What Benefits Can I Change Mid Year?

Transcription

1 What Benefits Can I Change Mid Year? Mid Year Benefits ment/change Summary* FAMILY STATUS EVENTS Options to Consider Marriage Add your legal spouse to your medical, dental, vision coverage Add newly acquired eligible children to your medical, dental, vision coverage Cancel medical, or vision coverage if enrolling in your spouse's plan /increase FSA (Medical/Dental and/or Dependent Care) /increase your Supplemental Life Insurance (see proof of health rules) /increase your AD&D Insurance in Spouse Life Insurance (see proof of health rules) in Child Life Insurance, if children are eligible in STD (see proof of health rules) in LTD (see proof of health rules) Legal Separation or Divorce Birth or Adoption of a Child Loss of Child s Eligibility (e.g. child reaches max age) You, or an eligible family member, becomes eligible for benefits in another plan (e.g. new employer) Remove your spouse from your medical, dental, vision coverage in medical, dental, vision coverage if previously covered under your spouse s plan. /increase your Supplemental Life Insurance (see proof of health rules) Decrease your Medical/Dental FSA Cancel Spouse Life Insurance Add child to your medical, dental, vision coverage Cancel medical, or vision coverage if enrolling in your spouse's plan /increase your Supplemental or Spouse Life Insurance (see proof of health rules) in Child Life Insurance /increase FSA (Medical/Dental and/or Dependent Care) Remove child from your medical, dental, vision coverage (may continue coverage under COBRA) Cancel Child Life Insurance Cancel Dependent Care FSA Cancel your medical, or vision coverage if you will be covered under another plan Remove your spouse and/or child(ren) from your medical, dental, vision coverage if they will be covered under the new plan You, or an eligible family member, becomes ineligible for benefits in another plan in medical, dental, vision coverage because you ve lost coverage under another plan Add your spouse and and/or child(ren) to your medical, dental, vision coverage if they have lost coverage under another plan You begin an FMLA leave Temporarily stop your Medical and/or Dependent Care FSA You return to work from FMLA leave Resume your Medical or Dependent Care FSA in Dependent Care FSA *The actions described above are permitted under Section 125 of the Internal Revenue Code within 30 days of a qualified life change. This list is a summary of the most commonly requested life events/changes; it is not all inclusive. If you experience a life change that is not listed above, please call the Benefits Hotline at to discuss your options. * Provided you submit the required information within 30 days of your qualifying event date, benefits take effect retroactive to the date of the event, except for the life and disability insurance; changes to these benefits will become effective as of the date you signed this form. If the benefits effective date is in a prior payroll period, missed payroll deductions will be captured from your future paycheck(s).

2 Benefits ment/change Form Name: Employee #: INSTRUCTIONS Go to to read about which benefits you may change due to your qualifying event. 1) Indicate the benefit changes you wish make on this form. Changes must be consistent with the IRS Section 125 rules. 2) Complete the Dependent & Beneficiary Information section, if applicable. 3) Submit the following to Human Resources within 30 days of the effective date of your event: Your complete Benefits ment Form remember to sign and date. Documentation of your event (e.g. marriage certificate, letter indicating gain or loss of coverage, etc.) Documentation to prove eligibility of your spouse and/or children if you are enrolling them. See page (4) for documentation requirements. Unity Health System Human Resources 89 Genesee Street Rochester, NY Benefit Hotline: / Fax: REASON FOR COMPLETING THIS FORM Effective Date of the Event:* Marriage Divorce / Legal Separation Birth / Adoption of Child Loss of Benefits (e.g. Health Insurance) Note: must be involuntary loss of coverage for an employee and or a dependent Gained Benefits (e.g. Health Insurance) Employment Status Change (part-time to full-time or from full-time to part-time) HEALTH PLAN (Pre Tax) PLANS Unity Basic Health Plan Employee Employee + Spouse / Domestic Partner Employee + Child Unity Enhanced Health Plan Employee + Children Family I wish to remove the following dependent(s) from my health plan: DENTAL PLAN Subject to two enrollment period lock in (Pre Tax) PLANS Unity Basic Dental Plan Unity Enhanced Dental Plan Employee Family (includes (2) or more individuals) I wish to remove the following dependent(s) from my dental plan: 2

3 EYEMED VISION PLAN (Pre Tax) Employee Employee + Spouse/ Domestic Partner Employee + Child(ren) Family I wish to remove the following dependent(s) from my vision plan: SUPPLEMENTAL EMPLOYEE LIFE INSURANCE Proof of Good Health May Be Required* (Pre Tax) 1x Annual Salary 2x Annual Salary 3x Annual Salary FLEXIBLE SPENDING ACCOUNT (FSA) DEPENDENT CARE ($5, Annual Maximum. By law, any unused contributions will be forfeited.) I ELECT TO: Change Amount Cancel I elect to contribute: $ per pay period / $ annually (2014) (Pre Tax) FLEXIBLE SPENDING ACCOUNT (FSA) MEDICAL ($2, Annual Maximum. By law, any unused contributions will be forfeited.) I ELECT TO: Change Amount Cancel I elect to contribute: $ per pay period / $ annually (2014) (Pre Tax) ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE (Pre Tax) $50,000 $100,000 $250,000 $500,000 3

4 DEPENDENT LIFE INSURANCE Note: Proof of Good Health May Be Required for Spouse Life Insurance* SPOUSE $15,000 $25,000 $50,000 $100,000 CHILD(REN) $5,000 $10,000 SHORT TERM DISABILITY INSURANCE (STD)* Optional Buy Up coverage 60% of salary up to $750 per week I ELECT TO: Cancel LONG TERM DISABILITY INSURANCE (LTD) 50 % of monthly salary I ELECT TO: Cancel DEPENDENT & BENEFICIARY INFORMATION Last Name, First Name MI Birth Date Sex (M/F) Health Dental Vision Medical Services Discount (E) Cancel (C) Beneficiary Primary (P)/ Contingent (C) Percent % Spouse: Other: Other 4

5 Dependent Eligibility Requirements: Dependents eligible for coverage include: Your legal spouse or domestic partner (signed affidavit [must be on file) Your children up to age 26 for health and vision Your children up to age 23 for dental If this is the first time you are requesting health, dental or vision coverage for a dependent, you must submit documentation that verifies your dependent s eligibility. Acceptable forms of documentation include: Legal marriage certificate/license for spouse Birth certificate for child(ren) Top half of your most recently filed Federal Income Tax Return (page 1) identifying the dependent Domestic Partner Affidavit EMPLOYEE AUTHORIZATION I authorize Unity Health System to reduce my salary by the applicable pre tax dollars or deduct the applicable post tax dollars from my paycheck for the insurance programs I have elected. I understand that I cannot change my elections until the annual Open ment, unless I have a qualifying change in family or employment status. Changes must be consistent with the IRS Section 125 rules. If I have a change in family or employment status, I understand that I must submit this completed document and supporting documents within 30 days of the event and that the request must be consistent with the event. If my election for life and/or disability insurance requires the completion of a Personal Health Application (PHA), I understand the coverage requested will not take effect until the insurance carrier approves the election. I affirm that any dependent(s) I elect to cover are eligible and I understand I must submit documentation to verify eligibility before the dependent(s) will be added to my coverage. Employee Signature Date Daytime Phone: 5