2015-16 Plan Year Midyear Change Form

2015-16 Plan Year
Midyear Change Form
Use this form to update your benefits within 31 days of
experiencing a qualified status change (QSC) event.
Entity Use Only
Approved by
Date Approved
Effective Date
These plan elections or changes will go into effect the first of the month after the event date unless you are requesting
coverage that requires carrier approval. Carrier approval coverage will go into effect the first of the month following
carrier approval. You may only make enrollment changes which are consistent with your QSC event. Some events may
not allow the change you are requesting. Review the Qualified Status Change (QSC) Matrix for more information:
http://www.oregon.gov/oha/OEBB/Pages/QSC-Matrix.aspx
1. Employee Information
Last Name
Member ID, Social Security
Number, or E Number:
First Name
Home Phone
Work Phone
Personal Email
Work Email
Contact Address
☐ Check if New Address
Apt or Space #
MI
City
Ethnicity (select one):
Gender
☐M ☐ F
Birth Date
(mm-dd-yyyy)
State
Zip
Medicare Eligible?
☐YES ☐NO
☐Hispanic
☐Non-Hispanic/Non-Latino
☐Refused
☐Unknown
Race (select at least one; if selecting
☐Asian ☐Black/African American ☐American Indian/Alaska Native
more than one, circle one as
☐Native Hawaiian/Other Pacific Islander ☐White ☐Other ☐Refused ☐Unknown
primary):
Are you serving or did you ever serve in the military? ☐YES ☐NO If “yes”, do you authorize OEBB to send your name and
address to the Oregon Department of Veterans’ Affairs (ODVA) for the purpose of receiving benefit information? ☐YES ☐NO
2. Tobacco Usage (Responses in this section are required regardless of enrollments)
In this section, OEBB is collecting tobacco usage information for you and your spouse/domestic partner (if applicable). This
information will be used to determine your premium amount(s) for Optional Employee and Optional Spouse/Domestic Partner Life
plans through The Standard. You must complete this section even if you do not enroll in these plans
Please select one of the following:
☐ I have used tobacco products in the last
12 months
☐ I haven’t used tobacco products in the last
12 months
☐ I have never used tobacco products
Please select one of the following:
☐ I do not currently have a spouse or domestic partner
☐ spouse/domestic partner has used tobacco products in the last 12 months
☐ spouse/domestic partner hasn’t used tobacco products in the last 12 months
☐ spouse/domestic partner has never used tobacco products
3. Qualifying Status Change Event
Event Date:
A. Change in Employment – affecting plan availability or gain/loss of other coverage
☐ By Employee
☐ By Spouse/Domestic Partner
B. Gain Spouse or Domestic Partner Through
☐ Marriage
☐ Domestic Partner Meets Eligibility
C. Loss of Spouse or Domestic Partner By
☐ Divorce/Annulment
☐ Termination of Domestic Partnership
☐ Death
D. Gain Dependent Through
☐ Birth/Adoption/Legal Custody ☐ Marriage/Domestic Partnership
☐ Court Order ☐ Meeting Eligibility
E. Loss of Dependent By
☐ Divorce/Termination of Domestic Partnership
☐ Ceasing to Meet Eligibility
☐ Death
F. Other Events
☐ Moving Out of Current Plan’s Service Area
☐ Other:
(rev. 04/08/2016)
Page 1 of 6
4. Dependent Information
Attach additional sheets if necessary
You must report to your employer’s benefits administrator within 31 days after a person enrolled as your spouse, domestic partner or
dependent child becomes ineligible for benefits. If you do not report this change on time, OEBB may consider that an intentional
misrepresentation of a material fact, for which OEBB may terminate the family member’s coverage effective the first of the month
after eligibility was lost.
If listing a Domestic Partner as a dependent, indicate the type of Domestic Partnership *:
☐ By OEBB Affidavit of Domestic Partnership**
☐ By Registered Certificate (no copy required)
*Domestic partner eligibility rules may vary by employing entity – verify with your benefits administrator before enrolling
**Affidavit Information – If you are adding a domestic partner by affidavit, you must submit the affidavit to your
employing entity within five business days of this enrollment or the individual’s coverage will not be effective.
