Health Care Open Enrollment (coverage effective 1/1/2010) Benefit Summary You may review your current benefits summary by: Clicking on myUT at the top of the www.utoledo.edu.
Download ReportTranscript Health Care Open Enrollment (coverage effective 1/1/2010) Benefit Summary You may review your current benefits summary by: Clicking on myUT at the top of the www.utoledo.edu.
Health Care Open Enrollment (coverage effective 1/1/2010) 1 Benefit Summary You may review your current benefits summary by: Clicking on myUT at the top of the www.utoledo.edu homepage Sign in to myUT Click on Benefit Summary in the left-hand column of the Employee tab Then click the select button 2 Open Enrollment Pharmacy will now be bundled with medical for both campuses (no longer available as a stand alone election except for AFSCME) Main Campus Full re-enrollment Health Science Campus Full re-enrollment 3 Open Enrollment Website No packets will be mailed – post card notification only If you do not have computer access, you can pick up a packet in HR http://hr.utoledo.edu Click on Open Enrollment Option Read general directions Click on either Main Campus, Health Science Campus Non-Union or AFSCME Click each needed form and type in the information, then print the form and go on to the next form to complete Turn in all completed forms at one time as one packet to Human Resources HR is located on the Main Campus in the Transportation Center and is open M-F 7:30 AM to 5:00 PM 4 Main Campus Health Insurance Choices… Ohio Benefit Administrators/FrontPath PPO 90/10 FrontPath & PHCS networks – (Promedica & Mercy) 70/30 Out-of-network Paramount Employer Select 100 UTMC, UTP, UT community faculty The following teaching facilities: Defiance, Flower, Fostoria, Lima, Toledo Hospital & Toledo Children’s Hospital for inpatient services and outpatient surgeries Tier 1 list is available on the http://hr.utoledo.edu website 90/10 Paramount & PHCS networks 70/30 Out-of-network Medical Mutual of Ohio CDHP 100 UTMC & UTP Tier 1 list is available on the http://hr.utoledo.edu website 90/10 MMO (Mercy & Paramount) & PHCS (and Cofinity for Michigan) networks 70/30 Out-of-network 5 Health Science Campus Health Insurance Choices… Paramount Employer Select 100 UTMC, UTP, UT community faculty The following teaching facilities: Defiance, Flower, Fostoria, Lima, Toledo Hospital & Toledo Children’s Hospital for inpatient services and outpatient surgeries Tier 1 list is available on the http://hr.utoledo.edu website 90/10 Paramount & PHCS networks 70/30 Out-of-network Medical Mutual of Ohio CDHP 100 UTMC & UTP Tier 1 list is available on the http://hr.utoledo.edu website 90/10 MMO (Mercy & Paramount) & PHCS (and Cofinity for Michigan) networks 70/30 Out-of-network 6 Main Campus OBA/FrontPath Co-Pays FrontPath & PHCS Networks Office Visit Co-Pay: $15 Out of Network Specialist Visit Co-Pay: $30 Specialist Visit covered 70% after deductible Office Visit covered 70% after deductible 7 Main Campus OBA/FrontPath Deductibles FrontPath & PHCS Networks Out of Network $100 Single $200 Single + 1 $300 Family $300 Single $600 Single + 1 $900 Family 90% Coverage 70% Coverage 8 Main & Health Science Campus Paramount ES Co-Pays Tier 1 UTMC & Tier 1 Providers Office Visit Co-Pay: $10 Tier 2 Paramount & PHCS Networks Tier 3 Out of Network Office Visit Co-Pay: $20 Specialist Visit Co-Pay: $25 Specialist Visit Co-Pay: $35 Office Visit covered 70% after deductible Specialist Visit covered 70% after deductible 9 Main & Health Science Campus Paramount ES Deductibles Tier 1 UTMC & Tier 1 Facilities No Deductible 100% Coverage Tier 2 Paramount & PHCS Networks Tier 3 Out of Network $100 Single $500 Single $150 Single + 1 $750 Single + 1 $200 Family $1,000 Family 90% Coverage 70% Coverage 10 Paramount ES 2010 Changes No longer requires selection of Primary Care Physician (PCP) No longer requires referrals Rates have decreased 11% Non-network co-insurance now 70%/30% rather than 60%/40% 11 What is a Consumer Directed Health Plan? Consumer Directed Health Plans (CDHPs) are made up of three elements: 1. A health plan 2. A fund or account that you can use to help pay for qualified, out-of-pocket medical expenses (known as a Health Savings Account or HSA) 3. Interactive tools and information to help you make more informed health care decisions Cannot be enrolled in another health plan as secondary unless it is also a high deductible health plan. No one enrolled in the CDHP may be covered by Medicare. 