Fillable 2020 Retiree Annual Enrollment Form (Fulton County Government)

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2020 Retiree Annual Enrollment Form (Fulton County Government)

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2020 Retiree Annual Enrollment Form
INFORMATION ABOUT YOU
Retiree Name (First Name, Last Name):
Social Security #:
Are you age 65 or older / Medicare Eligible: ☐ Yes ☐ No
Retiree Home Address:
Street:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Marital Status: ☐
Married
☐
Single
☐
Widowed
☐
Divorced
Date of Hire: / /
Date Retired: / /
☐
Part A / Effective date: / /
☐
Part B / Effective date: / /
☐
Part A / Effective date: / /
☐
Part B / Effective date: / /
Is your or your spouse’s Medicare coverage related to end-stage renal disease? ☐ Yes ☐ No
YOUR HEALTH PLAN OPTIONS
Medical Plan Coverage Tier (Select One):
☐ Retiree + Spouse
☐ Retiree + Child(ren)
☐ Waive Coverage
Medical Plan Options—Retirees Under Age 65:
( Non-Medicare )SELECT ONE MEDICAL PLAN
Medical Plan Options—Retirees Age 65 or Older:
(Medicare) SELECT ONE MEDICAL PLAN
☐
HSA Plan (Anthem BlueCross BlueShield)
☐ HMO Plan ((Anthem BlueCross BlueShield) - NEW
☐ POS Plan (BlueCross BlueShield of Georgia)
☐ HMO Plan (Kaiser Permanente)
☐
Basic Medicare Advantage Plan (Aetna) *
☐ Enhanced Aetna Medicare Advantage Plan (Aetna)*
☐ Medicare Indemnity Plan (Anthem BlueCross BlueShield)
☐ Medicare HMO Plan (Anthem BlueCross BlueShield)
☐ PPO Plus Plan (Anthem BCBS —current participants only) Closed
* To enroll in the Basic Aetna Medicare Advantage Plan or the
Enhanced Aetna Medicare Advantage Plan for the first time,
please contact Aetna directly: (800) 307-4830.
Dental Plan (SELECT ONE DENTAL PLAN)
☐ Comprehensive Dental PPO Plan ☐ Dental HMO Plan - Primary Dentist Office ID (Required)
Dental Plan Coverage Tier (Select One):
☐ Retiree + Spouse
☐ Retiree + Child(ren)
☐ Waive Coverage
Vision Plan Coverage Tier (Select One):
☐ Retiree + Spouse
☐ Retiree + Child(ren)
☐ Waive Coverage
INDIVIDUALS TO BE COVERED*
Name (Last, First, M.I.) Social Security #
Sex
(M or F)
Birthdate
(mm/dd/yyyy)
Disabled,
before
age 19?
Currently
covered by
Medicare?
Dependent Coverage Option
(If Retiree is enrolled in Aetna
Medicare Advantage Plan)
Self
☐ Yes
☐ Yes
Spouse
☐ Yes
☐ Yes
Anthem
☐ Medicare Indemnity Plan
☐ Medicare HMO Plan
Child
☐ Yes
☐ Yes
Child
☐ Yes
☐ Yes
Child
☐
Yes
☐
Yes
If any of your dependents listed above live at an address that is different than yours, please complete the following:
Name(s)
Address(es)
When enrolling dependents for the first time, you must submit with this enrollment form supporting documentation appropriate for the relationship of the
dependent to you (e.g., marriage certificate, birth certificate, adoption placement papers, court-ordered child health coverage support affidavit, physician
verification of permanent disability).
IF YOU ARE DECLINING COVERAGE
By completing this section, I acknowledge that I was given the opportunity to enroll for 2020 Fulton County health care coverage and am choosing not to enroll in
one or more of the above benefit plans. I understand that if my dependents or I wish to enroll at a later date for any of the coverage(s) I have declined,
I / they will be required to submit a new Enrollment Form and coverage may be subject to late enrollee provisions, as allowed by law and as directed by my
employer.
Reason for refusal: (Please check all that apply)
☐ Other group coverage sponsored by my employer
☐ Other group coverage sponsored by my spouse’s employer
☐ Other group coverage sponsored by another organization
☐
Other reasons (Please explain below)
FOR OTHER COVERAGE
Carrier:
Plan Number:
Telephone Number:
Retiree Signature
Date
I hereby authorize a deduction to be made from my pay or drafted from my bank account on file (if applicable) as my share of the premium cost, as authorized by the Fulton County Board
of Commissions. I certify the above information is true and correct and I am entitled to the coverage requested. I declare that all statements and information made hereon are complete
and true to the best of my knowledge, I understand that any misstatements or omissions may void all coverage applied for any member on this application on a retroactive basis for up to
two (2) years from the contract effective date.
(DB) Defined Benefit (Old Plan) 401A (New Plan)