Add to Coverage
Dependent A
Change Enrollment
Remove Dependent
Last Name
Relationship
to Employee:
(Check One)
Spouse
Domestic Partner
First Name
MI
Child of:
Overage Disabled Dependent of:
Employee/Spouse
Employee/Spouse
Domestic Partner
Domestic Partner
Birth Date
(mm-dd-yyyy)
Address (if different from employee address)
Social Security Number or Tax ID Number:
Apt #
Add to Coverage
Change Enrollment
Remove Dependent
Last Name
Non-Hispanic/Non-Latino
Relationship
to Employee:
(Check One)
Spouse
Domestic Partner
First Name
MI
Refused
Address (if different from employee address)
Apt #
Change Enrollment
Remove Dependent
Last Name
Relationship
to Employee:
(Check One)
Birth Date
Spouse
Domestic Partner
MI
Refused
Social Security Number or Tax ID Number:
Apt #
Race (select at least one; if selecting
more than one, circle one as primary):
(rev. 04/08/2016)
Enroll
Remove
Medical Vision Dental
State
Zip
Unknown
Birth Date
City
NO
Unknown
Gender
M F
Enroll
Remove
Medical Vision Dental
State
Zip
Medicare Eligible?
Non-Hispanic/Non-Latino
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
YES
Child of:
Overage Disabled Dependent of:
Employee/Spouse
Employee/Spouse
Domestic Partner
Domestic Partner
Ethnicity (select one):
Hispanic
Unknown
Gender
M F
American Indian/Alaska Native
White
Other
Refused
(mm-dd-yyyy)
Address (if different from employee address)
NO
Medicare Eligible?
Non-Hispanic/Non-Latino
First Name
YES
Child of:
Overage Disabled Dependent of:
Employee/Spouse
Employee/Spouse
Domestic Partner
Domestic Partner
City
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Add to Coverage
Dependent C
Unknown
Ethnicity (select one):
Hispanic
Race (select at least one; if selecting
more than one, circle one as primary):
Zip
American Indian/Alaska Native
White
Other
Refused
(mm-dd-yyyy)
Social Security Number or Tax ID Number:
State
Medicare Eligible?
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Race (select at least one; if selecting
more than one, circle one as primary):
Enroll
Remove
Medical Vision Dental
Ethnicity (select one):
Hispanic
Dependent B
City
Gender
M F
Refused
Unknown
American Indian/Alaska Native
White
Other
Refused
YES
NO
Unknown
Page 2 of 6
5. Medical, Dental and Vision Plan Selection
Write in a plan selection for Medical, Dental and Vision. You can Opt Out or Waive Medical or Decline Dental and/or Vision.
Medical Plan Selection:
If selecting a Moda Medical Synergy or Summit Plan, prior to the coverage start date you must contact Moda Health to select a
Medical Home Provider for each covered member. A list of Medical Home Providers can be found at:
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
If you are choosing to not enroll in an OEBB medical plan, select one of the following options:
☐ Opt Out - if you will receive a financial incentive from your employing entity to not enroll in medical coverage.
(You MUST have other employer-sponsored group medical coverage and complete Section 6 below.
Participation or enrollment in the Oregon Health Plan/Medicaid, Veteran’s Administration Benefit
Programs, Medicare or Student Health Insurance does NOT qualify for OEBB Opt Out.)
☐ Waive
- if you will not receive a financial incentive from your employing entity regardless of whether or not you
have other medical coverage
Note: Many employing entities do not offer a financial incentive – in those cases you should select “Waive”
Dental Benefit Plan Selection:
☐ Decline Dental
Vision Benefit Plan Selection:
☐ Decline Vision
(Must enroll in Kaiser Medical to enroll in Kaiser Vision)
LATE ENROLLMENT PENALTY: I understand if I decline Dental and/or Vision coverage when initially eligible or
have declined during a previous enrollment and choose to enroll or re-enroll in one or both of these plans at a future Open
Enrollment period, I and any dependents enrolled will be subject to a 12-month waiting period on these plans for services
other than basic services (cleanings, x-rays, and exams only for dental and exam only for vision).