12 How Much May I Contribute to my HSA? The University of Toledo contributions ($800/single, $1,600/family) will be accessible on January 4th in 2010. You may contribute by payroll deduction on a pre-tax basis. Payroll contributions you make are prorated over 24 pay periods but can be changed throughout the year by contacting UT HR. Your HSA contribution limits are $3,050 for persons with individual coverage and $6,150 for persons with family coverage. This includes contributions made by UT. Individuals age 55 to 64 may contribute an additional $1,000 annually 13 Using Your HSA: You may use HSA funds towards your medical plan deductible or any coinsurance or copayments. You may use your HSA funds for qualified health care expenses as allowed by the IRS. The following list provides some typical examples: Medical deductibles Dental care Prescription drugs LASIK eye surgery Braces Contact lenses Hearing aids Eyewear 14 CDHP Design Highlights Deductible $1,200 Single $2,400 Family Health Savings Account Employer Contribution $800 Single $1,600 Family 15 CDHP Highlights Meet the plan deductible then pay coinsurance Prescription drug costs count towards deductible Out-of-pocket maximum limits amount you pay annually Preventive care not subject to the deductible and covered at 100% with UTMC providers, 90% with MMO Providers 16 What is an HSA? Must be enrolled in HSA-compatible health plan to open & contribute to HSA • Pay for Qualified Medical expenses with Tax Free dollars • No use it or lose it provision – like Flexible Spending Accounts • Your balance plus investment earnings carry over year to year - Tax Free © 2009 Wells Fargo Bank, N.A. All rights reserved. For public use. 17 Triple tax savings* Increase your spending and savings power Pay for qualified medical expenses tax free Interest and investment earnings are tax free Contributions are pre-tax or tax deductible * All taxes are at the federal level. State taxes vary. Please consult a tax advisor. 18 Increase your buying power Your HSA Contribution Tax savings from your HSA contribution* Increased Buying Power $500 $125 $625 $1,000 $250 $1,250 $2,000 $500 $2,500 This example is for illustrative purposes only. Tax consequences may differ based on individual circumstances. Please consult your tax advisor regarding your individual situation. This chart assumes all distributions are used for qualified medical expenses. *Estimated federal tax savings of 25% based on 2008 tax table for a single taxpayer with income of $60,000. For more information, go to www.ustreas.gov and click on “Health Savings Accounts (HSAs).” Please consult your tax advisor. 19 What you receive with your new Wells Fargo HSA If you elect the Medical Mutual product a Wells Fargo HSA will be opened in your name You will receive a confirmation letter mailed to your home, including: Web site information Toll-free customer service number Your Visa HSA Debit Card card will arrive separately Activate the card before you use it Sample of the envelope the HSA Visa Debit card comes in. 20 Rollover process to Wells Fargo for Employees with an existing HSA account Employee completes and signs Wells Fargo rollover form provided in packet. Send completed form to University of Toledo Human Resources Benefits. Money will be transferred to Wells Fargo HSA for new plan enrollment year. Questions contact: (University of Toledo HR) wellsfargo.com/hsa 21 MMO CDHP Plan Plan Design Feature Tier 1 University Medical Center Tier 2 MMO Network Providers UT HSA Contribution $800 Single $1,600 Family Employee HSA Contribution $2,250 Single $4,550 Family Deductible $1,200 Single $2,400 Family Out-of-Pocket Maximum (Includes Deductible) $2,000 Single $4,000 Family Tier 3 Out of Network Coinsurance (Most Services) Subject to deductible 100% 90% / 10% 70/30 100% 90% / 10% 70% / 30% Preventive Care Not subject to deductible 22 CDHP Prescription Drug Coverage When you fill prescriptions you pay the cost of the prescription until the deductible has been met. Once the deductible has been met you pay the copay or coinsurance detailed below: Prescription Drugs UT pharmacies or at any MMO network Pharmacy. Deductible does not apply to certain preventive medications. 