Form Asef15 - Active & Satellite Employeeshealth Benefits Enrollment And Change Form - 2016 Page 3
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4ENROLLMENT FOR JANUARY 2016-DECEMBER 2016
Medical Benefits
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE MEDICAL PLAN:
New Enrollment
Employee Only
CareFirst BC/BS EPO
Change in plan
Employee & One Child
CareFirst BC/BS PPO
Addition or removal of dependent
Employee & Spouse
Kaiser IHM*
No, I do not want to enroll in
Employee & Family
UnitedHealthcare EPO
this benefit
End Stage Renal (ESRD)
UnitedHealthcare PPO
Bargaining Unit I members only (SLEOLA):
Cancel current coverage
(
Complete Medicare Information below)
CareFirst BC/BS EPO Mod-I
CareFirst BC/BS POS Mod-I
CareFirst BC/BS PPO Mod-I
*Employees and/or dependents with Medicare due to End Stage Renal Disease (ESRD) are not eligible to enroll in the Kaiser medical plan.
If you or a dependent have Medicare, write in name, Medicare number, and effective date of Medicare coverage.
PART A
PART B
PART D
MEDICARE
(Hospital Claims)
(Medical Claims)
(Prescription Drug)
NAMES OF INDIVIDUALS
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
Employee
Spouse
Child
Child
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.
Prescription Drug Coverage
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
New enrollment
Employee Only
Addition or removal of dependent
Employee & One Child
Employee & Spouse
No, I do not want to enroll in this benefit
Cancel current coverage
Employee & Family
Dental Coverage
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE DENTAL PLAN:
New enrollment
Employee Only
United Concordia DPPO
Change in plan
Employee & One Child
Delta Dental DHMO
Addition or removal of dependent
Employee & Spouse
For the DHMO Plan: You must select
a primary Dentist office once enrolled.
No, I do not want to enroll in this benefit
Employee & Family
Call plan or see plan website for details.
Cancel current coverage
Accidental Death and Dismemberment Benefits
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE BENEFIT AMOUNT:
New enrollment
Employee Only coverage
$100,000
Change of benefit amount
Family coverage
$200,000
Addition or removal of dependent
$300,000
No, I do not want to enroll in this benefit
Cancel current coverage
Flexible Spending Accounts – SELECTED AMOUNTS ARE PER PAY CHECK
YOU MUST COMPLETE THIS SECTION IF YOU WANT TO PARTICIPATE IN A FLEXIBLE SPENDING ACCOUNT FROM JANUARY 2016-DECEMBER 2016.
If you will be retiring before
HEALTHCARE
DAY CARE
January 1, 2017, only
CHOOSE ONE OPTION:
CHOOSE ONE OPTION:
expenses incurred prior to
retirement can be
Enroll in Healthcare Spending Account
Enroll in Dependent Day Care Spending Account
considered for
Change in Healthcare Spending Account
Change in Dependent Day Care Spending Account
reimbursement.
No, I do not want to enroll in this benefit
No, I do not want to enroll in this benefit
Cancel Healthcare Spending Account
Cancel Dependent Day Care Spending Account
.
.
$
$
Write in dollar amount to be deducted from each paycheck
Write in dollar amount to be deducted from each paycheck
See Benefits Guide for Minimum/Maximum deduction amounts. Check with your Agency Benefits Coordinator for your number of deductions.
Reminder: This is not a yearly deduction amount. THIS IS THE AMOUNT DEDUCTED PER PAY PERIOD FOR JANUARY 2016-DECEMBER 2016.
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