Health Insurance. Open Enrollment Lay Employee Plans. November 16, 2018 through December 14, 2018

Transcription

1 ALASKA CONFERENCE OF CATHOLIC BISHOPS 2019 Health Insurance Open Enrollment Lay Employee Plans November 16, 2018 through December 14, 2018 (For Policies effective January 1 through June, 2019) (Medical, Dental, & Vision)

2 Guide to your Health Care Special Announcement Enrollment Letter (important information) Health Insurance Coverages Medical Plan Overviews Dental Plan Overview Vision Plan Overview Prescription Drug Program Other Health Resources Online Health Management Doc Find (Medical) Doc Find (Dental) Vision Assistance Online Teledoc Health Savings Account explanation Benefit Pricing $$$ Explanation Enrollment/Change form a 3b 3c 3d 4 4a 4b 4c 4d 4e 4f 5 6 Continuation of Benefits-rate acknowledgement.7 Spouse Eligibility Affidavit 8

3 ALASKA CONFERENCE OF CATHOLIC BISHOPS Special Announcement We are opening the current Health plan year for a brief period of time for elective changes. Generally this is only an annual opportunity. This Mid-year Open Enrollment period, the plan coverages remain the same, however your options for enrolling dependents and the pricing for your dependent benefits have changed. The Dependent Medical option(s) have changed From: To: New Rule: +1 Dependent (Spouse or Child) +2 or more (Spouse & Child(ren) or (multiple children without Spouse) +Child(ren) a new lower cost one price no matter how many +Spouse only +Spouse & Child(ren) (the whole family) Spouses eligible for medical coverage with their own employer are no longer eligible for coverage on this plan. After this Mid-year Open Enrollment is completed, we will resume a once a year Open Enrollment opportunity in May each year for plans beginning July 1. **Remember - Christian Brothers Services has declared a Premium Holiday for June 2019! This means you will not pay your employee contribution or your dependent premiums for that month! Monika Scott, CFO Susan Clifton, CFO - Archdiocese of Anchorage - Diocese of Fairbanks Mike Monagle, CFO - Diocese of Juneau

4 ALASKA CONFERENCE OF CATHOLIC BISHOPS Dear Employee, Your Employer participates in a cooperative group called the Alaska Conference of Catholic Bishops (ACCB) in order to provide Quality Health Benefits to our employees and their families. Our Health plans are administrated by Christian Brothers Services, a Catholic Healthcare Trust. ACCB is providing this packet to help you make informative decisions regarding your personal healthcare, and options available for your dependents. Your Healthcare choices can only be adjusted during the Open Enrollment period unless there is a qualified event during the year. If you are enrolling for the first time, or are currently enrolled and wish to make changes to your plan coverages, you must return your completed, signed Enrollment Form at the back of this package. If you are currently enrolled and are not making changes, please sign and return the Rate Acknowledgement form at the back of this package. Open Enrollment begins November 16, 2018 and ends December 14, 2018 During the Open Enrollment period, you will have the opportunity to add, change, or drop your health plan for yourself or your dependents. This includes adding family members who are not currently enrolled in our group insurance program, as well as increasing coverage for those members already participating. Changes made to your benefits during this Open Enrollment will be effective January 1, The Open Enrollment period will close December 14, No exceptions. If you have any questions, please contact the appropriate person in your parish, school or agency, or call Eric Eligibility An employee must work 30 hours or more per week (on average over a 6 month period) in order to be eligible for health insurance benefits. A benefit eligible person may not waive insurance in lieu of additional compensation in wages, nor may an employer make such an offer. The option for a non-benefit eligible employee to purchase our insurance plan is not available. Employee benefits are effective the first day of the month following a 30 day waiting period from their date of hire. (ie: if hire date= May 28 (+ 30 days)= June 28 then the insurance effective date is July 1) Spouse/Dependent coverage is available for purchase. Dependents qualify until the age of 26, married or unmarried. If adding spouse or dependents, documentation must be provided. (Marriage Certificate (spouse), and/or Birth certificate(s) for dependent(s)) Spouse eligibility affidavit must be completed along with enrollment or continuation form Health Plan choices: Medical - Default Higher Deductible Health Plan ($2,700 deductible) 85% coverage in network Medical - Buy-up Lower Deductible Health Plan ($500 deductible) 75% coverage in network Dental PPO - $1,500 allowance /$50 deductible Vision-VSP Choice/$10/$25 copay Life/Ltd (Long Term Disability) Insurance: Life insurance coverage is $50,000 (decreased benefit amounts at age 65 & 70) Employee only plans a Benefit Eligible employee cannot waive these insurances. Employee must enroll when eligibility requirements are met.