30 day supply 90 day supply $5 generic $10 generic 20% formulary (up to $80 max per prescription) 20% formulary (up to $200 max per prescription) 30% non-formulary 30% non-formulary Once the out-of-pocket maximum has been met, all prescriptions are covered at 23 100%. Preventive Drugs (partial listing) not subject to CDHP deductible Antiasthmastics drugs & supplies Contraceptives, oral Antidiabetic drugs & supplies Estrogen replacement products Antiemetics/antivertigo agents Gout Antiestrogens High Cholesterol drugs Anti-infectives Hypertension drugs Antimalarials Osteoporosis drugs Anti-ulcer agents Prenatal vitamins Antivirals Prescription vitamins Blood Thinning Agents Smoking Cessation medications 24 Spousal/Domestic Partner Provision (for full-time and part-time employees) Does not apply to the MMO CDHP Must be completed annually if covering a spouse/domestic partner on health insurance For Spouse to be Primary: Unemployed, Self-Employed, Retired, No other benefits offered Or makes less than $25,000/yr and benefits cost more than $75/month for a single plan Spouse may be Secondary HSC AFSCME will continue to use existing HSC spousal/domestic partner provision 25 Main Campus / Health Science Campus Non-Union Spousal/Domestic Partner Healthcare Eligibility Affidavit Employee Name _________________________ R# or SS# ____________________ (Please Print) Spouse/Domestic Partner Name _________________________ (Please Print) A. Who must complete this form? If you are a Main Campus / HSC Non-Union employee who wishes to select UT’s health insurance coverage for your spouse/domestic partner, you MUST complete sections A and B of this form. If your spouse/domestic partner is employed, their employer MUST complete section C. The spousal/domestic partner criteria is as follows: If a spouse/domestic partner has accessibility to health insurance through their employer, they must enroll in that plan as primary for a minimum of single coverage and may stay on the UT plan as secondary. If the spouse/domestic partner makes $25,000 or less per year and the employee contribution for health insurance through their employer would cost them more than $75/month for a single plan, they may be carried on the UT plan as primary. a. Spouse/Domestic Partner is: employed @ UT-HSC employed @ UT-MC employed full time employed part time unemployed self employed retired disabled I hereby certify that the information provided above is correct. I understand that any misrepresentation in the information I have provided above will permit UT to terminate the spouse/domestic partner’s coverage and seek any other legal remedies available including possible prosecution for insurance fraud. Employee Signature _______________________________________ Date __________________ I authorize the release of the health care plan coverage information requested below and authorize its use in accepting the application for UT health benefit coverage. Spouse/Domestic Partner Signature _________________________________________ Date __________________ 26 A. Eligibility for Other Benefit Coverage To be completed by spouse/domestic partner’s employer: 1. Is the person named as spouse/domestic partner above eligible for medical coverage? NO If no, STOP. You do not need to complete the rest of this form. Please sign, date and return to the address listed below. YES If yes, continue to question 2. 2. Is the person named as spouse/domestic partner above making $25,000/year or less? NO If no, continue to question 4. YES If yes, continue to question 3. 3. Do you offer the person named as spouse/domestic partner a health plan that would cost them more than $75/month for a single plan/employee contribution? NO If no, continue to question 4. YES If yes, STOP. You do not need to complete the rest of this form. Please sign, date and return to the employee. 4. Has the person named as spouse/domestic partner above taken the coverage for which he or she is eligible? NO If no, date coverage was waived or cancelled ____________. Yes If yes, ____ Single or ____ Family Coverage effective ___________ Insurance Company ____________________________ Group # _____________________ Policy #_____________________ Employer Name ________________________________________________________________________ Employer Address ______________________________________________________________________ Employer Phone Number _________________________________________________________________ Authorized Employer Signature ____________________________________________________________ Title ____________________________________________________ Date _________________________ 27 Please note… If you and your spouse are both employed by UT and are both eligible for benefits coverage, you may either enroll together on one form or separately on individual forms, but not both. Your dependent children may only be enrolled on one form, either yours or your spouses, but not both. 28 Dependent Coverage For dependents age 19-24 (25 for the CDHP), they must be claimed as an IRS dependent by the UT employee, be a full time student and unmarried to be eligible for benefits. As long as a dependent meets this criteria they may remain covered on your plans until the end of the year in which they reach age 24 (25 for the CDHP). A Dependent Verification Affidavit must be completed annually. Same requirements will be used for Fee Waiver eligibility. Dependents under age 19 do not need a form. 29 Dependent Verification Affidavit (please complete a separate form for each dependent) ____________________________________ ___________________________ Employee Name (Last, First MI) Social Security Number or Rocket Number I hereby certify that __________________________, (Name of Dependent) _______________________, (Social Security Number of Dependent) ____/____/____ is: (Date of Birth) FOR ALL PLANS: age 19-24 (end of calendar year), unmarried, claimed as a dependent for IRS tax purposes, AND full-time student (at an accredited educational institution) FOR MMO CDHP: age 19-25 (end of calendar year), unmarried, AND a full-time student (at an accredited educational institution) (Educational Institution: high school, college, university, other) (City, State, Zip) For the semester ____/____/____ to ____/____/____ or school year____________. Expected graduation date: ____/____/____ I hereby certify that the information provided above is correct. I understand that I am obligated to inform UT of any change in noted dependent’s student status. I ensure accuracy, I acknowledge and agree that UT may investigate the status of the noted dependent during the period in which the dependent is claiming full-time student standing. I understand that any misrepresentation in the information I have provided above will permit UT to terminate the dependent’s coverage and seek any other legal remedies available including possible prosecution for insurance fraud. Date: ____/____/____ ______________________________ (Signature) Employee ______________________________ (Relation to Dependent) 30 Prescription AFSCME will remain on current HSC plan SXC changing their name to “Informed Rx a division of SXC” Bundled with Medical Coverage (except for AFSCME) Co-pays go by tiers Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand Formulary can be found at http://hr.utoledo.edu/benefits 31 Prescription Cost Sharing UT 30-day supply co-pays: (except for AFSCME) TIER 1: $6.60 per prescription TIER 2: $16.50 per prescription TIER 3: $33.00 per prescription 32 Prescription Cost Sharing UT 90-day supply co-pays: (except for AFSCME) TIER 1: $16.50 per prescription TIER 2: $30.80 per prescription TIER 3: $61.10 per prescription 33 Prescription Cost Sharing Main Campus Retail co-pays for a 30 day supply: Tier 1: $11 Tier 2: 20% Tier 3: 40% Health Science Campus Non-Union Retail co-pays: Tier 1: Only a 10 day emergency supply is available @$6.60 Tier 2: Only a 10 day emergency supply is available @$16.50 Tier 3: Only a 10 day emergency supply is available @$33.00 34 Dental Plan AFSCME will remain on current HSC plan Enhanced for HSC non-union (same plan as MC except for annual maximum) Preventive Services covered at 100% Minor & Major work covered at 80% 2 cleanings in 12-month period $100 deductible per calendar year per person Orthodontia (dep <19) at 60% ($1500 lifetime max) Main Campus $3,000 annual max per person Health Science Campus $1,500 annual max per person 35 HSC Dental (Non-Union) Current New per person per year max $750 $1,500 crowns 50% 80% periodontic services 50% 80% oral surgery 50% 80% prosthodontic services 50% 80% implants 50% 80% orthodontic services 50% 60% ortho lifetime limit $500 $1,500 $50 $100 deductible 36 HSC Dental (Non-Union) Charged Old 50/50 crown $ 800 $400 employee cost crown $ 800 $160 employee cost oral surgery $1,200 $600 employee cost oral surgery $1,200 $240 employee cost New 80/20 Old 50/50 New 80/20 old cap $ 750 new cap $1,500 37 Vision Coverage AFSCME will remain on current HSC plan Enhanced for HSC non-union (same plan as MC) Eye examination with a $10 co-pay once every 24 months Prescription lenses once every 24 months Every 12 months for students & children Every 12 months for students & children Frames/Contacts allowance of $120 every 24 months 38 HSC Vision (Non-Union) Current New $15 $10 lens (student & child) every 24 mo every 12 mo exam (student & child) every 24 mo every 12 mo Contacts/lenses (student & child) every 24 mo every 12 mo exam 39 Flexible Spending Account Must be set up annually Allows you to set aside additional money on a pre-tax basis May be used for out-of-pocket medical and/or dependent care expenses You will be reimbursed for charges incurred once claim form is submitted Reimbursements may be direct deposited Account DOES NOT rollover Reminder: If electing MMO CDHP medical coverage, you are only eligible for dependent care. 40 Main Campus Employee Clinic Location: Main Campus Medical Center Phone Number: 419-530-3451 Clinic Hours: Monday - Friday 8:15 am - 11:00am and 1:00pm - 4:00 pm Can generally be seen the same day, if not then within 24 hours No office visit co-pay 41 Health Science Campus Employee Clinic Location: Room 2410, Dowling Hall Phone Number: (419) 383-3000 Clinic Hours: Monday - Friday 7:30 am - 4:30 pm Can generally be seen the same day, if not then within 24 hours No office visit co-pay 42 University of Toledo Main Campus 2010 Twelve Month Premiums Effective January 1, 2010 University of Toledo Main Campus 2009 Nine Month Premiums Effective January 1, 2010 Employee Per Pay Employee Per Pay OBA/FrontPath PPO and Rx Full-Time Single $29.41 Single +1 $58.82 Family $90.09 Part-Time (20%)* Single $39.21 Single +1 $78.42 Family $120.12 Paramount 3-Tier Employer Select and Rx Full-Time Single $24.90 Single +1 $49.57 Family $73.18 Part-Time (20%)* Single $33.20 Single +1 $66.10 Family $97.57 MMO CDHP and Rx Full-Time Single $12.10 Family $35.57 Part-Time (20%)* Single $16.14 Family $47.42 Dental Plan Full-Time Single $0.00 Single +1 $0.00 Family $0.00 Part-Time (20%) Single $3.62 Single +1 $7.25 Family $11.10 Vision Plan Full-Time Single $0.00 Single +1 $0.00 Family $0.00 Part-Time (20%) Single $0.48 Single +1 $0.96 Family $1.47 OBA/FrontPath (PPO) and Rx Full-Time Single Single +1 Family Part-Time (20%)* Single Single +1 Family Paramount 3-Tier PPO and RX Full-Time Single Single +1 Family Part-Time (20%)* Single Single +1 Family MMO CDHP Plan and Rx Full-Time Single Family Part-Time (20%)* Single Family Dental Plan Full-Time Single Single +1 Family Part-Time (20%) Single Single +1 Family Vision Plan Full-Time Single Single +1 Family Part-Time (20%) Single Single +1 Family $39.21 $78.42 $120.12 $52.28 $104.57 $160.16 $33.20 $66.10 $97.57 $44.26 $88.13 $130.09 $16.14 $47.42 $21.52 $63.23 $0.00 $0.00 $0.00 $4.83 $9.66 $14.80 $0.00 $0.00 $0.00 $0.64 $1.28 $1.96 43 University of Toledo Health Science Campus - Non-union 2010 Monthly Premiums Effective January 1, 2010 Employee Per Pay PARAMOUNT 3-TIER EMPLOYER SELECT & Rx Full-Time Single 28.84 Single + 1 57.41 Family 84.75 Part-Time Single 57.67 Single + 1 114.82 Family 169.49 MMO CDHP & Rx Full-Time Single 17.75 Family 52.16 Part-Time Single 35.50 Family 104.33 DENTAL Full-Time Single 2.03 Single +1 5.19 Family 7.66 Part-Time Single 4.06 Single +1 10.38 Family 15.33 VISION SERVICE PLAN Full-Time Single 0.53 Single +1 1.06 Family 1.62 Part-Time Single 1.06 Single +1 2.11 Family 3.24 44 University of Toledo Health Science Campus - AFSCME 2010 Monthly Premiums Effective January 1, 2010 Employee Per Pay Paramount 3-Tier Employer Select Full-Time Single 28.84 Single + 1 57.41 Family 84.75 Part-Time Single 57.67 Single + 1 114.82 Family 169.49 MMO CDHP and Rx Full-Time Single 17.75 Family 52.16 Part-Time Single 35.50 Family 104.33 DENTAL Full-Time Single 0.00 Single +1 0.00 Family 0.00 Part-Time Single 9.22 Single +1 23.60 Family 34.84 VISION SERVICE PLAN Full-Time Single 1.23 Single +1 1.23 Family 1.23 Part-Time Single 4.23 Single +1 4.23 Family 4.23 PHARMACY Full-Time Single 0.00 Single +1 0.00 Family 0.00 Part-Time Single 0.00 Single +1 0.00 Family 0.00 45 Main Campus / Health Science Non-Union Rocket # HEALTHCARE Election Form: Medical/Rx, Dental, Vision SECTION I: PERSONAL INFORMATION Employee's Last Name FIrst Home Address City M.I. State Zip Date of Birth Social Security Number Home Phone Number Daytime Phone Number SECTION II: REASON FOR COMPLETING FORM Date of event: _____ / _____ / _____ (return form within 30 days of event date) Qualifying status change (please specify) Birth/Adoption/Legal Guardianship1 Hired/Newly Eligible Other Addition of Domestic Partner Coverage2 Marriage Open Enrollment 1 Loss of Other Coverage1 1 Addition of Dependent due to Eligibility1 (please describe): 1 2 Documentation may be required. Affidavit required. SECTION III: HEALTH PLAN COVERAGE SELECTION Please select: Main Campus Employee ______ HSC Employee ______ For HR Office Use Only I elect Medical/Rx coverage -- make plan selection below E-Class OBA/FrontPath PPO (Main Campus Only) I elect Dental coverage Paramount Healthcare ES I waive Dental coverage Medical Mutual CDHP (HSA Form must also be completed) F/T or P/T Deduction Code PDADEDN Medical Rx I waive Medical/Rx coverage I elect Vision coverage Dental I waive Vision coverage Vision SECTION IV-A: ELIGIBLE DEPENDENT ENROLLMENT INFORMATION For HR Office Use Only (Please list all family members to show new coverage) Name Relationship to Employee (see below) Date of Birth (M/D/Y) Gender M F Social Security Number Address different from employee?* Yes No Medical/Rx Yes No Choose coverage for each eligible dependent: Dental Vision Yes No Yes No B E N E B C O V *If dependent's address differs from employee's address, provide dependent's address in SECTION IV-C on back. Additional dependents may be added on back as well. Does anyone listed above have other coverage? NO YES, If yes please list on back under "Other Coverage" Please use the following numbers and letters to indicate Relationship to Employee 1 Employee 2 Spouse 3 Dependent Child (under age 24 unless fully disabled). 4 Domestic Partner 3A Dependent Child of Employee 3B Dependent Child of Employee's Spouse 3C Dependent Child of Employee's Domestic Partner NOTE: If Dependent Child is between the age of 19 and 24 (or 25 for CDHP), a Dependent Verification Affidavit is required. AUTHORIZATION I hereby apply to The University of Toledo Healthcare Benefits Program for the coverage indicated above. I have read and understand the material explaining the terms and conditions of The University of Toledo Healthcare Plans. I declare that any individual for whom I am requesting healthcare coverage meets the definition of an eligible dependent. I understand that any person who knowingly and with intent to defraud applies for coverage or files a claim containing any materially false information is guilty of fraud and is thereby subject to disciplinary action, up to and including termination of benefits and/or employment as well as possible prosecution for insurance fraud. I understand that my elections may not be changed or voluntarily cancelled at any time during the plan year unless a qualifying status change occurs, as defined by the plan. The Benefits Office must receive notification on the appropriate form(s) within 30 days. I understand that the kind of coverage for which I am making application contains coordination of benefits, workers' compensation and subrogation provisions, and I acknowledge The University of Toledo's right to enforce these provisions. I authorize The University of Toledo to deduct the required semi-monthly contribution from my pay on a pre-tax and/or after tax basis. I understand that The University of Toledo's contribution amount for coverage for Domestic Partner and his or her dependent(s) is considered imputed income and I will be taxed 46 Signature Date Health Science Campus - AFSCME Rocket # HEALTHCARE Election Form: Medical, Rx, Dental, Vision SECTION I: PERSONAL INFORMATION Employee's Last Name Home Address Street First City M.I. State Zip Date of Birth Social Security Number Home Phone Number Daytime Phone Number SECTION II: REASON FOR COMPLETING FORM Date of event: _____ / _____ / _____ (return form within 30 days of event date) Qualifying status change (please specify) Birth/Adoption/Legal Guardianship1 Hired/Newly Eligible Addition of Domestic Partner Coverage2 Marriage Open Enrollment Other1 Loss of Other Coverage1 1 Addition of Dependent due to Eligibility1 (please describe): 1 2 Documentation may be required. Affidavit required. SECTION III: HEALTH PLAN COVERAGE SELECTION A. I elect Medical coverage -- make plan selection below Paramount Healthcare ES For HR Office Use Only Medical Mutual CDHP C. I elect Dental coverage E-Class F/T or P/T (HSA Form must also be completed) I waive Medical coverage I waive Dental