Secure 072012 Final Waiver of Insurance and Certification of Other Medical Coverage Form 3012 by 81eN6G

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                                                Waiver of Insurance/Certification of Other Coverage
                                                                                Form #3012
                                                                   (Plan Year: January 1st – December 31st)


READ CAREFULLY AND COMPLETE ALL SECTIONS OF THIS FORM.

 Complete Your Personal Information
 Print Name (Last, First, Middle Initial)                                                                                 Banner ID                       Dept. Extension



 Home Address (street, city, state, zip code)    CHECK IF NEW                                                             Email Address




 Select Waiver Option
      Waive Medical Coverage                                                                      Waive Dental Coverage                      Waive Vision Coverage
  Complete “Certification of Medical Coverage” section below.
 Certification of Medical Coverage
 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires Lawrence Technological University to inform you of
 your right to Special Enrollment under any of the medical insurance plans offered by the University when you or your eligible
 dependents (spouse/children) decline coverage during the initial enrollment period.
               If you are declining enrollment for yourself, or your dependents (spouse/children) because of coverage under another plan,
                you may be able to enroll yourself or your dependents in the University plan in the future, provided you request enrollment
                within thirty (30) days after your other coverage ends.
               If you are declining enrollment for yourself, or your dependents (spouse/children) because of coverage under Medicare or
                Medicaid, you may be able to enroll yourself or your dependents in the University plan in the future, provided you request
                enrollment within sixty (60) days after your other coverage ends.
 In order to qualify for this special enrollment period, you must certify other coverage was the reason for declining/waiving enrollment
 in coverage provided through Lawrence Tech. I certify that I have other medical/prescription insurance coverage (check box below:
         Outside of Lawrence Tech (enter information below):
         Name of the policy holder              .       Name of policy holder’s employer                  .
         Name of other medical plan                 .     Policy or Group Number              .
         Through another Lawrence Tech employee (identify employee’s name)                                    .
         Through a governmental-sponsored health plan or group insurance policy                                     .
 Opt-Out Cash Plan                                       Opt-out cash                      Complete and Return if Enrolling or Canceling Coverage
         Plan 1: Waive Medical Coverage                                                Benefits Election/Change Summary- Form #3075
                                                        $25.00 per pay
         Only                                                                          Applicable Insurance Forms - Enroll or Cancel
                                                                                              o     AHL-HAP or BCN Medical Enrollment/Change Form
         Plan 2: Waive Medical, Dental                                                        o     ADN Dental Enrollment- Form #3074
                                                        $30.00 per pay
         and Vision Coverage                                                                  o     EyeMed Vision Enrollment- Form #3080
                                                                            Download forms at https://www.ltu.edu/human_resources/benefit_forms.asp
 Certification and Signature
I understand that if I do not gain special enrollment rights upon a loss of other coverage, my next opportunity to enroll in a Lawrence
Tech medical insurance plan will be the next annual open enrollment period, unless special enrollment rights apply because of a new
dependent by marriage, birth, adoption, or placement for adoption. I understand that I am also waiving prescription drug coverage. I have
read the second page of this form and agree to the terms and conditions listed there. The information listed above is correct to the best of
my knowledge.



Employee’s Signature: _______________________________________________________________________ Date: ________________________________________________________________________________


How to Return Your Completed and Signed Forms to Human Resources


            By inter-office Campus Mail                                                                         Bring your forms to the Office of Human Resources
            By fax to 248.204.2118                                                                               (BSB)
                                                                                                                 Scan and email to benefits@ltu.edu

Doc. #3012.v8.0                                                                                                                                                   Revised July 2012
Waiver of Insurance and Certification of Other Coverage

