Certification Of Other Comparable Coverage printable pdf download

Certification of Other Comparable Coverage

Opt-Out of Medical Coverage

Instructions (Please print clearly)

Attach proof of other comparable medical insurance coverage that shows you as a covered member (ID card, letter from insurance company,

copy of enrollment information.) Dates must be included and coverage is subject to verification.

Return this form with proof of other comparable medical coverage to the Human Resources Department by the applicable deadline.

Check one box only and enter the dates requested.

New-Hire

Annual Enrollment

Qualified Change in Status Event

Hire Date _________________

Due on or before November 30

Event Date _____________________

Due within 14 days of hire date

Notification Date ________________

Opt-Out begins 1

of month following notification

date, provided signed form is received within 31

days of qualified change in status event

_______________________________________

_______________________________ ____

_____________________________________

Last Name

First Name

Email Address

_______________________________________

____________________________________

_____________________________________

Last 4 Digits of Social Security Number

Work/Cell Phone

Medicare ID Number (if enrolled in Medicare)

_______________________________________

____________________________________

_______________________

___________

Home Address

City

State

Zip

Comparable Coverage Insurance coverage obtained through the Health Insurance Marketplace is not valid as other comparable coverage.

Coverage Type:

Traditional Plan (ex. PPO, HMO)

Qualified High Deductible Plan

Government (Medicare, TRICARE, VA)

Other

Primary cardholder (name of person whose plan you are enrolled under) __________________________________ Relationship ____________________

I elect to opt-out of my employer’s sponsored medical plan. This opt-out election is subject to the provisions of my Employer’s Cafeteria Plan, benefit plans and

personnel policies. Any reference to "other coverage" means "other comparable coverage” and generally refers to another employer’s group health plan which is

considered affordable Minimum Essential Coverage (MEC) as defined by the Affordable Care Act (ACA), (the ACA requires all persons to have MEC or pay a tax

penalty), TRICARE medical plan or VA coverage (not a TRICARE supplement), Medicare Parts A, B and D (all three) or Medicare Part C. Medicaid is not

considered other comparable coverage for Opt-Out purposes. I have been given an opportunity to ask questions about the opt-out election and understand and

agree to all of the conditions listed below.

1. My Employer can disregard this form. If my Employer has reason

Spending Account rules apply. If I am enrolled in the retiree group

to believe this Certification is incorrect, invalid, or that I do not have

medical plan, I understand I am ineligible for employer non-elective

other comparable coverage, my Employer reserves the right to disregard

contributions to a FLEX account. The annual non-elective contribution is

this Certification. My employer can request proof of other comparable

prorated for partial year eligibility and in no event can exceed the

coverage at any time.

Employer established annual maximum. If my employer makes a non-

elective contribution, the amount of the non-elective contribution is

2. I cannot change this election unless specific circumstances

subject to change without notice. If I fail to provide the required

apply. Once I opt-out of medical coverage, the election cannot be

documents by the applicable deadline or if this election is found to be

changed until the next annual enrollment period, unless I experience a

invalid, my employer may, without notice, discontinue any non-elective

Qualified Change in Status Event. If I experience a Qualified Change in

FLEX account contributions and/or require I repay reimbursements made

Status Event, I can make a new election for medical coverage as long as

to me during the period of time this election was in force.

the election is consistent with the Qualified Change in Status Event.

6. Employer Health Savings Account (HSA) seed-money

3. I must turn in my documents before the deadline. My employer

contribution. I acknowledge that employer seed-money contributions

must receive this signed Certification and proof of other comparable

are subject to validation of my other comparable coverage, and that a

coverage, no later than the applicable deadline described above in order

seed money contribution will not occur without validation of other

to opt-out. The information is considered received by my employer when

comparable coverage. I further acknowledge that I am solely responsible

received by my employer’s Human Resources Office.

for any income tax and/or penalties (as they may apply) resulting from

4. If I do not turn in my documents on time, I cannot opt-out,

HSA funds deposited into an account based on the comparable coverage

even if I have other comparable medical coverage. If I elect to opt-

information I provided.

out of my employer’s sponsored medical plan but fail to provide the

7. If I opt-out, I am considered absent from my employer’s

signed Certification of Other Comparable Coverage Form and valid proof

medical plans. Therefore, I am not eligible for continuation of medical

of other comparable medical coverage by the date due, and:

coverage (COBRA).

a) I am a newly-hired employee, I will be enrolled in my employer’s

8. I am not required to provide insurance coverage to a

designated default election plan, employee coverage only (no dependent

dependent(s) under a court order. I further confirm I am not

coverage); or

required to provide insurance to dependents under a Qualified Medical

b) I am currently enrolled in my employer’s medical plan, then this

Child Support Order (QMCSO) or National Medical Support Notice

opt-out election is considered void and I will remain enrolled in the plan

(NMSN).

and coverage level in force as if this election was not made, subject to the

terms of the underlying plans.

9. It is my responsibility to notify my employer within 31 days of

the date my comparable medical insurance coverage ends. If I fail

5. Employer non-elective contributions to my FLEX Spending

to do so, I acknowledge I may be enrolled in my employer’s designated

Account (subject to employer participation) are not guaranteed.

default election plan, employee coverage only, and I authorize payroll

As a result of this election, my employer may, in its sole discretion, make

deductions for premium due.

a non-elective contribution to a general purpose or limited purpose

Health Care FLEX Spending Account on my behalf and all Flexible

Signature

I certify that all information provided is true and correct, that I am covered by other comparable medical coverage, and I agree to comply with all conditions

as described above.

_________________________________________________________________________

________________________________________

Signature

Date

pebc102215