Health Insurance Enrollment Form

HEALTH CARE AND DENTAL COVERAGE ENROLLMENT FORM
Employee Name
Employee ID #
Address
City
State
Zip Code
Email Address
Home Phone
Work Phone
I experienced the following event during the past 90 days:
[ ] New Hire
[ ] Loss of Other Coverage: Date ____________
[ ] Transferred to a Benefit-Eligible Position from an Ineligible Position
[ ] Moved from a Part-time (50-74% FTE) to Full-Time (75%+ FTE) Position
HEALTH PLAN CHOICES (Choose one option in each box below):
Plan Design
Network
[ ] Advantage
[ ] Comprehensive
[ ] CDHP * (Preferred
ValueCare Network Only)
Dental Coverage
[ ] BlueCross BlueShield (PAR)
[ ] Preferred ValueCare
[ ] Yes
Coverage Level
[ ] Single Coverage
[ ] Two-Party Coverage
[ ] Family Coverage
[ ] Waive
*The Consumer Directed Health Plan (CDHP) includes providers in the Preferred ValueCare network. The CDHP design option may be
combined with a Health Savings Account (HSA) by completing a separate HSA enrollment form.
Dependents
to be
Enrolled
Name (First, Middle, Last)
Address
(If different from
employee’s address)
Relationship
Social Security
Number
Birthdate
Month/Day/Year
[ ] Husband
Spouse
[ ] Wife
[ ] Daughter
[ ] Son
[ ] Daughter
[ ] Son
Eligible
Children
[ ] Daughter
(See
definition of
eligible
children on
reverse side
of this form)
[ ] Son
[ ] Daughter
[ ] Son
[ ] Daughter
[ ] Son
[ ] Daughter
[ ] Son
Certification
I have read and I agree to the conditions contained on the back of this form. I understand I may enroll in health care coverage within 90 days of my
date of hire or transfer into a benefit-eligible position from a non-eligible position, during Open Enrollment, or if I experience an event that results in a
special enrollment period for me. I also understand that I may not change or cancel these elections until Open Enrollment, unless I experience a
qualified status change event (as defined by the Internal Revenue Code) consistent with the requested change and submit the completed paperwork to
the Benefits Department within 90 days of the event. If at any time I participate in unpaid leave under the Family & Medical Leave Act (FMLA), I
authorize the University to deduct any unpaid contributions retroactively upon my return. I understand if my FTE drops between 50-74%, I will
automatically be charged the part-time rate, and must notify the Benefits Department within 90 days if I wish to cancel coverage or drop enrolled
dependents (the change to my contribution rate will not be retroactive). I understand if my FTE drops below 50%, I will no longer be eligible and my
coverage will be terminated. I agree to notify the Benefits Department if one of my listed dependents ceases to qualify as an eligible dependent or if the
address of one of my dependents changes. I hereby authorize payroll deductions of contributions on a pre-tax basis as required.
I certify the information I have provided on all parts of this form is true and correct. I understand that if I knowingly file a statement
of claim for an individual who does not qualify as an eligible dependent or otherwise containing any misrepresentation or any false,
incomplete, or misleading information I may be subject to adverse employment action up to and including termination, my coverage
may be cancelled without the right to elect COBRA, and I may be guilty of a criminal act punishable under law and subject to civil
penalties.
Employee Signature: _________________________________________
Benefits Dept
Use Only:
Entry Date:
Entered By:
Date: ______________________________
QC By:
QC Date:
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Statement of Understanding and Agreements
HEALTH AND DENTAL COVERAGE
As an employee in a benefit-eligible position, I may enroll in the University of Utah Employee Health Care Plan medical and
dental options within 90 days of the date I am hired into a benefit-eligible position. I understand that participation in one of
the medical options is a prerequisite for participation in the dental option and that all dependents enrolled in health coverage
will automatically be enrolled in dental coverage, if dental coverage is elected. I understand I may make changes to my
coverage if I experience a status change event (as defined by the Internal Revenue Service; e.g., marriage, divorce, birth,
loss of other coverage, etc.) if such change is requested in writing within 90 days of the date of the status change event. If
the written request is not submitted to the Benefits Department 90 days, I will forfeit any right to make a change until the
next annual open enrollment, if any.
