City Of Minneapolis - Health Plan Enrollment Change Form (Page 2 of 4) in pdf

CITY OF MINNEAPOLIS - HEALTH PLAN ENROLLMENT/CHANGE FORM

For changes not available through HRIS Employee Self Service due to documentation requirements.

Employee Name

Employee Payroll ID #

Effective Date

Home Phone

Work Phone

Enrollment/Change Reason: Check one and see requirements below.

Waive or change coverage due to enrollment in another group plan.

Enroll in City plans due to loss of group coverage under another plan.

Enroll dependent(s) newly eligible due to birth, adoption, legal custody, marriage, loss of other coverage, etc.

Remove dependent(s) no longer eligible due to marriage, divorce, etc.

(provide explanation below).

If change is due to a gain or loss of coverage under a non-City group plan, attach a copy of proof of ‘other’ coverage or LOSS of coverage

showing the date coverage either went into effect or was cancelled.

To add a dependent, you must provide copies of marriage and/or birth certificate or court documents related to placement/adoption or

custody. To add a grandchild you must provide a copy of a federal tax return listing the child as a dependent and a copy of current report

card, school registration, doctor’s bill, or day care statement showing your current address.

If change is due to divorce, you must provide a copy of your divorce decree - first page, last page, other page(s) referring to health insurance.

CURRENT MEDICAL COVERAGE:

CHANGE MEDICAL COVERAGE TO:

WAIVE

Single

Family

WAIVE

Single

Family

Complete only if enrolling mid-year

Medica Elect (Standard or Wellness)

Medica Essential (Standard or Wellness)

Medica Choice (Standard or Wellness)

CURRENT DENTAL COVERAGE:

CHANGE DENTAL COVERAGE TO:

Single

Family

Single

Family

FLEXIBLE SPENDING ACCOUNTS:

Decrease

Increase (or enroll) Annual Health Care Flexible Spending

New Annual Amount

Decrease

Increase (or enroll) Annual Dependent Care Spending

New Annual Amount

DEPENDENTS: Complete the information in the chart below.

SSN -Required by

MEDICAL

DENTAL

PRIMARY CLINIC

NAME

SEX

RELATION-

Federal law for

DATE OF

NUMBER*

Enroll

Delete

Enroll

Delete

SHIP

Spouse

BIRTH

(11 digits)

SPOUSE

* Primary care clinic elections for Elect and Essential networks: All family members must choose a primary care clinic within either the Elect network or the

Essential network. You cannot split family members between the two networks. If you elect Medica Elect or Medica Essential, you must enter the 11-digit clinic

number in the space provided. Visit the CityTalk website at

insurance

to find network providers.

DELETING DEPENDENTS:

Print name / address of deleted dependent(s) and explanation for removing dependent(s)

As an employee, eligible to participate in the City of Minneapolis Medical Plan, I hereby authorize the City of Minneapolis to deduct required pre-

tax premiums for coverages elected above. Further, I understand that if I fail to complete a health care option change on a timely basis that I may

not be eligible to apply for medical plan coverage until the next Open Enrollment period.

Employee Signature

Date

Fax completed form to 612-673-2533 or mail your completed form to:

City of Minneapolis, Human Resources-Benefits, Room 100 Public Service Center, 250 S 4

Street, Minneapolis MN 55415-1339

Some of the requested information on this form is private data under the Minnesota Government Data Practices Act, Minn. Stat. Chapter 13. The data requested

allows Benefit staff to verify eligibility and enroll you and your dependents in health plan(s) and allows the plan provider(s) the ability to establish an enrollment

record for you and your dependents. You are not required to provide this information, however, failure to do so may result in ineligibility and non-enrollment. This

form may be available to City and plan provider employees or agents, labor union representatives, arbitrators and administrative hearing examiners, State and

Federal courts, and attorneys representing any of the mentioned individuals or entities, or to others through subpoena or pursuant to Federal and State law.

Updated 6/2013

City Of Minneapolis - Health Plan Enrollment Change Form Page 2

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