Fillable Change in Participation Form

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Change in Participation Form

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STATE OF MINNESOTA
Change in Participation Form
MDEA & DCEA
Benet Year: ____________________ State Employee ID Number: ____________________________________
First Name: __________________________ MI: ________ Last Name: _______________________________
Address: _______________________________________________________________________________
City: ___________________________________________ State: __________ Zip: ________________
____
Daytime Phone: ( ________ ) _____________________ E-mail: _____________________________________
CHANGE IN PARTICIPATION or MID-YEAR ENROLLMENT DUE TO A STATUS CHANGE
I hereby revoke any previous authorization for the current year and authorize the State of Minnesota to make the pre-
tax payroll deductions, which I have indicated below. I understand that the deducted amounts will be available for
the reimbursement of my qualifying expenses incurred during the period of the calendar year in which I am an active,
contributing employee under the terms of the formal plan document. I also understand that deductions will be taken in
equal amounts from each of my paychecks, but only if my pay is sucient to cover those amounts.
Note - Changes cannot be made retroactively and the mid-year election change must be consistent with the status change
that aects insurance eligibility for coverage under the plan, e.g. birth of a child – you may increase your MDEA account,
not decrease it. The change must be made within 30 days of the event date.
Change in Marital Status:
o Marriage o Divorce or Annulment o Legal Separation o Death of Spouse
Change in Number of Tax Dependents:
o Birth o Adoption o Death of Dependent
Change in Employment Status That Aects Insurance Eligibility For You, Your Spouse or Dependents:
o Termination of
employment/retirement
o Commencement of
employment
o Change in work
schedule, hours, or shift
o Hourly to salaried or
salaried to hourly
o Commencement of unpaid
leave of absence/
lay o/unpaid FMLA
o Return from unpaid
leave of absence/lay o/
unpaid FMLA/PPL
Change in Spouse or Dependent’s Insurance Eligibility Under an Employer’s Plan:
o Loses eligibility (age, student status, marital status) o Gains eligibility (student status, marital status)
Change Due to:
o Judgments, Decrees or Order
o Enrollment or dis-enrollment in Medicare, Medicaid, or
Medical Assistance
Changes Specic to Dependent Care Expense Account (DCEA) Only:
o Signicant increase or decrease in cost (no change can be made when provider is a relative)
o Addition, elimination, or reduction of your spouse or dependent’s dependent care expense plan
o Change in coverage or open enrollment of spouse or dependent under their employer’s dependent care expense plan
NOTE - if your employment terminates and you are rehired within 30 days, your prior election amounts are reinstated
unless another event has occurred that allows a change. If your employment terminates and you are rehired after 30
days, you may make new elections. Please see the Plan Summary for more information.
Event date: ____________________
NOTE - The eective date of the change is the later of the event date or the rst day of the pay period in which SEGIP
receives your completed and signed Change in Participation form. Changes cannot be made retroactively.
Please explain the event(s) marked above on which you are basing your request for a mid-year coverage change and
describe how the requested change is consistent with the event:
______________________________________________________________________________________
Enter your new annual election amount: MDEA: $ ____________________ DCEA: $ _____________________
The minimum election for the MDEA is $100 and the maximum is $2,750. The minimum election for the DCEA is $100 and the
maximum is $5,000 per year per family.
Employee Signature: _________________________________________ Date: _________________________
SUBMIT THIS FORM TO:
MINNESOTA MANAGEMENT AND BUDGET | STATE EMPLOYEE GROUP INSURANCE PROGRAM
658 Cedar Street | St. Paul, MN 55155 | Fax: (651) 797 - 1313 | Email: segip.mmb@state.mn.us
121 BENEFITS | 730 2ND AVENUE SOUTH SUITE 400 | 730 BUILDING | MINNEAPOLIS MN 55402
WWW.121BENEFITS.COM | (612) 877 - 4321 | (800) 300 - 1672 | REV 5/2020
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MINNESOTA MANAGEMENT AND BUDGET
Notice of Collection of Private Data
Minnesota Management and Budget administers the State Employee Group Insurance Program (SEGIP). This notice ex-
plains why we may request information (data) about you, your dependents and beneciaries, how we will use it, who will
see it, and your obligation to provide that information.
What information will we use?
We will use the information you provide us at this time, as well as information you have previously provided us about
