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Forms To Complete
FOR DENTAL INSURANCE | FOR
EMPLOYEE, SPOUSE, AND CHILD LIFE INSURANCE
MINNESOTA LIFE EVIDENCE OF INSURABILITY FORM |
AMPLIFIED BLOOD TEST
FLEXIBLE BENEFITS BENEFICIARY ELECTION FORM |
FOR SPECIFIED ILLNESS INSURANCE | AIG AMERICAN GENERAL EVIDENCE OF INSURABILITY FORM |
FOR LONG-TERM CARE INSURANCE | FOR AD&D INSURANCE |
FOR LONG-TERM DISABILITY |
THE STANDARD EVIDENCE OF INSURABILITY FORM |
ADDITIONAL REQUIRED INFORMATION |
Depending on the benefit choices made, you may be required to complete additional
forms, such as:
- Minnesota Life Evidence of Insurability Form for approval of employee life, spouse life, and child life. If you make any of these benefit selections on the web, you must complete the medical underwriting form on the web.
- Health Savings Account Enrollment Form to be approved for the Health Savings Account. The
form must be completed in full and provided to SHPS, Inc.
- AIG American General Evidence of Insurability Form to be approved for specified illness.
If you select specified illness on the web, you must complete the medical
underwriting form on the web.
- UnumGroup
Long-Term Care Insurance Application Evidence of Insurability Form to be
approved for long-term care coverage. This medical underwriting form is not
available on the web. When you have completed the form, return it to your
personnel office.
- The Standard Company Evidence of Insurability Form to be approved for long-term
disability. If you select long-term disability on the web, you must complete
the medical underwriting form on the web.
- Enrollment forms for the Prepaid Dental option.
FOR DENTAL INSURANCE
If you enroll in the Prepaid Dental Option, you must complete a dentist Selection Form to pre-select a participating dentist prior to being able to use your dental insurance. Be sure to include dependent information on this form. Call CIGNA's Dental Member Services at 1-800-642-5810 or go online at www.cigna.com to obtain the Dental Selection Form
Note: Health insurance forms are not applicable to the dental benefit.
FOR EMPLOYEE, SPOUSE, AND CHILD LIFE INSURANCE
In addition to your Option Statement or web enrollment, you may be required to complete the life medical underwriting process. If you are a current employee or new employee, the chart below will assist you in determining medical underwriting requirements.
Minnesota Life Evidence of Insurability Form
If you or your dependents are required to undergo the employee life, spouse life and child life medical underwriting process, you must complete the underwriting process on the web during open enrollment, or if you are hired after October 1, 2007, you must obtain the paper Minnesota Life Evidence of Insurability Form from your personnel/payroll office and submit within 30 days of your hire date. Based on the information you provide on the form, the insurance company may require additional medical information for clarification.
Amplified Blood Test
In addition to the Minnesota Life Evidence of Insurability Form, your employee and/or spouse life insurance selection may require the completion of an amplified blood test. After Minnesota Life receives your Evidence of Insurability Form, the paramedic company responsible for collecting a blood sample will contact you. The amplified blood test includes measurement of blood pressure, pulse, height, and weight. It may also include an EKG in certain circumstances. You will not be charged for this test. The amplified blood test is never required for child life insurance selections. If you have any questions about the amplified blood test process, please call Minnesota Life toll free at 1-800-660-2519.
When you request new or additional coverage, and your medical history warrants, the
insurance company may ask for additional information, including an amplified blood test,
even if your new coverage is for less than $150,000. You must complete by the deadline or
coverage may be denied.
Minnesota Life Insurance Beneficiary Election Form The first time you enroll in employee life insurance coverage, remember to complete the Flexible Benefits Beneficiary Election Form to name your beneficiaries. If your address changes or you desire a beneficiary change, update your beneficiary information by completing another Flexible Benefits Beneficiary Election Form. Be sure to return the completed form to your Personnel Office. You are always the beneficiary of your spouse life and/or child life insurance option.
For Specified Illness Insurance In addition to your
Option Statement or web enrollment, you may be required to complete the medical
underwriting process. If you are a current employee or new employee, the chart
below will assist you in determining medical underwriting requirements.
AIG Evidence of Insurability Form
If you are required to undergo the specified illness medical underwriting process, you must complete the underwriting process on the web during Open Enrollment or if you are hired after October 1, 2007, you must obtain the paper AIG American General Evidence of Insurability Form from your personnel/payroll office and submit within 30 days.
AIG Beneficiary Form
The first time you enroll in Specified Illness, complete
the AIG Beneficiary Form and mail it to the address on the form. If you wish to
update your information, complete another form and mail it to AIG.
Long-Term Care Insurance
FOR THE PY 2008 OPEN ENROLLMENT ONLY - current employees may select or increase LTC
coverage with no medical underwriting required.
Outside of the PY 2008 Open Enrollment period, if you
are a current employee and wish to choose long-term care for the first time or
have discontinued coverage and are re-enrolling or are currently in the plan and
wish to increase your benefit level or add options, you must complete the
Long-Term Care Application. Call Unum at 1-888-SOG-FLEX (1-888-764-3539) or
contact your local personnel/payroll office for an application. The long-term
care medical underwriting process cannot be completed on the web.