5 Health Insurance Plans

6 ACCB Lay Employee Medical Plans - Beginning January 1, Oveview (Summary) Lay "Default" Plan "Buy-up" Plan Higher Deductible -PPO Lower Deductible - PPO Medical In Network In Network Coinsurance 85% 75% Deductible 2,700 Ind / 5,400 Fam 500 Ind / 1000 Fam Out of Pocket Cost 5,400 Ind / 10,800 Fam 5,000 Ind / 10,000 Fam PCP/Specialist Copay No Copay $40 ER Copay No Copay $100 InPatient Hospital Copay No Copay No Copay Out of Network Out of Network Coinsurance 75% 75% Deductible 5,400 Ind / 10,800 Fam 500 Ind / 1000 Fam Out of Pocket Cost 10,800 Ind / 21,600 Fam 5,000 Ind / 10,000 Fam PCP/Specialist Copay No Copay $40 ER Copay No Copay $100 IP Hospital Copay No Copay No Copay RX Prescription plan RX Plan Deductible 2,700 Ind / 5,400 Fam None Out of Pocket Cost 5,400 Ind / 10,800 Fam 1,850 Ind / 3,700 Fam Generic $10 / $20 Paid at coinsurance level after Preferred Brand $20 / $40 deductible is met Non Preferred Brand $30 / $60 Retail Refill Allowance No No ~HSA Qualified ~ Pricing for Plans Higher Deductible -PPO Lower Deductible - PPO Payment Responsibility: (January 1 - June 30, 2019) (January 1 - June 30, 2019) Employer Employer Contribution for Employee $ monthly monthly Employee Employee Cost for Self $10 monthly $ monthly Employee Cost for +Spouse $1, monthly $ monthly Employee Cost for +Child(ren) $ monthly $ monthly Employee Cost for +Spouse+Child(ren) $1, monthly $1, monthly

7 Christian Brothers Employee Benefit Trust Dental Plan DEDUCTIBLE $50 / Individual - $150 / Family YEARLY MAXIMUM $1,500 PREVENTIVE DENTAL: Oral exam each 6 months Emergency exam X-rays with frequency limits Prophylaxis (Cleaning) each 6 months Fluoride each 6 months for children under 16 Sealants each 24 months for children under 16 PREVENTIVE (Special provisions with Medical Necessity) Prophylaxis (Cleaning) Fluoride BASIC DENTAL: Fillings Stainless steel crown for children Extraction of teeth Oral Surgery Periodontal services; each with frequency limits Endodontic services General anesthesia for complex oral surgery Repairs to bridges or dentures Relining of dentures with frequency limits MAJOR DENTAL: Gold inlays/onlays; replacements; limited to 5 years from last placement Crowns; replacements limited to 5 years from last placement Implant Services Fixed bridges & full or partial dentures; Initial placement limited to extractions while on the plan Replacements limited to 5 years from last placement Temporomandibular Joint Disorders (TMJ) SOME SERVICES NOT COVERED (All Charges Subject to Prevailing Fees) 100 % No Deductible The Plan may allow up to 3 cleanings and fluoride treatments per year if you are being treated for a serious medical condition. Your medical doctor must submit documentation to the Plan for pre-approval. Benefits will be paid at the Preventive Dental level of benefits. 80 % After Deductible 50 % After Deductible Cosmetic services, occlusal analysis or adjustments, oral hygiene instruction, services to alter vertical dimension, duplication or replacing lost or stolen prosthetics, temporary services, and orthodontics. Non-emergency service performed outside USA. This Benefit Summary provides a brief outline of the services covered by CBEBT. THIS IS NOT A CONTRACT. The complete terms of the plan are contained in Your Employee Benefits booklet issued to members. For more information regarding benefits, please call Customer Service at Dental P 3 / Ortho 1000

