is time sensitive and yu may be subject t substantial financial penalties if yu fail t meet federal deadlines. Cntact yur lcal SSA ffice three mnths befre yur 65 th birthday: call 800 MEDICARE ( ), r visit fr mre infrmatin. TTY users call Enrlling in state grup Medicare secndary cverage r a Medicare advantage plan: the state ffers three Medicare cverage tiers when yu r a dependent is Medicare eligible: Medicare I: a single plicy fr yu Medicare II: a family plicy fr yu and yur eligible dependents and at least ne is eligible fr Medicare Medicare III: a family plicy fr yu and ne dependent and yu are bth Medicare eligible Yu d nt meet Medicare eligibility requirements: If yu have nt wrked enugh quarters t be eligible fr Medicare at age 65, call the Scial Security Administratin and request an ineligibility letter. Please send a cpy f that letter immediately t Peple First t ensure yur health insurance cverage cntinues withut interruptin. Mail r fax cpies f Medicare dcumentatin with yur Peple First ID number t: Peple First Service Center Fax: PO Bx 6830 Tallahassee, FL Sectin F: Imprtant reminders Addresses: Keep yur mailing and ntificatin address up t date in Peple First t receive pen enrllment materials and imprtant ntices timely. Medicare card: Fr prper enrllment and claims prcessing, send cpies (yurs and yur dependent s) f Medicare ID cards t Peple First as sn as yu receive them frm the SSA. Use the Peple First website: T see yur benefits infrmatin in Peple First, lg in and g t Insert New Retiree Cver Letter

6 Health & Insurance > My Benefits. T see yur mnthly premium payments g t Health & Insurance > Benefit Premium Histry and select the mnth yu want t see. Authrizatin t Disclse Prtected Health Infrmatin (PHI): If yu want t give Peple First r yur insurance cmpany permissin t disclse PHI t an individual, yu must submit an authrizatin frm t each party. Fr example, if yu want yur spuse t be able t call Peple First t discuss yur mnthly premiums, yu must send Peple First an authrizatin frm (enclsed); therwise, representatives will be unable t talk t yur spuse per Health Insurance Prtability and Accuntability Act f 1996 (HIPAA) guidelines. Call Peple First r yur insurance cmpany fr mre infrmatin. Fr mre infrmatin, including HMO service areas and annual premium changes: Visit mybenefits.myflrida.cm. Waiver f premium fr ttal disability: the life insurance cmpany may waive premiums if yu becme disabled while still actively emplyed. Call the life insurance cmpany at fr mre infrmatin n the Waiver f Premium prvisins. If yu have questins abut yur insurance benefits upn retirement, call us at r TTY We are pen Mnday thrugh Friday, frm 8 a.m. t 6 p.m. Eastern time. Sincerely, Peple First Service Center Insert New Retiree Cver Letter

7 Special Ntice abut the Medicare Part D Drug Prgram January 1, 2018 Please read this ntice carefully. It explains the ptins yu have under Medicare prescriptin drug cverage and can help yu decide whether r nt yu want t enrll in Medicare Part D. Medicare prescriptin drug cverage (Medicare Part D) became available in 2006 t everyne with Medicare thrugh Medicare prescriptin drug plans and Medicare Advantage Plans that ffer prescriptin drug cverage. All apprved Medicare prescriptin drug plans must ffer a minimum standard level f cverage set by Medicare. Sme plans may ffer mre cverage than required. As such, premiums fr Medicare Part D plans vary, s yu shuld research all plans carefully. The State f Flrida Department f Management Services has determined that the prescriptin drug cverage ffered by the State Emplyees Health Insurance Prgram (State Health Prgram) is, n average, expected t pay ut as much as r mre than the standard Medicare prescriptin drug cverage pays and is cnsidered Creditable Cverage. Yu can jin a Medicare drug plan when yu first becme eligible fr Medicare and each year frm Oct. 15 t Dec. 7. Hwever, if yu lse yur current creditable prescriptin drug cverage, thrugh n fault f yur wn, yu will als be eligible fr a tw mnth Special