If you are a new employee and select this coverage, you
do not have to complete this form. Simply, select this coverage on your Option
Statement.
For AD&D Insurance
If you have enrolled in life insurance coverage, the beneficiary you name for your life insurance
benefits is also the beneficiary for your AD&D benefits. If you did not take life insurance coverage,
you should complete a Flexible Benefits Program Beneficiary Election Form for your AD&D coverage.
You can change beneficiaries any time by filing a new form with your department.
For Long-Term Disability Insurance
If you are a current employee choosing coverage for the first time, or discontinued coverage and/are
re-enrolling, you must complete the disability medical underwriting process on the web during Open
Enrollment or if you are hired after October 1, 2007, you must obtain the paper form from your
personnel/ payroll office and submit timely.
The Standard Company Evidence of Insurability Form
The Long-Term Disability medical underwriting process includes the completion of the Evidence
of Insurability Form. The form must be completed by the designated deadline. Based on the
information you have provided, the insurance company may require additional medical information
for clarification.
If you are a new employee and select the long-term disability option, you do not have to complete the medical underwriting process
After you've decided which benefits are best for you, it's time to sign up for them. Refer to the employee checklist to assure you are covering all bases.
Additional Required Information
Additional information you may be required to furnish may include medical history questions, medical records from your physician, an amplified blood test, and/or a paramedical examination. There is no additional expense to you for the blood test or for medical records. To speed up the medical underwriting process, you may be contacted by telephone for additional information by The Standard or one of The Standard's representing companies. If you have any questions, please contact The Standard's Medical Underwriting staff toll-free at
1-888-641-7186.
Specified Illness Medical Underwriting
For Current and New Employees
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Enrolling in Level 1 & 2
($5,000 & $10,000 coverage)
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Current Employee - No Medical Underwriting required if selected during the 2008 Open Enrollment period. New Employee - No Medical Underwriting required.
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Enrolling in Level 3,4,5, or 6
$20,000, $30,000, $40,000
or $50,000
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Medical Underwriting required by the carrier
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Enrolling in Spouse
Coverage
($5,000)
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Current Employee - No Medical Underwriting required if selected during the 2008 Open Enrollment period. New Employee - No Medical Underwriting required.
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Life Insurance Medical Underwriting
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CURRENT EMPLOYEES
Enrolling for the first time, re-enrolling or increasing coverage
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Employee Life
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Life Medical Underwriting Requirements |
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Enrolling for the first time in any level.
Discontinued coverage and re-enrolling.
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Evidence of Insurability form required. Amplified Blood Test required for coverage
over $150,000. |
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Currently Enrolled in Employee Life and increasing coverage.
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Evidence of Insurability form required. Amplified Blood Test required for coverage
over $150,000. |
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Spouse Life
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Life Medical Underwriting Requirements |
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Enrolling for the first time in any level.
Discontinued coverage and re-enrolling.
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Evidence Of Insurability form required. Amplified Blood Test required for coverage
over $150,000 |
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Child Life
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Life Medical Underwriting Requirements None |
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Enrolling for the first time in any level of coverage.
Discontinued coverage and re-enrolling.
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Evidence of Insurability
form required. |
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NEW EMPLOYEES
Enrolling for the first time
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Employee Life
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Life Medical Underwriting Requirements
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Enrolling in One times pay (capped at $250,000)
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NONE |
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Enrolling in Two, Three, Four, Five, six or seven time pay
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Coverage over $100,000 Minnesota Life Evidence of Insurability form required. Amplified Blood Test
required for coverage over $150,000 |
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Spouse Life
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Life Medical Underwriting Requirements |
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Enrolling in coverage up to $30,000
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NONE |
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Enrolling in coverage over $30,000
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Evidence of Insurability form required. Amplified Blood Test required for coverage
over $150,000. |
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Child Life
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Life Medical Underwriting Requirements |
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Enrolling for the first time in any level
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NONE |
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When coverage begins
Coverage for new options selected during the Plan Year 2008 Open Enrollment will begin on January 1, 2008 as long as you have met all contractual and administrative requirements.
Your new premiums for your health benefit plan and spending account reductions begin December 14; other premiums begin December 31 (for semi-monthly pay periods). See specific plan descriptions for information about when your coverage begins.
If you are a new employee, complete your personalized paper Option Statement and other needed forms by your department's deadline, but no later than 30 days after your hire date. Your coverage will begin on the first day of the month after you have completed a full calendar month of continuous employment.
Confirming Your Choices
You will receive a Confirmation Statement. Check it to be sure your choices were correctly entered. The Confirmation Statement does not guarantee your coverage in some benefit coverages that require additional information. If you have not completed and submitted the additional forms/information required by your selected plan and have not been approved by the respective agencies, the choices shown on your Confirmation Statement for employee life, spouse life, child life insurance, and long-term disability insurance, specified illness, health savings account; long-term care, and State Health Benefit Plan PPO, Indemnity and HMO Options may not be valid.
