Form Retef15 - Retiree Health Benefits Enrollment And Change Form - 2016 Page 3
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4ENROLLMENT FOR JANUARY 2016-DECEMBER 2016
Medical Benefits - A Beneficiary is considered a “Retiree”
Choose One Option:
Choose One Coverage Level:
Choose One Medical Plan:
New Enrollment
Choose from #1 to #4 if no one covered is eligible for
CareFirst BC/BS EPO
Medicare Parts A & B
Change in plan
CareFirst BC/BS PPO
Add or remove a
1.
Retiree Only, No Medicare
Kaiser IHM*
dependent
2.
Retiree & One Child, No Medicare
UnitedHealthcare EPO
Change due to Medicare
3.
Retiree & Spouse, No Medicare
UnitedHealthcare PPO
Eligibility
4.
Retiree & Two or More, No Medicare
*Retirees and/or dependents
I do not want Medical
eligible for Medicare are not
Coverage
eligible to enroll in the Kaiser
Choose from #5 to #11 if anyone covered is eligible for Medicare
Cancel current Medical
medical plan.
(the Retiree must be one of the individuals covered):
Coverage
5.
Retiree Only (with Medicare Parts A & B)
6.
Two People (only one with Medicare Parts A & B)
7.
Two People (both with Medicare Parts A & B)
8.
Three People (only one with Medicare Parts A & B)
9.
Three People (only two with Medicare Parts A & B)
10.
Three or More People (all with Medicare Parts A & B)
11.
Four or More People (at least one, but not all with
Medicare Parts A & B)
NOTE: Vision and Mental Health/Substance Abuse benefits are included if enrolled in a medical plan.
Medical plans do not include Prescription Drug or Dental coverage. Separate selections are required.
Medicare Information - A Beneficiary is considered a “Retiree”
Medicare information must be provided for anyone covered under your Retiree enrollment who is eligible for Medicare due to
age (age 65) or disability (any age). Medicare-eligible individuals who do not carry both Part A (Hospital) and Part B (Physician) will be
responsible for paying the amount that Medicare would have paid (approximately 80% of all eligible services). Medicare rules for End Stage
Renal Disease (ESRD) differ; see Benefits Guide for more information.
PART A
PART B
PART D
MEDICARE
(Hospital Claims)
(Medical Claims)
(Prescription Drug)
NAMES OF INDIVIDUAL(S)
NUMBER
MEDICARE DUE TO (P):
Effective Date
Effective Date
Effective Date
WITH MEDICARE
(with suffix)
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
Age 65
Disabled
ESRD
Retiree
Spouse
Child
Prescription Drug Coverage - A Beneficiary is considered a “Retiree”
Choose One Option:
Choose One Coverage Level:
New enrollment
Retiree Only
Add or Remove a Dependent
Retiree & One child
I do not want Prescription Drug Coverage
Retiree & Spouse
Cancel current Prescription Drug Coverage
Retiree & Two or More People
Dental Coverage - A Beneficiary is considered a “Retiree”
Choose One Option:
Choose One Coverage Level:
Choose One Plan:
New enrollment
Retiree Only
United Concordia DPPO
Change in plan
Retiree & One Child
Delta Dental DHMO
Add or remove a dependent
Retiree & Spouse
For DHMO Plan: Once enrolled, you must
I do not want Dental Coverage
Retiree & Two or More People
contact the plan to select a primary Dentist
Cancel current Dental Coverage
office. Call plan or see plan website for details.
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