Enrllment Perid (SEP) t jin a Medicare drug plan. If yu d decide t enrll in a Medicare prescriptin drug plan and drp yur State Health Prgram cverage, be aware that yu and yur dependents will be drpping yur hspital, medical and prescriptin drug cverage. If yu chse t drp yur State Health Prgram cverage, yu will nt be able t re enrll in the State Health Prgram. If yu enrll in a Medicare prescriptin drug plan and d nt drp yur State Health Prgram cverage, yu and yur eligible dependents will still be eligible fr health and prescriptin drug benefits thrugh the State Health Prgram. Hwever, if yu are enrlled in a state spnsred HMO ffering a Medicare Advantage Prescriptin Drug Plan, yu may have t change t the State Emplyees PPO Plan t get all f yur current health and prescriptin drug benefits. If yu drp r lse yur cverage with the State Health Prgram and d nt enrll in Medicare prescriptin drug cverage after yur current cverage ends, yu may pay mre (a penalty) t enrll in Medicare prescriptin drug cverage later. Additinally, if yu g 63 days r lnger withut prescriptin drug cverage that s at least as gd as Medicare s prescriptin drug cverage, yur mnthly premium will g up at least 1 percent per mnth fr every mnth that yu did nt have that cverage, and yu may have t wait until the fllwing Nv. t enrll. Additinal infrmatin abut Medicare prescriptin drug plans is available frm: Yur State Health Insurance Assistance Prgram (see the inside back cver f yur cpy f the Medicare & Yu handbk fr their telephne number) (800) MEDICARE r ( ). TTY users shuld call Fr peple with limited incme and resurces, payment assistance fr Medicare prescriptin drug cverage is available. Infrmatin abut this extra help is available frm the Scial Security Administratin (SSA). Cntact yur lcal SSA ffice, call , r fr mre infrmatin. TTY users call Fr mre infrmatin abut this ntice r yur current prescriptin drug plan, call the Peple First Service Center at Remember: Keep this Creditable Cverage ntice. If yu decide t jin ne f the Medicare drug plans, yu may be required t prvide a cpy f this ntice when yu jin t shw whether yu have maintained creditable cverage and, therefre, whether yu are required t pay a higher premium amunt (a penalty).

8 SGI-12 11/15 Dependent Eligibility Certificatin Frm If yu cver dependents under any State Grup Insurance plan, yu must certify their eligibility by cmpleting this frm befre any changes t yur insurance can be prcessed. In accrdance with Chapter 60P, Flrida Administrative Cde, dependents m ust meet specific eligibility requirements t be cvered under State Grup Insurance plans. Eligible dependents include: Yur spuse a persn t whm yu are legally married. The term spuse des nt include cmmn law m arriage partners, registered dm estic partners r ther partners f relatinships nt defined as m arriage under the law f the state r freign cunt y in which the y were entered. Yur child yur bilgical child. Dependent children m ay be eligible thrugh the end f the calendar year in which they reach 26, ptentially lnger if they are disabled. Yur child w ith a disability yur cvered child wh is permanently m entally r physically disabled. This child m ay cntinue health insurance cverage after reaching age 26 if yu prvide adequate dcumentatin validating disabilit y upn request and the child rem ains cntinuusly cvered in a State Grup Insurance health plan. The child must be unm arried, dependent n yu fr care and fr financial supprt, and have n dependents f their wn. Legal guardianship a child (yur ward) fr whm yu have legal guardianship in accrdance with an Order f Guardianship pursuant t applicable state and federal laws. Yur ward m ay be eligible thrugh the end f the calendar year in which the y reach 26, ptentially lnger if they are disabled. Yur grandchild a newbrn dependent f yur cvered child. Cverage m ay rem ain in effect fr up t 18 m nths f age as lng as the newbrn s parent rem ains cvered. Yur Legally Adpted child yur legally adpted child pursuant t a Judgment f Adptin; r a child