CHECK YOUR RETIREMENT PLAN
Return completed form with any required supporting documentation to the
Fulton County Pension Office via:
fax: (404) 612-1312
email: pensionunit@fultoncountyga.gov
RIGHTS AND OBLIGATIONS
2020 Retiree Annual Enrollment Form
I hereby apply for myself and my eligible family members for the coverage specified in the Contract between my
Group/Employer and BlueCross and BlueShield of Georgia, Aetna Medicare Advantage PPO, Kaiser Foundation Health
Plan of Georgia HMO, Aetna Health Dental PPO or HMO, or EyeMed Vision (hereinafter referred to as the Plans).
I understand and agree that the effective date of coverage will be governed by the stipulations of the Group Application
and the Master Group Contract under which this application is made. I understand that membership will continue
according to the terms of the contract between the employer and the Plans. I hereby authorize the employer to
periodically deduct any charge due from me hereunder and to remit same to the Plans along with any contribution due
from the employer.
I hereby authorize any hospital, physician, psychiatrist, psychologist, counselor, psychiatric hospital or other provider,
dispenser of prescription drugs, appliances, ambulance service or any person or any institution rendering services to me
or members of my family, if covered hereunder, to furnish the Plans all requested information concerning treatment,
advice, psychiatric care or medical care for previous or future conditions, illnesses or disabilities.
I declare that all statements made hereon including the information provided on the front of this application are complete
and true to the best of my knowledge and belief, and agree that the Plans may cancel this coverage within two (2) years
from the effective date, for any ineligible family member or one on whom erroneous or false information has been
submitted, personally assuming liability for reimbursement to the Plans for any benefit payment made on behalf of such
family member. After this contract has been in force for a period of two (2) years during the lifetime of the insured, it shall
become incontestable as to the statements in the applications. I understand that I am responsible for giving notice to my
Group/Employer of any changes in my status and that of my family members that affect coverage.
ABBREVIATED NOTICE OF INSURANCE INFORMATION PRACTICES
PRIVACY ACT. Georgia state law establishes standards for the collection, use and disclosure of information gathered in
connection with insurance transactions. The application attached to this notice contains specific personal questions about
you and your dependents. Your answers are required to determine if you qualify for coverage. Plans are required to
advise you that personal information may be collected from persons other than you or other individuals proposed for
coverage. An investigative consumer report may be made to help obtain additional medical data from physicians or
hospitals.
ALL DATA IS CONFIDENTIAL. Plans are required by law to keep such data confidential. It will be seen only by their
employees and authorized agents. This data may in certain circumstances be disclosed without your authorization. Plans
may furnish such data to authorized federal or state agencies, consumer investigative service bureaus or others if part of
standard business practice or required by law.
ACCESS TO YOUR DATA. You have the right to see or obtain a photocopy of your personal information. You also have
the right to send a written request if you want any of your personal information to be amended, corrected or deleted. If you
wish to have a more detailed explanation of information practices, please contact the applicable carrier:
•
Anthem BlueCross and BlueShield of Georgia, Customer Service Department, Post Office Box 7368, Columbus,
Georgia 31908–7368
•
Aetna, Inc., RT-52, 151 Farmington Avenue, Hartford, Connecticut 06156
•
Kaiser Foundation Health Plan of Georgia, Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305
•
EyeMed Vision Care, 4000 Luxottica Place, Mason, OH 45040.
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2020 Retiree Annual Enrollment Form (Fulton County Government)

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Completed 17 July 2020

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