8 Christian Brothers Employee Benefit Trust Orthodontia DEDUCTIBLE ( Separate from Dental Plan Deductible ) LIFETIME MAXIMUM ( Separate from Dental Plan Maximum ) $50 / Individual - $150 / Family $1,000 ELIGIBILITY Covered Dependent Only Under Age 19 COVERED PROCEDURES: Formal, full-banded retention and treatment X-rays Other diagnostic procedures Removable or fixed appliances for tooth or bony structure guidance or retention. 50 % after Deductible SOME SERVICES NOT COVERED Cosmetic services, implants, occlusal analysis, oral hygiene instruction, services to alter vertical dimension or restore occlusion (except for orthodontic related charges), duplication or replacing lost or stolen prosthetics, and temporary services. This Benefit Summary provides a brief outline of the services covered by CBEBT. THIS IS NOT A CONTRACT. The complete terms of the plan are contained in Your Employee Benefits booklet issued to members. For more information regarding benefits, please call Customer Service at Dental P 3 / Ortho 1000

9 Your VSP Vision Benefits Summary ALASKA CONFERENCE OF CATHOLIC BISHOPS and VSP provide you with an affordable eye care plan. VSP Coverage Benefit WellVision Exam Description Your Coverage with a VSP Provider Focuses on your eyes and overall wellness VSP Provider Network: VSP Choice Copay Frequency $10 Every 12 months Prescription Glasses Frame Lenses Lens Enhancements $130 allowance for a wide selection of frames $150 allowance for featured frame brands 20% savings on the amount over your allowance $70 Costco frame allowance Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Progressive lenses Anti-reflective coating Average savings of 20-25% on other lens enhancements $25 Included in Prescription Glasses Included in Prescription Glasses $0 $0 See frame and lenses Every 24 months Every 12 months Every 12 months Contacts (instead of glasses) $130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Up to $60 Every 12 months Extra Savings Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities Your Coverage with Out-of-Network Providers Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will be less or you ll receive a lower level of benefits. Visit vsp.com for plan details. Exam... up to $45 Frame... up to $70 Single Vision Lenses... up to $30 Lined Bifocal Lenses... up to $50 Lined Trifocal Lenses... up to $65 Progressive Lenses... up to $50 Contacts... up to $105 Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business. Contact us vsp.com 1. Brands/Promotion subject to change. 2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSP members with applicable plan benefits. Ask your VSP network doctor for details Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, eyeconic.com, and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

10 Prescription Drug Program Express Scripts The Christian Brothers Employee Benefit Trust has chosen Express Scripts to manage the prescription drug benefit for our members. Express Scripts has captured the No. 1 position in the Health Care: Pharmacy and Other Services sector on the Fortune World s Most Admired Companies List, and it s No. 2 in the world for Social Responsibility and Long-Term Investment. Of all companies surveyed globally, Express Scripts was ranked No. 5 in Innovation and No. 10 in People Management. With Express Scripts s sophisticated dispensing technology and mail-order pharmacies, our Trust members are provided high-quality prescription drugs at discounted prices. Express Scripts by Mail In the mail-order pharmacies, quality process activities as well as customer satisfaction are driven by performance measurement in four key areas: Compliance, Quality, Service, and Cost. Each of Express Scripts pharmacies adheres specifically to the requirements of the state in which it is located. In addition, Express Scripts and each of its mail-order pharmacies are fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are diligent in adhering to all applicable standards of that organization. Each mail-order pharmacy has a Director of Pharmacy Practice who is a registered pharmacist. It is the Director of Pharmacy Practice who is responsible for all dispensing-related activities. Additional registered pharmacists supervise every activity in the dispensing process, including maintenance of dispensing records. All prescriptions are checked by registered pharmacists who are licensed in the state in which they practice. Instant Access to Express Scripts When you register at mycbs.org/health and click on My Prescription Drugs, you will have instant access to: My Rx Choices Prescriptions Claims & Balances Order Status Locate a Pharmacy Price a Medication Benefit Highlights Forms and Cards Learn About Formularies Drug Information Visit mycbs.org/health for more information Contact Express Scripts at (800) /2018