placed in yur hm e fr the purpse f adptin in accrdance with applicable state and federal laws. Dependent children may be eligible thrugh the end f the calendar year in which the y reach 26, ptentially lnger if they are disabled. Yur fster child a child that has been placed in yur hm e by the State f Flrida Fster Care Prgram r the fster care prgram f a licensed private agency. Fster children m ay be eligible thrugh the end f the calendar year in which they reach 26, ptentially lnger if they are disabled. Yur stepchild the child f yur spuse fr as lng as yu rem ain legally m arried t the child s parent. Dependent children m ay be eligible thrugh the end f the calendar year in which they reach 26, ptentially lnger if they are disabled. Yur ver-age dependent yur child after the end f the calendar year in which they turn age 26 thrugh the end f the calendar year in which they reach 30, if they are unm arried; have n dependents f their wn; are dependent n yu fr financial supprt; live in Flrida r attend schl in anther state; and have n ther health insurance. Based n the definitins abve, please list all eligible dependents belw that are currently cvered under ANY state insurance plan r thse yu w ant t add t a plan(s). If yu d NOT list a cvered dependent, the dependent will be remved frm cverage as f the first f the mnth fllw ing this ntificatin if yu are requesting a QSC (Qualified Status Change), r as f January 1 if this is an Open Enrllment Change. Attach enrllment frms as necessary. * Required t be cmpleted. *Name (Last, First, MI) Please Print *Scial Security Number *Date f Birth *Gender *Relatin I hereby affirm and attest that the dependent(s) listed abve m eet the requirements f eligibility. If an y dependent is determ ined t be ineligible r I fail t ntif y Peple First f a lss f eligibility r any supprting dcum entatin is nt prvided upn request, I understand that I m ay be liable fr any and all claim s paid fr any dependent deem ed ineligible. *Peple First ID Number: 0 *Signature *Date Page 1 f 1

9 SGI-06 11/15 New Retiree Health and Life Insurance Electin Frm Learn abut plans, use the cst estimatrs and mre at mybenefits.myflrida.cm. Fr help, call (866) r TTY (866) weekdays, frm 8 a.m. t 6 p.m. Eastern time. SECTION A Retiree Infrmatin - REQUIRED FIELDS* Peple First ID* Date f Birth (MMDDYYYY)* Gender* Area Cde Primary Phne Area Cde Alternate Phne 0 M F First Name* Last Name* Suffix Hme Address Line 1* Hme Address Line 2 Hme Cunty* City* State* ZIP Cde* Cuntry* Ntificatin Address. Check this bx if yur mailing address is the same as yur hme address. Mailing Address Line 1* Mailing Address Line 2 City* State* ZIP Cde* Cuntry* SECTION B Event T ype - Please check () apprpriate bx. W hat type f event is this? Pensin Plan Retirement Investment Plan Disability Retirement Plan Other Optinal Retirement Plan Page 1 f 2 State Grup Health Insurance - Please check () yur chice(s). I want t cntinue my current level f health insurance cverage as a retiree. I want t change my family health insurance cverage t individual cverage. I am nt Medicare eligible. I understand that I must experience a Qualifying Status Change (QSC) event t g back t family cverage; therwise, I can nly make a change during Open Enrllment. I n lnger live in my HMO service area. Change my plan t: Plan Name. I want t end my state health insurance cverage. If I end my health cverage, I will nt be allwed t jin the plan at a later date as a retiree. If yu and/r yur dependent(s) are eligible fr Medicare¹, yu may nly select frm these ptins: Medicare I - An individual plan fr yu if yu are eligible fr Medicare Parts A and B due t age 65 r disability. Medicare II - A family plan fr tw r mre peple, if at least ne family member is eligible fr Medicare Parts A and B due t age 65 r disability. Medicare III - A family plan fr nly tw peple and bth are eligible fr Medicare Parts A and B due t age 65 r disability. ¹State grup health insurance plans pay claims secndary t Medicare, even if yu d nt enrll in Medicare.