I understand that eligible dependents are the person to whom I am legally married and my (or my spouse’s) children by
birth, placement for legal adoption or foster care, or legal court-appointed guardianship, who are under age 26. I agree to
notify the Benefits Department if one of my enrolled dependents is no longer an eligible dependent. I understand that I must
provide notification within 60 days in order for the dependent to be eligible for COBRA Continuation Coverage.
Social Security Numbers are Now Required for All Dependents
Beginning January 1, 2009, Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 requires all health plans
in the United States to report group and member information to the Centers for Medicare and Medicaid Services (CMS). The
new law will help CMS accurately coordinate Medicare and group benefits for people who have both coverages. Since
individuals under age 65 who have end stage renal disease or other disabilities are eligible for Medicare, we need to provide
information, including social security numbers, for all enrolled members.
AGREEMENT
I hereby make application on behalf of myself and listed eligible family dependents for membership in the University of Utah
Employee Health Care Plan as indicated hereon and agree to the terms and conditions in the Master Policy. I understand
that if I am eligible and this enrollment form is completed and provided to the University Benefits Department timely, my
benefits will begin on my effective date as determined by the enrollment rules of the Plan.
To the minimum extent necessary to implement coverage and to provide coverage benefits, and in accordance with rules set
forth in the HIPAA Privacy Regulations, I authorize Regence BlueCross/BlueShield of Utah, University Health Care Plus,
Blomquist Hale Consulting, UNI BHN, OmedaRX, HealthEquity and ASI Flex to request and use any medical, health,
employment, and/or insurance information necessary to complete my enrollment, provide coverage benefits, and administer
my coverage benefits. I authorize pretax payroll deduction of contributions as required through the provisions of IRC Section
125 Flexible Benefits. I agree to abide by the Plan’s enrollment provisions. I authorize my employer to act as my agent in
all matters of administration of the group program, and acknowledge that my employer is in no way acting as agent for those
companies administering the Plan. To the extent authorized under applicable law, I accept Binding Arbitration as the method
of resolving any disputes arising between me or my covered family member and the Plan, or a participating physician,
concerning the applicability of benefits payable under the Plan. I understand that the University intends to continue the
Plan(s) indefinitely; however, it reserves the right to amend, suspend or discontinue the Plan(s) at any time.
I certify that all information on this form is true and correct and acknowledge that my coverage is subject to cancellation if
any completed information is found to be false or incorrect and I will be responsible for reimbursement to the Plan for any
claims paid in error. I understand that knowingly providing a statement that contains any false, incomplete or misleading
information may result in adverse employment action, up to and including termination of employment.
For detailed plan information, please refer to the Plan’s Summary Plan Description.
Summary Plan Descriptions are available on the internet at www.hr.utah.edu/ben or in the
Benefits Department located at 420 Wakara Way, Ste. #105, Salt Lake City, UT 84108.