coverage Deduction Code PDADEDN Medical B. I elect Pharmacy (Rx) coverage D. I waive Pharmacy (Rx) coverage I elect Vision coverage Rx I waive Vision coverage Dental Vision SECTION IV-A: ELIGIBLE DEPENDENT ENROLLMENT INFORMATION (Please list all family members to show new coverage) Choose coverage for Name Relationship to Employee (see below) Date of Birth (M/D/Y) Gender M F Social Security Number Medical Yes No each eligible dependent: Rx Dental Yes No Yes No Vision Yes No B E N E B C O V *If dependent's address differs from employee's address, provide dependent's address in SECTION IV-C on back. Additional dependents may be added on back as well. If you or your dependents have other coverage, please list on back under "Other Coverage" Please use the following numbers and letters to indicate Relationship to Employee 1 Employee 2 Spouse 3 Dependent Child (under age 24 unless fully disabled). 4 Domestic Partner 3A Dependent Child of Employee 3B Dependent Child of Employee's Spouse 3C Dependent Child of Employee's Domestic Partner NOTE: If Dependent Child is between the age of 19 and 24 (or 25 for the CDHP), a Dependent Verification Affidavit is required. AUTHORIZATION I hereby apply to The University of Toledo Healthcare Benefits Program for the coverage indicated above. I have read and understand the material explaining the terms and conditions of The University of Toledo Healthcare Plans. I declare that any individual for whom I am requesting healthcare coverage meets the definition of an eligible dependent. I understand that any person who knowingly and with intent to defraud applies for coverage or files a claim containing any materially false information is guilty of fraud and is thereby subject to disciplinary action, up to and including termination of benefits and/or employment as well as possible prosecution for insurance fraud. I understand that my elections may not be changed or voluntarily cancelled at any time during the plan year unless a qualifying status change occurs, as defined by the plan. The Benefits Office must receive notification on the appropriate form(s) within 30 days. I understand that the kind of coverage for which I am making application contains coordination of benefits, workers' compensation and subrogation provisions, and I acknowledge The University of Toledo's right to enforce these provisions. I authorize The University of Toledo to deduct the required semi-monthly contribution from my pay on a pre-tax and/or after tax basis. I understand that The University of Toledo's contribution amount for coverage for Domestic Partner and his or her dependent(s) is c 47 Signature Date HEALTH Election Form: Medical, Rx, Dental, Vision SECTION IV-B: EMPLOYEE AND ELIGIBLE DEPENDENT ENROLLMENT INFORMATION (cont'd) Use the space below to record additional eligible dependent information as needed. Name Relationship to Employee Birth Date (M/D/Y) Gender M F Social Security Number Address Choose coverage for employee different from and each eligible dependent: employee?* Medical/Rx Dental Vision Yes No Yes No Yes No Yes No PCP (If PHC is selected) *If dependent's address differs from employee's address, provide dependent's address in SECTION IV-C below. SECTION IV-C: DEPENDENT ADDRESS INFORMATION (if different from employee's address) If you indicated in SECTION IV-A or IV-B that any dependent's address differs from the employee's address, please provide that dependent's name and mailing address below: Dependent's Name Street Address City State Zip OTHER INSURANCE Policy Holder Name Effective Date Insurance Company Family Members Covered Policy Number If you have questions, contact the Office of Human Resources Benefits Department at (419) 530-4747 Return completed form to: Office of Human Resources, Benefits Department, MS #205, 15115 South Towerview Blvd., Toledo, OH 43606. Fax: (419) 530-1492 48 HIPAA additional changes Due to additional changes to HIPAA that were effective 9/23/2009, you will need to contact the vendors personally when you have a claims issue Benefits vendor contact information is available on the http://hr.utoledo.edu benefits website or on the back of your ID card 49 Open Enrollment Website http://hr.utoledo.edu Please remember Open Enrollment runs from October 15 to November 13. All forms must be turned into HR and time stamped by 5:00 pm on November 13. Any questions that may come up can be emailed to [email protected] 50