11 Other Resources Section 4 Other Helpful Resources Available!

12 Online Health Management 4a Be sure to visit mycbs.org/health to activate your Health ID Card! This site will provide valuable resources, health news, access to your benefit information, and much more! Online EOBs (explanation of benefits paid) Medical plan summaries Find Network providers Current Health News RX Drug information

13 Find a Provider Online Doctor Directory The Simplest Way to Find a Doctor Selecting a doctor and other health care professionals for you and your family is important. The Find a Provider online directory, available 24 hours a day, 7 days a week, makes it easy. Find a Provider is the premier online search tool from Aetna. Up-to-date listings of participating doctors, medical professionals, and facilities are available at your fingertips. With the easy-to-use format, you can search online by name, specialty, gender and/or hospital affiliation. What Does Find a Provider Allow me to do? Choose the search option that works for you. Search by using a variety of criteria such as specialty, gender and/or hospital affiliation, or search using the health care professional s name. Make the informed choice. Find a Provider gives you easy access to information about health care professionals. This includes information about medical school attended, board certification status and gender, as well as information about the provider s office(s), such as handicapped access, etc. Get up-to-date information. Find a Provider is typically updated daily, giving you access to the latest available information. Review a list of transplant facilities and pediatric congenital heart surgery facilities in our Institutes of Excellence network. Locate health care professionals and facilities using the criteria that s best suited to your needs. Visit mycbs.org/health for more information Step-by-Step Instructions To access Find a Provider, simply log on to mycbs.org/ppo-aetna. 1) On the Aetna Find a Provider page, click on the Medical button. 2) Under the What type of provider are you looking for? heading, select one of the options for provider type. 3) Under the Do you want to search by ZIP or state? heading, enter the geographic information for the area where you wish to find a participating provider. Under the Search by state option, you can further narrow your selection by county and city. 4) You can run a search with the information you provided at this point or click on the + Advanced Search link to open more options. NOTE: You must enter the information in steps 2 and 3 in order to access the Advanced Search options. Under the Advanced Search options, you can also narrow your search by doctor or facility name and/or specialty type or medical condition. 5) If you already know the name of the provider or facility you are looking for, type the name in the Doctor/Facility name box. 6) Under Specialty Type, you may add up to five specialties by clicking on the list provided and clicking Add. If you want to change the specialty criteria, click on the Remove button. 7) You may also search for a specialist based on medical condition by clicking on the Condition button. 8) Click Search. 9) You will be presented with a list of providers matching your criteria. You can obtain additional information about each provider by clicking on the "More Details" link under the provider s contact information. 10) You can create a list of providers you are interested in by clicking on the yellow Add to my list button under the contact information. There is also a Compare side by side button to help you find the right provider. 7/2018

14 DocFind Online Dental Directory The Simplest Way to Find a Dentist Selecting a dentist for you and your family is important. DocFind online directory, available 24 hours a day, 7 days a week, makes it easy. DocFind is updated three times per week, providing access to the latest available information. DocFind is the premier online search tool from Aetna providing up-to-date listings of participating dentists. With the easy-to-use format, you can search online by name, specialty, language, and/or if they are accepting new patients. DocFind allows you to make an informed choice, and gives you easy access to information about dental care professionals, including information that is not available in paper directories. This includes information about which plans the provider accepts, medical school attended, board certification status, gender, and information on the provider s office(s), as well as maps and driving directions. You can use DocFind anywhere you have Internet access. If you have questions while searching for a dentist, just click on the Contact DocFind link located at the top of any DocFind page to send a comment or question. Locate dental professionals and facilities using the criteria that s best suited to your needs. Visit mycbs.org/health for more information Step-by-Step Instructions To access DocFind, simply log on to mycbs.org/health. 1) Click on "Find a PPO Provider", then click "Dental PPOs" on the righthand side. 2) Click the orange "Start a New Search" button. 3) From the "Search for" dropdown, under Dental, select either Dentists (Primary Care) or Dental Specialists. 4) From the "Type" dropdown, make the selection which best fits your needs. 5) Enter the geographic information for the area where you wish to find a participating dentist. 6) From the "Select a Plan" dropdown, select Aetna Dental Administrators SM. 7) You can also narrow your search by specialty, language spoken and/or name, as well as request a list of all dentists who match your geographic and plan requirements. If you already know the name of the dentist you are looking for, use the Search by Name link. 1) From the "Search for" dropdown, select Dentists/Dental Professionals. 2) Type in the name of the dentist you wish to find. 3) Enter the geographic information for the area the participating dentist is located. 4) From the "Select a Plan" dropdown, select Aetna Dental Administrators SM. 5) You will be presented with a list of dentists which match your criteria. You can obtain additional information about each provider by clicking on the "View Details" link. 2/2018