Employee Signature
Date
6. Other Group Coverage
To Opt Out of Medical coverage you must complete this section and provide proof of other group coverage to your
employing entity within five business days or your opt out will not be effective.
Plan
Type:
Plan
Carrier
Policy Number
Group Number
☐ Medical
Primary Policyholder of the Other Group Coverage
Employer
Effective Date
__ / __ / ____
7. Optional Plans
Employee paid voluntary payroll deduction plans. Plan offering and availability is determined by your employing entity.
As a newly eligible employee for your first time enrollment the Optional Employee Life has a guarantee issue enrollment
amount of up to $100,000 and Optional Spouse/Domestic Partner Life has a guarantee issue enrollment amount of up to
$30,000 without needing to submit a medical history to The Standard Insurance Company underwriting for approval. Link
to the Medical History Statement is on the OEBB website: http://www.oregon.gov/oha/OEBB/Pages/Forms.aspx, Links to
external forms section.
Contact your employing entity for coverage information and to find out which plans are available to you.
(rev. 04/08/2016)
Page 3 of 6
A. Optional Life Insurance
Employee Optional Life Insurance
You are required to submit a medical history statement on any coverage amount that is not guarantee issue
Additional Requested Amount
Enroll
Change Enrollment
Decline Coverage
Total Requested
Current Enrollment
If initial request is made with a QSC guarantee issue amount is applicable.
Must submit medical history statement for additional amount above
guarantee issue.
($500,000 maximum)
$_____________________
$_____________________ ($10,000 increments)
$__________________
Spouse or Domestic Partner Optional Life Insurance
You are required to submit a medical history statement on any coverage amount that is not guarantee issue.
Total requested amount must be equal to or less than employee optional life insurance coverage.
Enroll
Change Enrollment
Decline Coverage
Additional Requested Amount
Total Requested
Current Enrollment
If initial request is made with a QSC guarantee issue amount is
applicable. Must submit medical history statement for any amount
above guarantee issue.
($500,000 maximum)
$_____________________
$_____________________ ($10,000 increments)
$__________________
Child or Children Optional Life Insurance
Medical history is not required. You must enroll in employee optional life to enroll your child or
children in this coverage.
Enroll
Change Enrollment
Decline Coverage
Total Requested Amount: $________________ ($2,000 increments up to $10,000 maximum)
B. Optional Accidental Death & Dismemberment (AD&D) Insurance
Employee Optional AD&D
Medical history is not required.
Enroll
Change Enrollment
Decline Coverage
Total Requested Amount: $________________ ($10,000 increments up to $500,000 maximum)
Spouse or Domestic Partner Optional AD&D
Medical history is not required. Total requested amount must be equal to or less than employee
optional AD&D coverage.
Enroll
Change Enrollment
Decline Coverage
Total Requested Amount: $________________ ($10,000 increments up to $500,000 maximum)
Child Optional AD&D
Medical history is not required. You must enroll in employee optional AD&D to enroll your
child/children in this coverage.
Enroll
Change Enrollment
Decline Coverage
Total Requested Amount: $________________ ($2,000 increments up to $10,000 maximum)
(rev. 04/08/2016)
Page 4 of 6
C. Voluntary Disability Insurance
Short Term Disability plans pay weekly benefits with coverage dates ending after 60 or 90 days depending upon plan
enrollment. Long Term Disability plans pay monthly benefits with benefits starting after 60 or 90 day waiting periods
depending upon plan enrollment. Monthly premium is calculated on a percentage of your basic monthly salary. A late
enrollment penalty will apply if you choose to enroll in coverage at a later date or allow coverage to lapse.
Check with your employing entity for coverage information and to find out which benefits are available to you.