yourself, your dependent(s), and/or your beneciary. If you provide any information about yourself or your dependent
or beneciary that is not necessary, we will not use it for any purpose.
SEMA4, the information system used to administer employee benets, contains required information elds that may
not be necessary for us to process your request. We do not need the gender or marital status for your beneciary
designation, so you may enter “unknown” in these elds. We only need your dependent’s date of death to process a
death benet claim or to discontinue the dependent’s coverage due to his or her death. Student status and disability
status are needed only to determine eligibility for insurance continuation for your dependent. We only need your
dependent’s social security number to oer insurance continuation or process a death benet.
Why we ask you for this information?
We ask for this information to process your request to add or change coverage for yourself, your dependent or a ben-
eciary. The requested information helps us to determine eligibility, to identify you and your dependents and bene-
ciaries, and to contact you or your dependents and beneciaries. We use the information so that we can successfully
administer SEGIP, including analyzing unidentiable aggregate data to develop new programs and ensure current
programs are eectively and eciently meeting member needs. We may ask for information about you that we have
already collected, including all or part of your social security number, in order to ensure we are matching you to the
correct change request or other insurance benet transaction.
Do you have to answer the questions we ask?
You are not legally required to provide any of the information requested.
What will happen if you do not answer the questions we ask?
If you do not answer these questions, the insurance benet transaction you requested for you or your dependent or oth-
er insurance benet transaction may be delayed or denied.
Who else may see this information about you and your dependents and beneciaries?
We may give information about you and your dependents and beneciaries to the insurance carrier you have chosen,
SEGIP’s representatives, vendors, The State of Minnesota’s actuary, the Legislative Auditor, the Department of Health,
any law enforcement agency or other agency with the legal authority to the information, and anyone authorized by a
court order. In addition, the parents of a minor may see information on the minor unless there is a law, court order, or
other legally binding instrument that blocks the parent from that information. We can use or relates this information
only as stated in this notice unless you give your written consent to authorize release of the information to another per-
son/entity, or if Congress or the Minnesota Legislature passes a law allowing or requiring us to release the information
or to use it for another purpose.
We ask for this information to process your request to add or change coverage for yourself, your dependent or bene-
ciary. The requested information helps us to determine eligibility, identify you and your dependents and beneciaries,
and contact you or your dependents and beneciaries. We use the information so that we can successfully administer
SEGIP, including using unidentiable, aggregate data to develop new programs and ensure current programs eectively
and eciently meet member needs. We can use or release this information only as stated in this notice unless you give
us your written permission to release the information or to use it for another purpose.
You are not legally required to provide us any of this information and you may refuse to provide the information.
However, if you do not provide us the requested information, the insurance transaction you requested for you or your
dependent or other insurance benet transaction may be delayed or denied.
We may give information about you and your dependents and beneciaries to the insurance carrier you have chosen,
SEGIP’s representatives, vendors, and actuary, the Legislative Auditor, the Department of Health, any law enforcement
agency or other agency with the legal authority to the information, and anyone authorized by a court order. In addition,
the parents of a minor may see information on the minor unless there is a law, court order, or other legally binding
instrument that blocks the parent from that information. This information may also be used or released if Congress
or the Minnesota Legislature passes a law allowing or requiring us to release the information or to use it for another
purpose.
121 BENEFITS | 730 2ND AVENUE SOUTH SUITE 400 | 730 BUILDING | MINNEAPOLIS MN 55402
WWW.121BENEFITS.COM | (612) 877 - 4321 | (800) 300 - 1672 | REV 5/2020
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Change in Participation Form

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Completed 31 July 2020

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