15 Life is better in focus. TM Get access to the best in eye care and eyewear with ALASKA CONFERENCE OF CATHOLIC BISHOPS and VSP Vision Care. Why enroll in VSP? As a member, you ll receive access to care from great eye doctors, quality eyewear, and the affordability you deserve, all at the lowest out-of-pocket costs. You ll like what you see with VSP. Value and Savings. You ll enjoy more value and the lowest out-of-pocket costs. High Quality Vision Care. You ll get the best care from a VSP network doctor, including a WellVision Exam the most comprehensive exam designed to detect eye and health conditions. Choice of Providers. The decision is yours to make choose a VSP network doctor, a participating retail chain, or any out-of-network provider. Great Eyewear. It s easy to find the perfect frame at a price that fits your budget. Enroll in VSP today. You'll be glad you did. Contact us vsp.com Using your VSP benefit is easy. Create an account at vsp.com. Once your plan is effective, review your benefit information. Find an eye doctor who s right for you. Visit vsp.com or call At your appointment, tell them you have VSP. There s no ID card necessary. If you d like a card as a reference, you can print one on vsp.com. That s it! We ll handle the rest there are no claim forms to complete when you see a VSP provider. Choice in Eyewear From classic styles to the latest designer frames, you ll find hundreds of options. Choose from featured frame brands like bebe, Calvin Klein, Cole Haan, Flexon, Lacoste, Nike, Nine West, and more. 1 Visit vsp.com to find a Premier Program location that carries these brands. Plus, save up to 40% on popular lens enhancements. 2 Prefer to shop online? Check out all of the brands at eyeconic.com, VSP's preferred online eyewear store.

16 What is an HSA? What is it? How do I get it? Who owns it? Who puts money in it? How is money put in it? Is there a limit on how much I can put in it? If I don t spend it all this year, can I use it next year? Can I cash it out at any point? Can I keep it if I leave my employer? What happens to the money? When can I start spending it? Do I have to pay taxes on it? If I don t spend it, will it earn interest for me? What can I pay for with it? Can I use it for things other than health care? Can I have any other accounts with it? Can I use it to pay for Extension of Benefit plan premiums or other plan premiums? HSA A Health Savings Account is a personal bank account to help you save and pay for covered health care services and qualified medical expenses. You have to sign up for a high deductible health plan that meets a deductible amount set by the IRS. You also have to meet other IRS guidelines to be eligible to have it. You can learn about these at irs.gov. You do. You. Your employer, family, and others can put money into it if they choose. You can make deposits like you do with other personal bank accounts. Your employer and family can also put money into the account. Your employer may allow you to deposit money straight from your paycheck, before the money is taxed. Yes. The IRS sets a limit on how much you can put into it each year. You can usually find the limits in your health plan documents and at irs.gov. While there are annual limits, there is no limit to how much you can save over time. Yes. Since you own the account, the money will stay in it until you choose to spend it. You can save and use it into retirement. Yes. But if you cash it out and do not use the money for qualified medical expenses, you will have to pay taxes on it. And you may also have to pay a 20% tax penalty. Yes. You own the account. You can start spending the HSA once you have signed up for a high-deductible health plan and have opened the account. No. You don t have to pay federal or, in most instances, state income taxes on: - Deposits you or others make to an HSA - Money you spend from an HSA on qualified medical expenses - Interest earned from an HSA If you put money into an HSA using pre-tax payroll deposits through your employer You don t have to pay Social Security taxes on it either. Yes, an HSA can earn interest. But the amount you can earn depends on the bank you use and how much you have in the account. You can pay for hundreds of qualified medical expenses, which are determined by the IRS. This can include services covered by a health plan. You can also use it to pay for dental, vision and many other health care services and supplies that are listed under Section 213(d) of the Internal Revenue Code. No, as long as you are under the age of 65. And if you use it for services that aren t qualified medical expenses, you could pay a 20% penalty tax. If you are over the age of 65, you can use it for pretty much anything. Yes. You can have a limited-purpose Flexible Spending Account or limited-purpose HRA, which can only be used for eligible dental and vision services. Yes. What s the difference between a qualified medical expense and an eligible medical expense? A qualified medical expense is a health care service, treatment or item that the IRS says can be purchased without having to pay taxes. An eligible medical expense is a health care service, treatment or item that the IRS says can be covered or reimbursed (paid back) by a benefit plan.