10 New Retiree Health and Life Insurance Electin Frm Peple First ID* 0 SECTION D Dependent Enrllment (Attach additinal page if necessary) Cmplete all fields in the chart belw and then check the apprpriate clumn t ENROLL, t CONTINUE cverage fr eligible dependents, r t CANCEL cverage fr dependents. G t mybenefits.myflrida.cm fr dependent eligibility requirements. 1 - Spuse 2 - Child 3 - Legal Guardianship 4 - Grandchild 5 - Legally Adpted Child 6 - Fster Child 7 - Stepchild 9 - Over-age Dependent Name (Last, First, MI) Please Pr int Scial Security Number Date f Birth (mm/dd/yyyy) Gender Relatin Enrll Cntinue Cancel SECTON E Basic Life Insurance Electin Chse ne f the ptins belw. These benefits and rates are subject t change: I elect $10,000 f basic life insurance cverage with a mnthly premium f $ I elect $2,500 f basic life insurance cverage with a mnthly premium f $4.83. I want t end my basic life insurance cverage under the state grup life insurance plan as a retiree. If I end my life cverage, I will nt be allwed t jin the plan at a later date as a retiree.. SECTION F Methd f Premium Payment T cmplete yur enrllment, yu must submit the required premium fr the first mnth f cverage t Peple First. Yu must submit a check, mney rder, r cashier's check t the payment address at the bttm f this page. All payments are due a mnth in advance fr the next mnth's cverage. After yu pay yur first mnth's premium, yu have tw payment ptins (check ne): I will submit premium payments t Peple First by the 10th day f each mnth fr the fllwing mnth's cverage. I authrize the State f Flrida t deduct frm my FRS mnthly pensin payment the amunt necessary t pay the premiums fr the cverage I have selected. SECTION G Retiree and Dependent Certificatin I hereby affirm and attest that the dependent(s) listed abve meet the requirements f eligibility. If any dependent is determined t be ineligible r I fail t ntify Peple First f a lss f eligibility r any supprting dcumentatin is nt prvided upn request, I understand that I may be liable fr any and all claims paid fr any dependent deemed ineligible. I understand the ptins I am chsing and that my participatin is subject t applicable rules in Chapter 60P, Flrida Administrative Cde. I understand that my enrllment in the State Health and Life Insurance Prgrams will be cmplete nly if Peple First receives my first mnth's premium and this applicatin within 60 days f my retirement. If checked abve as my preferred payment methd, I authrize the State f Flrida t deduct frm my FRS mnthly pensin payment the amunt necessary t pay the premium fr the cverage I have selected. If I d nt receive a mnthly retirement benefit r if it is nt sufficient t pay the premium, I will submit the amunt due by persnal check, mney rder r cashier's check by the 10th day f each mnth fr the fllwing mnth's cverage. I understand that I may cancel my insurance cverage at any time but will nt be allwed t jin at a later date as a retiree. All ther changes can nly be made if I have a Qualifying Status Change event r during Open Enrllment. I must request changes within 60 calendar days f the Qualifying Status Change event. Retiree Signature* Date* Mail this cmpleted frm t Peple First Service Center PO Bx 6830 Tallahassee, FL r fax t (800) Mail payments t Peple First Service Center PO Bx Orland, FL Falsifying dcuments, misrepresenting dependent status, r using ther fraudulent actins t gain cverage may be criminal acts. Peple First is required t refer such cases t the State f Flrida.

11 Authrizatin fr Release f Prtected Health Infrmatin Peple First and Chard Snyder, serving yu n behalf f the State Grup Insurance Prgram ( Prgram ), cannt use r disclse 1 prtected health infrmatin (r the health infrmatin f yur children r ther peple n whse behalf yu can act) withut the apprpriate authrizatin. This means we are nt permitted t discuss r prvide t any persn, including yur spuse, any infrmatin cncerning yur health insurance, health care flexible spending accunt, r health savings accunt, as applicable. T allw us t disclse yur infrmatin t the persn r rganizatin f yur chice, please cmplete the frm belw and return as directed n the last page f the frm. If yu wish t authrize us t discuss yur prtected health infrmatin with mre than ne persn, yu must cmplete a separate frm fr each persn. If yu wish t authrize us t discuss prtected health infrmatin fr yur cvered dependent(s) n whse behalf yu can act, yu must cmplete a separate frm fr each dependent. If yur cvered dependent(s) ver the age f eighteen wishes t authrize us t discuss their prtected health infrmatin, they must cmplete a separate frm. If yu have a valid medical pwer f attrney and yu want t authrize