Compare your paycheck statements with your Confirmation Statement. It is your responsibility to notify your personnel/payroll office immediately if there is an error. Any changes to your benefit selections must be in accordance with IRS §125 and Employee Benefit Plan Council rules and regulations and approved by plan administrators
To Change Your Decisions at Annual Open Enrollment
Every Open Enrollment you can change your benefit decisions, based on which benefits are available and right for you. Remember, this is an annual agreement to allow the State to purchase some benefits for you through pre-tax premiums. You will not be able to change these benefit decisions until the next Open Enrollment unless you have a qualifying change in status as described in the Terms and Conditions.
To Change Your Decisions Outside Annual Open Enrollment Qualifying Change in Status Event
In general, the Internal Revenue Service prohibits you from changing any coverage elections, or enrolling in or canceling any coverage under the Flexible Benefits Program outside of Open Enrollment. However, the rules of the Internal Revenue Service, the Board of Community Health and the Employee Benefit Plan Council do permit you to change coverage or enroll or cancel coverage in certain limited circumstances, if the change corresponds to a qualifying change in status event*.
*Note: Deductions for Health Savings Accounts (HSAs)
fall outside of this requirement. Please contact your payroll department for
details regarding changing your deduction mid-year.
The Employee Benefit Plan Council and the Board of Community Health have the responsibility to interpret these rules and make the final decision as to whether you may enroll or change any coverage outside of the Open Enrollment period. Your request for enrollment or a change outside of the enrollment period will only be considered if you submit the proper documentation within the time frame allotted.
To submit a request for enrollment or changes to coverage under the State Health Benefit Plan, you must submit a completed Membership or Discontinuation Form to your employer's Benefits Coordinator within 31 days of a qualifying event (unless another time period is specified). Your request for enrollment or a change in any other coverage under the Flexible Benefits Program must be submitted on the Change in Status Event Form and given to your employer's Benefits Coordinator within 30 days of a qualifying event (unless another time period is specified). There will be no refund of premiums paid into the Plan, when a timely change is not made.
Submission of a request for enrollment or a change, or the occurrence of a qualifying event, does not guarantee that you will be able to change coverage outside the enrollment period. Please see your Benefits Coordinator if you have questions about when you may enroll or make changes outside the enrollment period. For a list of possible change in status events that might permit you to change one or more coverages under the Flexible Benefits Program, please refer to the Terms and Conditions in the front of this booklet. The changes outlined include dependent eligibility to participate in the Plan. When a dependent or a spouse ceases to be eligible to participate in the Plan, it is the responsibility of the employee to notify the Plan.
Generally, any changes will go into effect the first of the month following the date when the payroll deduction is changed to reflect your new choice. For some benefits, however, when you change coverage based on the acquisition of dependents, the coverage effective date for the new coverage may be retroactive to the date of the acquisition of the dependent in some circumstances, or may be the first of the month following the request to change coverage. Please see your Benefits Coordinator for the rules that apply to any specific coverage program.
If you have questions regarding a change in any of your coverages, first call your employer's Benefits Coordinator. If you need further information about eligibility for health coverage, call the State Health Benefit Plan at 404-656-6322 or 1-800-610-1863. For questions regarding other coverages, call the Flexible Benefits Program at 404-656-2730 or 1-888-968-0490.
What Happens If You Leave State Employment*
If you leave State employment, you can continue some of your Flexible Benefits Program choices. Please refer to the chart.
You may be eligible to continue your medical, dental,
vision coverage and/or Health Care Spending Account (general or limited) for you
and eligible family members after your last day of employment.
A conversion or portability feature may apply to your
employee life, spouse life, and child life insurance, specified illness,
long-term disability and/or AD&D coverage. It is the employee's
responsibility to contact the vendors for the conversion or portability of
coverage.
You can be billed and pay directly for legal service
insurance (Signature LegalCare) coverage for the rest of the plan year.
You can continue long-term care. Unum will bill you
directly.
You can convert your Prepaid Dental option coverage to
an individual policy and be billed directly by CIGNA Dental.
Your Health Savings Account is owned by you, and will
continue to exist even after leaving State employment. You will be contacted by
the HSA custodian after your departure to request information with how you would
like your account to be administered moving forward.
*It is the responsibility of
each employee to contact the vendor directly, within the required timeframe, to
continue coverage (see chart) , unless you are retiring
and wish to continue your dental insurance via your retirement annuity or
continue your vision and/or Health Care Spending Account via COBRA. In these
situations, you should contact the Flexible Benefits Program.
If you leave active State employment and then return during the same plan year, your previous choices will remain in effect unless you report a qualifying change in status event.
When you go on leave without pay, contact your personnel/payroll office, the State Health Benefit Plan, and the Flexible Benefits Program. If you do not continue paying premiums for coverage, your benefits will be cancelled and you may be subject to penalties and wait periods, if allowed to re-enroll. You may be required to wait until the next Open Enrollment period to re-enroll. Be sure to review each Plan Description for each option and see your personnel/payroll office for more information.
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