17 Benefit Election Pricing Employer pays this for employee only Employee copay for self Health Benefits - Effective January 01, 2019 Employee cost for Spouse Plan Description Covered Person Total Premium Monthly Amount Paid by Employer Monthly Amount Paid by Employee Medical "Default" Employee only Lay Plan Spouse 1, , Child(ren) Family 1, , Medical "Buy-up" Employee only 1, Lay Plan Spouse 1, , Child(ren) Family 1, , Dental PPO Employee only Lay Plan Spouse Child(ren) Family Vision VSP Employee only Lay Plan Please note the following 1 Dependent Family Employee cost for 1 or more Children Employee cost for Family (Spouse + Child(ren)) Employer pays this for employee only Employee copay for self Employee cost for Spouse Employee cost for 1 or more children Employee cost for Spouse & children No Employee copay for "self" on Dental Employee cost for Spouse Employee cost for 1 or more children Employee cost for 2 or more Dependents No Employee copay for "self" on Vision Plan Employee pays for Dependents on Vision Employees may choose any combination of medical, vision, and dental benefits Dependents may not have a benefit that the employee does not have

18 ALASKA CONFERENCE OF CATHOLIC BISHOPS Continuation of Coverage Rate Acknowledgement This Open Enrollment period, the plan coverages remain the same, however, all rounding of premiums have been removed, and the dependent pricing has changed. I have reviewed the new medical rate schedules for plans beginning January 1, 2019, and I wish to continue my coverage as is without changes. Employee signature Date *If "continuing" Spouse Coverage, you must also complete & sign the Spouse Eligibility Affidavit.

