Cigna Enrollment Change Form by xiuliliaofz


									                Two Employee Family Open Enrollment Form - Medical, Dental and/or Vision
                                                   (I am married to a DCSD employee and have a child or children I would like to include on my plan.)

Effective Date 7/1/2011

Employee Name (Last)                                               ____ (First)                                              __ (M.I.)                           Emp#

Address (Street)                                                                                         (City)                                       (State)                    (Zip)

Home Phone                                         _____Work Phone_                                           _Work Site                              ___

Please Complete the Following to Add and/or Delete:
                                                                             Medical        Dental              Vision       Social Security Number              Date of Birth               Gender
                  Last Name                First            MI             Add/Delete     Add/Delete         Add/Delete         (Required by Law)               MM DD YYYY                    M/F
                                                                           (Circle One)   (Circle One)       (Circle One)
                                                                            A      D      A       D           A      D
                                                                            A      D      A       D           A      D
Dependent **
                                                                            A      D      A       D           A      D
Dependent **
                                                                            A      D      A       D           A      D
Dependent **
                                                                            A      D      A       D           A      D

Select Medical Plan (Dependent(s) must be on the same plan as employee.)

__________ DCSD Cigna-Allegiance HDHP                       __________ DCSD Cigna-Allegiance PPO                            __________ Kaiser HMO                  __________            Kaiser HDHP
           (HSA Eligible)                                              (No HSA)                                                        (No HSA)                                          (HSA Eligible)

Select Dental Plan (Dependent(s) must be on the same plan as employee.)

__________ Delta Dental Preventive Plan (cleanings, exams, x-ray only)                                      __________ Delta Dental Premier/PPO Plan (Buy Up)

______Y           ______N I elect to reduce my gross wages and have all eligible premiums paid on my behalf with pre-tax dollars.
                          (Employees within their Highest Average Salary (HAS) period for PERA retirement should not use pre-tax)

*Spouse - Includes Common Law and/or Domestic Partner
**Dependents – A dependent child is eligible to be covered on your medical, dental and/or vision coverage through the end of the month in which they turn 26 years of age.

                                                                                                                                                                                                  Revised 4/4/2011
                                                     IRS Restrictions on Enrollment in a Health Savings Account

The IRS prohibits people from contributing into a health savings account (HSA) if they meet specific criteria. Please check the criteria below to determine whether you are eligible for contributions in
an HSA, should the medical plan you elected include a health savings account. If you meet any of the criteria below, you can still enroll in any of the health plans, but according to IRS regulations you
will not be able to open or contribute to an HSA, nor will you be eligible for the Douglas County School District HSA contribution.

IRS Criteria for HSA Exclusion:

          Employee is enrolled in Medicare
           _____Yes                 _____No

          Employee is enrolled in TRICARE
           _____Yes                  _____No

          Employee received Veteran’s Administration medical benefits within the last 3 months
           _____Yes                _____No

          Employee is covered on a spouse’s health plan that is not a qualified high deductible plan (annual deductible of $2,399 or less as defined by the IRS)
           _____Yes                  _____No

Please note that if you selected YES to any of the questions above, according to IRS regulations, you will NOT be eligible for a
Health Savings Account.

You may also contribute on a voluntary basis to your Health Savings Account via payroll deduction if you are enrolled in one of the
district’s HSA high deductible plans. Each family may contribute up to $170.80 (family coverage) per month to the HSA.

                                                  Amount I wish to contribute to my HSA through monthly payroll deductions

                                                         $__________each month for a total of $__________ per plan year.
                                (I understand that the above amount will continue through June 30, 2012. I may change this amount by e-mailing my benefits specialist.)

The maximum IRS allowable contribution amount (employee and district) per calendar year is $6,150 (family coverage).

                                                                                                                                                                                          Revised 4/4/2011

                               Authorization to Disclose Confidential Individually Identifiable Health Information and Fraud Notice

         I understand that after I enroll, Cigna/Allegiance, Kaiser Permanente, Delta Dental, and/or the Vision Service Plan (the Plans) may need to obtain
          Confidential Information. I also understand that the Plans may need to provide this Confidential Information to others. Any person or entity having
          Confidential Information has my permission to provide this Confidential Information upon request to the Plans, or any other provider or entity
          performing a service for the purpose of plan administration, the performance of any programs or operations, or to assess the quality of and access to
          health care services and supplies. The Plans have my permission to give any Confidential Information to any person, company or entity when it
          determines that such disclosure is necessary or appropriate for the administration of the Plan, the performance of the Plan’s, programs or operations,
          assessing quality and accessibility of health care services and supplies, or reporting to third parties involved in plan administration. I am making this
          authorization for myself and as the agent or representative of my spouse and any dependent children. Confidential Information or Individually
          Identifiable Health Information is information that can be linked to a specific member of the health plan and is related to that member’s health status, or
          related to the provision of health care for that member. It can relate to current, past, or future health conditions or treatments. It can be in written,
          electronic, or verbal form. Individually Identifiable Health Information includes general information such as the member’s name, Social Security
          number, and also claim expenditure amounts. However, information related to the employee, and their coverage, without a health status or diagnosis,
          and which is used for Health Plan Operations is limited by HIPAA.
         Any person who, knowingly and with intent to defraud any insurance company or other entity, files an application for insurance or statement of claim
          containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
          fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Authorization to Deduct Contributions

         I authorize deductions from my earnings of the required contributions, if any, toward the cost of the coverage. I understand that if my employment
          status changes and my total scheduled annual hours fall below full time status, deductions for my portion of the insurance premium will begin.

Assignment of Benefits

         I agree, for myself and my dependents, that, in the event any health services provided are the primary responsibility of any other party by way of other
          group health coverage or by the act or omission of another person to fully inform the health plan and will execute such assignments, liens or other
          documents which may be necessary to enable the health plan to recover the value of the services provided. I further agree that in the event I or any of
          my dependents collect benefits or damages from any other party who has primary responsibility for services provided by the health plan, I will
          immediately reimburse the health plan to the extent of services provided, to the extent permitted by state law.

Special Provision for Employers with Section 125 Plans

         I also understand that, after I have enrolled, I may only make changes to my enrollment during the annual open enrollment period in May for an
          effective date of July 1st or within 31 days of a qualifying event/family status change as defined by the IRS (example: loss of other coverage, marriage,
          divorce, birth/adoption, change in employment status).

The information provided above is true and correct to the best of my knowledge, and I accept the provisions on the reverse side of this form, which I have read and understand.

Employee Signature ______________________________________________________________                                             Date
                                                                                                                                                                            Revised 4/4/2011

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