Ma Health Care Coverage Waiver Form - Harvard Pilgrim Health Care printable pdf download

MA Health Care Coverage Waiver Form

Employer Company Name: ______________________________________________________________________

Employee Name: ______________________________________________________________________________

On behalf of myself and my eligible dependents (if any), I waive the option to enroll in Harvard Pilgrim Health Care health

insurance offered at this time by or through my employer for the following reason:

Waiving Group Health Coverage

(Please select one of the following)

I am covered under another group plan as a spouse or dependent

I am covered by the MassHealth, Medicare, or Veterans Program

I am covered under another group plan sponsored by a second employer

I am covered under another carrier’s plan sponsored by this employer

I am covered through a non-group, individual or private health care plan not offered through my employer

I do not wish to participate in health care benefits at this time

(I am declining health insurance entirely)

If the reason stated above for waiving coverage is that you have coverage elsewhere, please provide the following

information:

Carrier Name:

___________________________________

Subscriber Name: __________________________________

I affirm that the information I have provided on this form is true and complete to the best of my knowledge and

belief. I understand that Harvard Pilgrim may either refuse to renew coverage or terminate coverage, retroactive to

the effective date, for any material misinformation (including omissions) contained in this form.

I understand that any person choosing to enroll at a time other than during my employer’s open enrollment must

meet Harvard Pilgrim’s requirements for eligibility and the special enrollment rights summarized below.

Employee Signature:

Date:

_______________________________________________________

____________

Notice of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you

may in the future be able to enroll yourself or your dependents in this health plan, provided that you request enrollment within 30 days

after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for

adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage,

birth, adoption, or placement for adoption.

Special enrollment rights may also apply if you lose coverage under Medicaid or the Children's Health Insurance Program (CHIP) or

become eligible for state premium assistance under Medicaid or CHIP. An employee or Dependent who loses coverage under Medicaid or

CHIP as a result of the loss of Medicaid or CHIP eligibility may be able to enroll in this Plan, if enrollment is requested within 60 days

after Medicaid or CHIP coverage ends. An employee or Dependent who becomes eligible for group health plan premium assistance under

Medicaid or CHIP may be able to enroll in this Plan if enrollment is requested within 60 days after the employee or Dependent is

determined to be eligible for such premium assistance.

Ma Health Care Coverage Waiver Form - Harvard Pilgrim Health Care