19 ACCB Alaska Conference of Catholic Bishops Insurance Division Employee Benefits ENROLLMENT / CHANGE FORM This form can be used as an initial enrollment or to report a change in information. Please complete all information by printing clearly and firmly or by typing. If additional space is needed, please attach a statement with the appropriate information. Please check the applicable boxes below. I. Location Name Term Date: New Enrollment Re-Enroll Waiver Change Transfer from Location # to # Extended Benefits Terminate II. EMPLOYEE INFORMATION LAY EMPLOYEE DIOCESAN PRIEST OTHER LAST NAME FIRST MI SOC. SEC. NO. STREET ADDRESS CITY STATE ZIP DATE OF HIRE DATE FULL TIME OCCUPATION ANNUAL SALARY HOURS WORKED PER WEEK EMPLOYEE DATE OF BIRTH SEX MARITAL STATUS Home Phone (including area code) III. DEPENDENT INFORMATION (Required if dependent coverage is to be added or changed) ( ) CELL PHONE (Including area code ) SEX DATE OF RELATIONSHIP Medical Dental Vision FULL NAME (Including middle initial) SOC. SEC. NO. (M/F) BIRTH TO EMPLOYEE (X) (X) (X) SPOUSE ( ) DEPENDENT #1 DEPENDENT #2 DEPENDENT #3 IV. EMPLOYEE COVERAGE ELECTION LAY MEDICAL Default LAY MEDICAL Buy-up DENTAL VISION SEMINARIAN MEDICAL PRIEST MEDICAL NONE, COMPLETE WAIVER SECTION V. LIFE/AD&D & LTD INSURANCE COVERAGES Eligible employees are automatically enrolled in the Basic Life and AD&D Plan, sponsored by ACCB. NAME OF PRIMARY BENEFICARY ADDRESS CITY STATE ZIP CODE RELATIONSHIP DATE OF BIRTH NAME OF CONTINGENT BENEFICARY ADDRESS CITY STATE ZIP CODE RELATIONSHIP DATE OF BIRTH NOTE: If you require additional space for additional Dependents or Contingent Beneficiaries, please attach separate sheets PLEASE READ SECTIONS VI. & VII. CAREFULLY (if waiving coverage-please sign both!) VI. RELEASE and APPLICATION SIGNATURE: I hereby certify that I am an eligible employee/beneficiary as defined in the Summary Plan Document, that the above information is complete and accurate, and all claims submitted will be for individuals who are eligible members of the health plan. I hereby authorize the Plan Sponsor to deduct, from my pay, my contributions to the cost of the benefits, which I indicated above and for which I am or may become eligible. The current benefits have been explained to me thoroughly. I understand that I am responsible for a greater portion of my health costs when in excess of the amounts payable under the plan. I also authorize any physician or other health care professional, hospital or other health care facility, counselor, therapist, or any other medical or medically related facility or professional to give the health plan, respective agents or representatives any and all information or records relating to health history, health examinations, services rendered, or treatment given including treatment for alcohol, substance abuse or mental or emotional disorders, A.I.D.S., or A.R.C. of me or any of my dependents applying for coverage or of any claim for benefits. I also authorize the health plan to disclose all such health or personal information related to myself or any covered dependent, to a health care provider, a health care service plan, a self-insurer, or any insurance company for the purpose of investigating or evaluating any claim for benefits. If my coverage is under a master policy held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure of them for the purpose of administering my coverage, utilization review or financial audit. This authorization is effective immediately and shall remain in effect for use in connection with any claim for benefits for as long as any health coverage may be in effect. A photocopy of this authorization is as valid as the original. I HAVE READ AND UNDERSTOOD SECTION VI APPLICANT SIGNATURE X VII. WAIVER of COVERAGES DATE The current benefits have been explained to me thoroughly. I DO NOT wish to enroll in the following coverage(s) ENROLLEE : MEDICAL DENTAL VISION Is the coverage being waived due to coverage by another health plan? YES NO I understand that by waiving the coverage above, I will not be entitled to any benefits provided by the plan. DEPENDENT: MEDICAL DENTAL VISION THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I HAVE READ, UNDERSTOOD, AND AGREE TO SECTIONS VI AND THE TERMS OF THIS ENROLLMENT FORM. WAIVER OF COVERAGE SIGNATURE X DATE TO BE COMPLETED BY LOCATION EFFECTIVE DATE ADMINISTRATOR ONLY VIII. REASON FOR THE CANCELLATION / CHANGE EMPLOYEE COVERAGE: Discharged Deceased: Date Last day worked: Retirement: Date Resignation: Date Date of disability: Reduction of work hours New dependent (Spouse or Child) New name: Increase of work hours New address Other please specify: DEPENDENT COVERAGE: Death of covered employee Date of divorce / legal separation Eligible for Medicare No longer an eligible dependent Termination of dependent s health coverage LOCATION ADMINISTRATOR NAME SIGNATURE DATE File Location: Finance/AOA Health Ins/FY 2016/ Enrollment Package

20 ACCB Alaska Conference of Catholic Bishops Insurance Division Spouse Eligibility Affidavit (check & complete one of the options) o My spouse is not currently employed and is eligible for this plan. If my spouse s employment status changes and he/she becomes eligible for insurance at his/her place of employment, I will notify the benefits person of his/her status change. o My spouse is employed by but is not eligible for their medical coverage or they do not offer medical coverage. o My spouse is employed by and will be covered on their insurance plan. Signature of Employee Date Employee s Printed Name Signature of ACCB Benefits Representative Date Printed Name of ACCB Benefits Representative