Voluntary Short Term Disability
Enroll for Coverage
Decline Coverage
Voluntary Long Term Disability
Enroll for Coverage
Decline Coverage
D. Voluntary Long Term Care Insurance
Employee Long Term Care enrollment as a newly eligible employee has a guarantee issue amount of up to $6,000 in
monthly benefit, professional home care option for 3 or 6 year duration without having to submit medical history for
enrollment approval. Any changes to enrollment or enrollment requests for unlimited duration, amount over $6,000, total
home care and 5% simple inflation options, enrollment after first eligible or a future date, and Spouse/Domestic Partner
Long Term Care will require the UNUM medical history statement to be filled out and submitted to UNUM. The link to
UNUM forms is on the OEBB website: http://www.oregon.gov/oha/OEBB/Pages/Forms.aspx, Links to external forms.
Contact your employing entity for coverage information and to find out if you may enroll.
Employee Long Term Care - Voluntary
You are required to submit a medical history statement on any coverage amount that is not
guarantee issue or if you are requesting a change in enrollment coverage.
Plan Option
Request Coverage
Change Coverage
Decline Coverage
Coverage Amount
Duration
Professional Home Care
Professional Home Care - 5% Inflation
$2,000
$5,000
$8,000
3 Years
Total Home Care
Total Home Care - 5% Inflation
$3,000
$6,000
$9,000
6 Years
$4,000
$7,000
Spouse or Domestic Partner Long Term Care - Voluntary
You are required to submit a medical history statement for enrollment approval or changes in
coverage.
Plan Option
Unlimited
Request Coverage
Change Coverage
Decline Coverage
Coverage Amount
Duration
Professional Home Care
Professional Home Care - 5% Inflation
$2,000
$5,000
$8,000
3 Years
Total Home Care
Total Home Care - 5% Inflation
$3,000
$6,000
$9,000
6 Years
$4,000
$7,000
(rev. 04/08/2016)
Unlimited
Page 5 of 6
8. Beneficiary Designation
I elect:
The Standard Order of Survivorship - If you have a Domestic Partner an Affidavit must be on file for distribution.
To designate the following as beneficiary - Attach additional sheets if necessary.
Total of primary percentages must = 100%
Name
Total of contingent percentages must = 100%.
Address
Relationship
Primary Contingent
Whole %
or
%
or
%
or
%
or
%
9. Employee Signature and Authorization
I declare the dependents listed above and I are eligible for the coverages requested per OEBB Administrative Rule (OAR)-Division
10. I have read and understand OAR-Division 10 concerning Definitions and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_010.html
I have read and understand OAR-Division 80, Sections 111-080-0040, 111-080-0045 and 111-080-0050 concerning Eligibility and
Policy Term Violations and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_080.html
I understand I have 31 days to notify my employer of a Qualified Status Change (QSC) which affects eligibility. I have read and
understand OAR-Division 40 concerning Enrollment and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_040.html
I understand the benefit elections I make are in effect for as long as I continue to meet OEBB's eligibility requirements, or until I
elect to change them subject to the provisions of OEBB's plan. I understand I cannot alter my plan selections during the plan year
unless I have a QSC; then I am subject to the restrictions of the OEBB QSC’s. I have reviewed and understand the Qualified Status
Change (QSC) Matrix and can find the matrix at
http://www.oregon.gov/oha/OEBB/Pages/QSC-Matrix.aspx
I have read the benefit materials and I understand the limitations and qualifications of the OEBB benefits program. If necessary, I
authorize premium payments deducted from my pay, unless I self-pay premiums. If I self-pay the premiums, I agree to submit
monthly payments by the date specified, or my coverage will terminate; I will not be able to reinstate coverage until the next open
enrollment period or may lose OEBB eligibility altogether.
A person who knowingly makes a false statement in connection with an application for any benefit may be subject to imprisonment
and fines. Additionally, knowingly making a false statement may subject a person to termination of enrollment, denial of future
enrollment, or civil damages.
This election supersedes all elections and submissions I previously made for OEBB coverage. I hereby declare that the above
statements are true to the best of my knowledge and belief, and I understand that they are subject to penalty for perjury.
Employee Signature
Date
Submit completed form to your Employing Entity. Do not submit this form to OEBB.
(rev. 04/08/2016)
Page 6 of 6