Phone: (801) 581-7447, Fax: (801) 585-7375, e-mail: [email protected]
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MONTHLY CONTRIBUTION RATES
JULY 1, 2016 THROUGH JUNE 30, 2017
FULL-TIME EMPLOYEES (75% TO 100% FTE) *
All rates are monthly
Medical Only
Network Option
Preferred
ValueCare
Plan Option
Single
Advantage
$52.00
Comprehensive
Family
Single
$91.00
$137.28
$52.00
$91.00
$-
Advantage
Comprehensive
CDHP
BlueCross
BlueShield
Participating [PAR]
Two-Party
Medical and Dental
Two-Party
Family
$62.60
$115.30
$175.62
$137.28
$62.60
$115.30
$175.62
$-
$-
$10.60
$24.30
$38.34
$81.66
$142.88
$212.98
$92.26
$167.18
$251.32
$81.66
$142.88
$212.98
$92.26
$167.18
$251.32
University Contribution Rates – All Options
Single
$509.02
Medical Only
Two-Party
$890.78
Family
$1,343.80
Single
Medical and Dental
Two-Party
$528.46
$935.46
Family
$1,414.26
PART-TIME EMPLOYEES (50% TO 74% FTE)*
All rates are monthly
Medical Only
Network Option
Preferred
ValueCare
BlueCross
BlueShield
Participating [PAR]
Medical and Dental
Plan Option
Single
Two-Party
Family
Single
Two-Party
Family
Advantage
$306.50
$536.38
$809.18
$326.82
$583.02
$882.74
Comprehensive
$306.50
$536.38
$809.18
$326.82
$583.02
$882.74
CDHP
$254.50
$445.38
$671.90
$274.82
$492.02
$745.46
Advantage
$336.16
$588.26
$884.88
$356.48
$634.90
$958.44
Comprehensive
$336.16
$588.26
$884.88
$356.48
$634.90
$958.44
University Part-time Contribution Rates – All Options
Single
$254.52
Medical Only
Two-Party
$445.40
Family
$671.90
Single
$264.24
Medical and Dental
Two-Party
$467.74
Family
$707.14
*Complete the requirements to participate in the WellU program to receive a discount of up to $40.00/month
from the above rates. If your rate is less than $40.00, you will pay nothing.
0716
October 1, 2015
IMPORTANT NOTICE to Individuals Enrolled in a University of Utah
Health Care Plan Who are Eligible for Medicare or Who Will Become Eligible for Medicare in
the Next 12 Months
This notice is required by law and has information about your current prescription drug coverage
and your options under Medicare’s prescription drug coverage.
The University of Utah has determined that the prescription drug coverage in the
University’s Employee Health Care Plan and University of Utah Early Retirement Incentive Health Care Plan
(the “Plan”) is Creditable Coverage.
“Creditable Coverage” means that the amount the Plan expects to pay on average for prescription drugs for
individuals covered by the Plan in the 2016 calendar year is the same or more than what standard Medicare D
prescription drug coverage would be expected to pay on average.
Because the coverage in the Plan is Creditable, individuals enrolled in the Plan do not need to purchase
separate Medicare D prescription drug coverage as long as you remain enrolled in the Plan.
If you lose your coverage in the Plan, you may be eligible for a 60-day Special Enrollment Period to sign up for a
Medicare D prescription drug plan. If you don’t enroll in Medicare D prescription drug coverage during your 60day Special Enrollment Period or enroll in other creditable coverage (e.g., another employer’s group health plan)
within 63 days after your current coverage ends, you may only enroll in a Medicare D prescription drug plan
during a Medicare Open Enrollment Period (usually October 15 th through December 7th) and you could be
required to pay a higher monthly premium (including a Medicare penalty) as long as you retain Medicare D
prescription drug coverage.
If you have any questions concerning the information provided in this notice, contact the University’s Benefits
Department at (801) 581-7447. You will receive this notice annually and if the prescription drug coverage
through the Plan changes. You may also request a copy at any time by contacting the Benefits Department.
Additional Information from Medicare:
More detailed information about Medicare plans that offer prescription drug coverage is in the
“Medicare & You” handbook. The handbook is available on Medicare’s website and if you are eligible
for Medicare, a copy should be sent to you in the mail each year by Medicare. To get more
information about Medicare prescription drug plans and the coverage offered in your area:
 Visit www.medicare.gov
 Call 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048
For individuals with limited income and resources, extra help paying for a Medicare prescription drug
plan may be available. Information regarding this program is available through the Social Security
Administration (SSA). Visit SSA online at www.socialsecurity.gov or call the SSA at 1-800-772-1213
(TTY users call 1-800-325-0778).
Keep This Notice
If you enroll in a Medicare D prescription drug plan after May 15, 2006, you may be required to provide a copy of
this notice when you join to show that you had Creditable Coverage and are not required to pay a higher
premium amount
0716