Introduction                                                                     • Death of an employee
By completing this form, you are certifying that you are waiving medical         • Termination of employment
insurance coverage and prescription drug coverage offered by Lawrence            • Reduction in the number of hours of employment that results in a loss of
Tech because you have medical coverage elsewhere. If you should lose that        eligibility for plan participation (including a strike, layoff or lock-out)
other medical coverage, you may be able to enroll in the University medical      • An individual no longer resides, lives, or works in an HMO service area
insurance under special enrollment rights as described below.                    (whether or not within the choice of the individual), and no other benefit
Special Enrollment                                                               package is available to the individual through the other employer
Under a federal law known as HIPAA, special enrollment rights that allow you     • A situation in which a plan no longer offers any benefits to the class of
to enroll yourself or your eligible dependents in a Lawrence Tech group          similarly situated individuals that includes the individual
insurance plan may apply if you previously declined the University               • A situation in which an individual incurs a claim that would meet or exceed
enrollment for yourself or for an eligible dependent (including your spouse)     a medical plan lifetime limit on all benefits (additional requirements apply).
while other health insurance coverage was in effect for those individuals. In
order for these special enrollment rights to apply, certain conditions must be   If Coverage Was Under COBRA, Entire COBRA Period Must Be Exhausted
met.                                                                             If an eligible employee or dependent has COBRA coverage, the coverage
                                                                                 must be exhausted in order to trigger a special enrollment right. Generally,
Opt-Out Cash Provisions                                                          this means that the entire 18-, 29-, or 36-month COBRA period must be
1. In lieu of “medical only” or “medical, dental and vision” coverage, you       completed in order to trigger a special enrollment for loss of other coverage.
     may receive opt-out cash per pay period based on your selection.            However, exhaustion of COBRA coverage also occurs when:
2. By selecting Plan 1, you are opting out of medical coverage only, but         • The other employer or another responsible entity failed to remit premiums
     may elect the Dental and / or Vision Insurance coverage. By selecting       on a timely basis, or
     Plan 2, you are opting out of medical, dental and vision coverage.          • A situation in which an individual incurs a claim that would meet or exceed
3. The opt-out cash amount you receive is a taxable benefit and is subject       a lifetime limit on all benefits and there is no other COBRA continuation
     to FICA, federal, state and city tax. The amount deducted for taxes         coverage available to the individual (additional requirements apply). Note:
     depends on individual circumstances. Calculations will not be provided      An employee or dependent who is offered COBRA under the plan under
     prior to actual payment.                                                    which the coverage is lost (the old plan) is not required to elect COBRA to
4. This election binds you for the entire plan year. Therefore my benefit        preserve his or her special enrollment rights under the new plan. In other
     election cannot be changed unless a status change occurs.                   words, the individual could choose not to elect COBRA under the old plan
5. During the annual benefit open enrollment period, you may elect               and still have special enrollment rights under the new plan. But if the
     coverage. However, this election will automatically continue into the       employee or dependent does elect COBRA coverage under the old plan, then
     next plan year unless you report in writing to the Office of Human          the entire COBRA period must be exhausted in order for the individual to
     Resources that you want to change my election.                              have another special enrollment right under the new plan. Loss of eligibility
                                                                                 does not include a loss resulting from failure of the employee or dependent
6. If your terminate employment during the plan year will; you forfeit any
                                                                                 to pay premiums on a timely basis.
     remaining waiver opt out fee.
                                                                                 Who Can Enroll
Changes to Health Care Flexible Spending Accounts
                                                                                 To qualify for special enrollment rights, the employee and/or any eligible
The special enrollment right for loss of other coverage may permit either an
                                                                                 dependent(s) must lose coverage under another group health plan.
enrollment or increase in a Health Care Flexible Spending Account.
                                                                                 Situations That Do Not Qualify for Special Enrollment
Employee or Dependent Must Have Had Coverage When Coverage Was                   • Reduction of Contributions or Level of Benefits Is Not Sufficient
Previously Offered                                                               The special enrollment right for loss of other coverage generally requires that
In order to qualify for special enrollment rights because of loss of coverage,   coverage be lost. A reduction in the level of benefits under a plan will not
the employee or dependent must have had other group health plan coverage         trigger a special enrollment right. For example, if an employee loses eligibility
at the time Lawrence Tech coverage was previously offered. The employee          for an option (such as an HMO alternative) under his or her spouse’s plan but
must have also stated in writing at that time, that Lawrence Tech coverage       is still eligible for another health insurance option under that same plan, then
was declined because of the other coverage.                                      no special enrollment will be triggered—coverage was not lost under the
                                                                                 plan. However, if no other health insurance option is available to the
Coverage Must Be Involuntarily Lost                                              employee under the plan, then the employee has lost eligibility and would be
In order to qualify for special enrollment rights because of loss of other       entitled to special enrollment. The reason for the loss of eligibility does not
coverage, the employee or dependent must have lost other group health            matter.
plan coverage because:                                                           • Increase in Cost of Coverage Won’t Trigger Special Enrollment Rights
• The coverage was provided under COBRA, and the COBRA coverage was              Increases in the cost of coverage do not trigger special enrollment rights
exhausted; or,                                                                   unless the other employer completely stops contributing toward the cost of
• The coverage was non-COBRA coverage and (a) the coverage terminated            the other coverage for you or your family members.
due to loss of eligibility for coverage, or (b) the employer stopped
contributing toward the other coverage for you or your family members.           Job Status Change of Spouse or Dependent
                                                                                 If your spouse or dependent becomes eligible for benefits through their
If Coverage Was Non-COBRA, Loss of Eligibility or Employer Contributions         employer or has Open Enrollment, you may remove them from your
Must End                                                                         benefits. You must notify Human Resources within 30 days of the event. You
A “loss of eligibility” for special enrollment includes:                         may remove them only from those benefits in which they actually newly
• Loss of eligibility for coverage as a result of divorce                        enroll (i.e., you may not remove your dependent from your dental coverage
• Cessation of dependent status (such as attaining the maximum age to be         if the dependent newly enrolls in medical coverage only.) Coverage will be
eligible as a dependent child under the plan)                                    canceled the last day of the month in which they are newly eligible.




Doc. #3012.v8.0                                                                                                                                  Revised July 2012

								
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