Enrollment Change Form - Request For Enrollment Change Page 2

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HEALTH COVERAGE WAIVER FORM

(Complete Waiver only if you are waiving coverage for yourself & / or any dependent)

GROUP / EMPLOYER NAME:

GROUP NUMBER

EMPLOYEE NAME: (LAST)

(FIRST)

(INITIAL)

SOCIAL SECURITY NUMBER

I decline to enroll in health coverage for:

Myself

My Spouse

Reason for waiver:

the existence of other coverage _________________

(Plan Name)

My Dependent Child/Children (please list below)

other reason (explain)_________________________

1._______________________________________________

2.________________________________________________

3._______________________________________________

4.________________________________________________

5._______________________________________________

6.________________________________________________

I understand that this waiver of coverage may affect the ability of each person listed above to obtain coverage at a later date. Specifically, except during applicable “Special

Enrollment Periods”, each person listed above may be considered to be a Late Enrollee, and subjected to an exclusionary period of up to eighteen (18) months for any pre-

existing condition, as that term is defined by Federal Law (HIPAA).

EMPLOYEE'S SIGNATURE ______________________________________________

DATE SIGNED ______________________

SPOUSE'S SIGNATURE __________________________________________________

DATE SIGNED______________________

(If Spouse is waiving coverage)

Statement of HIPAA Portability Rights

Pre-existing condition exclusions. Some group health plans restrict coverage for medical conditions present before an individual’s enrollment. These

restrictions are known as “pre-existing condition exclusions.” A pre-existing condition exclusion can apply only to conditions for which medical advice,

diagnosis, care, or treatment was recommended or received within a specified period of time before your “enrollment date.” Your enrollment date is your first

day of coverage under the plan, or, if there is a waiting period, the first day of your waiting period. In addition, a pre-existing condition exclusion cannot last

for more than 12 months after your enrollment date (in some cases, 18 months if you are a late enrollee.) Finally, a pre-existing condition exclusion cannot

apply to pregnancy or genetic information and cannot apply to a child who is enrolled in health coverage within 30 days after birth, adoption, or placement

for adoption.

If a plan imposes a pre-existing condition exclusion, the length of the exclusion must be reduced by the amount of your prior creditable coverage. Most health

coverage is creditable coverage, including group health plan coverage, COBRA continuation coverage, coverage under an individual health policy, Medicare,

Medicaid, State Children’s Health Insurance Program (SCHIP), and coverage through high-risk pools and the Peace Corps. If you do not receive a certificate

for past coverage, talk to your new plan administrator.

You can add up any creditable coverage you

have.

However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a

plan may not have to count the coverage you had before the break.

Right to get special enrollment in another plan. Under HIPAA, if you lose your group health plan coverage, you may be able to get into another group

health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment according

to the Special Enrollment provisions of your plan (usually within 30 or 60 days). (Additional special enrollment rights are triggered by marriage, birth,

adoption, and placement for adoption.)

Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a spouse’s plan), you should request special

enrollment as soon as possible.

Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan

based on anything related to your health. Also, a group health plan may not charge you (or your dependents) more for coverage, based on health, than the

amount charged a similarly situated individual.

Right to individual health coverage. Under HIPAA, if you are an “eligible individual,” you have a right to buy certain individual health policies (or in

some states, to buy coverage through a high-risk pool) without a pre-existing condition exclusion. To be an eligible individual, you must meet the following

requirements:

- You have had coverage for at least 18 months without a break in coverage of 63 days or more;

- Your most recent coverage was under a group health plan;

- Your group coverage was not terminated because of fraud or nonpayment of premiums;

- You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or continuation coverage under a similar state

provision); and

- You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other health insurance coverage.

The right to buy individual coverage is the same whether you are laid off, fired, or quit your job.

- Therefore, if you are interested in obtaining individual coverage and you meet the other criteria to be an eligible individual, you should apply for

this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break.

ENROLLMENT CHANGE FORM 10/2005