him r her t receive yur prtected health infrmatin, yu are nt required t cmplete this frm; hwever, yu must send a cpy f the valid medical pwer f attrney t prvide authrizatin fr disclsure. Nte: this frm nly authrizes Peple First and/r Chard Snyder t disclse yur infrmatin. Yur health plan, CVS/caremark, and healthcare prvider each have separate authrizatin frms. Fr assistance with cmpleting this frm, please call Peple First at PERSON COMPLETING FORM First Name* Peple First ID Number* Primary Phne* Last Name* Date f Birth (mm/dd/yyyy)* Secndary Phne Address Street Address* City* State* ZIP Cde* *required 2. PERSON WHOSE PROTECTED HEALTH INFORMATION MAY BE DISCLOSED (separate frm required fr each persn) Self Dependent n whse behalf yu may act FIRST NAME LAST NAME 1 Except as permitted under federal law (HIPAA) and as described in the Prgram s privacy ntice, available at mybenefits.myflrida.cm. 1 v12.15

12 3. PERSON OR ORGANIZATION AUTHORIZED TO RECEIVE/DISCUSS PROTECTED HEALTH INFORMATION Name Phne Address City State ZIP Cde Relatinship t Yu Spuse Adult Child Parent Friend Legal Representative Other Purpse: 4. INFORMATION TO BE RELEASED TO RECIPIENT NAMED IN #3 ABOVE Check all that apply: I hereby authrize Peple First t disclse prtected health infrmatin recrded in the Peple First system fr the persn named in #2 abve as indicated: All accunt infrmatin recrded in the Peple First system Enrllment infrmatin Premium Payment infrmatin Benefit infrmatin Dependent infrmatin Authrizatin t disclse prtected health infrmatin expires: On the fllwing date: Upn disenrllment frm the Prgram. I hereby authrize Chard Snyder t disclse the prtected health infrmatin related t my flexible spending accunt (FSA) and/r my health savings accunt as indicated belw. Yu MUST check the apprpriate bx: Healthcare FSA; and/r Health Savings Accunt Authrizatin t disclse prtected health infrmatin expires: On the fllwing date: Upn disenrllment frm the Prgram. 5. IMPORTANT INFORMATION ABOUT PARTICIPANT S RIGHTS I have read and understand the fllwing statements abut my rights: This authrizatin is vluntary and I may refuse t sign this authrizatin. I am nt required t sign this frm t receive my health care benefits. The infrmatin used r disclsed pursuant t this authrizatin may be redisclsed by the recipient named in #3 abve. I have the right t seek assurances frm such recipient that he/she will nt redisclse the infrmatin t any ther party withut my further authrizatin. Neither Peple First nr Chard Snyder will be held liable fr any redisclsure f prtected health infrmatin by such recipient. I may revke this authrizatin at any time prir t its expiratin date by ntifying Peple First in writing, but the revcatin will nt have any effect n any actins that Peple First r Chard Snyder tk befre receiving the revcatin ntice. I understand this authrizatin will expire as stated abve and I will need t cmplete a new frm t allw individuals authrizatin t my prtected health infrmatin. By authrizing Chard Snyder t disclse infrmatin related t my healthcare FSA and/r my health savings accunt, my recrds may include infrmatin regarding drug r alchl use, cunseling referrals and/r a histry f testing r treatment f acquired immune deficiency syndrme (AIDS) r related cnditins. 2 v12.15

13 AUTHORIZATION AND SIGNATURE Signature f Persn Named in #1 Abve* Date* Printed Name SUBMISSION Keep a cpy fr yur recrds and send the cmpleted frm t: Peple First Service Center Fax t (800) PO Bx 6830 OR Tallahassee, FL *LEGAL REPRESENTATIVE N additinal dcuments are required, as lng as the persn signing this frm is acting fr himself r herself r has the authrity t act n behalf f a dependent. If the persn is unable t sign this frm fr any f the fllwing reasns, the persn s legal representative must prvide ne f the fllwing and cmplete the infrmatin belw: 1. If the persn is deceased, the legal representative must prvide dcumentatin that he r she is the executr r administratr f the participant s estate. We may nt rely n a durable pwer f attrney, advance directive, guardianship r cnservatrship papers after the death f the persn, as the papers are nt valid after death. 2. If the persn is incapacitated and, as a result, a legal representative needs t act n behalf f the persn, submit this cmpleted authrizatin frm and include the legal dcumentatin shwing wh the legal representative is. Legal dcumentatin includes durable pwer f attrney, guardianship r cnservatrship papers. First Name f Persn s Legal Representative Last Name f Persn s Legal Representative Primary Phne f Persn s Legal Representative Address f Persn s Legal Representative Street Address f Persn s Legal Representative City State ZIP Cde 3 v12.15