Fillable EMPLOYEE CHANGE CARD New Mexico Public Schools Insurance (New Mexico Public School Insurance Authority)

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EMPLOYEE CHANGE CARD New Mexico Public Schools Insurance (New Mexico Public School Insurance Authority)

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Revised September 2020
For Employer Use:
PAYROLL
DEDUCTIONS
MEDICAL DENTAL VISION DISABILITY
ADDITIONAL LIFE
$ $ $ $ $
Former Employer
(if covered under NMPSIA)
Basic Life Eff. Date
(mm/dd/yyyy)
Other Cvg Eff. Date
(mm/dd/yyyy)
New Mexico Public Schools Insurance Authority
District/Entity Name
District/Entity #
EMPLOYEE CHANGE CARD
1
Name (Last, First, Middle)
Date of Birth
Mailing Address
City
State
Zip Code
Home Phone Number
Marital Status
S M
Gender
F M
Preferred E-Mail Address
By furnishing my e-mail address on this form, I am consenting to
receive communications related to my participation in NMPSIA’s benefit program by e-mail.
Check this box only if you do NOT wish to receive plan communications by e-mail.
Work Phone Number
Cell Phone Number
REASON FOR CHANGE: Answer questions below
New address and/or phone number What event took place?
Late Enrollment
Open/Switch Enrollment
Qualifying Event What date did event take place?
2
ENROLLMENT
What is your current enrollment status? Employee Only 2-Party (Employee + Spouse or Child) Family (Employee + 2 or more)
What enrollment status are you requesting? Employee Only 2-Party (Employee + Spouse or Child) Family (Employee + 2 or more)
Check One: ADD COVERAGE CANCEL COVERAGE SWITCH ENROLLMENT
BASIC LIFE: The Standard
MEDICAL:
Blue Cross Blue Shield of NM
High Option (Default)
Low Option
EPO Option
Presbyterian
High Option (Default)
Low Option
Decline Medical
Reason:
Eligible for Medicaid? Yes No
DENTAL:
High Option (Default)
Low Option
Decline Dental
VISION: Davis Vision (2 year enrollment required)
Decline Vision
LONG TERM DISABILITY: The Standard (Qualifying Event or Evidence of Insurability)
Decline Long Term Disability
ADDITIONAL LIFE: The Standard
(Qualifying Event or Evidence of Insurability)
Select:
1X 2X 3X Base Annual Salary Decline Employee Additional Life
Spouse Life Child Life Decline Dependent Life
3
DEPENDENT INFORMATION List all dependents you wish to enroll. Provide requested information for additional dependents on separate sheet if necessary.
Indicate an A (add), D (drop), C (continue coverage), or N/A (not applicable) for all names listed below.
Med Dntl Visn
Add’l
Life
Dependent’s Name (Last, First, Middle)
Social Security
Number
(REQUIRED)
Date of Birth
(mm/dd/yyyy)
Gender
Dependent’s
Relationship to
You
Proof of Marriage, Birth,
Loss of Coverage, or
Court Order Attached
F M
Yes No
F M
Yes No
F M
Yes No
F M
Yes No
4
EMPLOYEE AUTHORIZATION STATEMENT
I hereby authorize my school district/employer to deduct from my earnings until further written notice, amounts equal to
the contribution required of me toward the plan(s) herein enrolled. I hereby apply to the Authority
for the coverage offered to myself and dependents shown above. I understand that services will be available subject to the exclusions, limitations and the conditions described in the Master Group Insurance Policies.
I authorize any hospital, physician, or other health care provider to furnish (when applicable) to the Insurance Carrier such medical information as it may require for myself and my dependents. I authorize the
Insurance Carrier to coordinate benefits and/or reimbursements with other health plans or insurance companies. Under penalties of perjury and insurance fraud, I declare that I have examined this application and
supporting documentation, and to the best of my knowledge and belief, they are true, correct, and complete. Read reverse side before signing.
EMPLOYEE SIGNATURE DATE
RETURN THIS FORM TO YOUR EMPLOYEE BENEFITS OFFICE NO LATER THAN 31 DAYS FROM YOUR QUALIFYING EVENT
5
EMPLOYER CERTIFICATION
ONLY complete this section for QUALIFYING EVENTS: Part-time to Full-time with a salary increase; Promotion into a new
job class with a salary increase; Decrease in salary and hours worked per week. FORM MUST BE SIGNED BY EMPLOYER.
I attest that to the best of my knowledge that this applicant is an employee of my district/entity (or meets the one-bus owner definition) and works the minimum number of hours per week
required for NMPSIA benefits.
Date of Hire
Base Annual
Salary
# of hours
worked weekly
Job Title
Check only if
Variable Hour
Employee
List date Variable Hour
Employee became eligible
for medical only coverage
Date Received in
Your Office
$
BENEFITS SPECIALIST SIGNATURE:
DATE
:
Cigna
High Option Plan (Default)
Low Option Plan
Delta Dental:
United Concordia:
High Option (Default)
Low Option
Eligibility Administrative Office (505) 988-4974 (800) 233-3164 FAX (505) 988-8943
RESET FORM
Revised September 2020
Please read the NMPSIA Program Guide (provided to you by your
employee benefits office) as you complete this change card.
NMPSIA’s Program Guide outlines the NMPSIA Eligibility Rules and
administrative guidelines for enrollment. If you do not have this Guide,
you can obtain a copy from your school district/entity benefits office or
at https://nmpsia.com
.
ELIGIBILITY
If you are reporting a change in status, you must turn in this form within 31
days from your qualifying event.
Contractors are not eligible to participate in NMPSIA coverage,
except for one-bus owners. Fleet bus owners and their employees are
not eligible to participate in NMPSIA coverage.
To be eligible for NMPSIA Group Coverage, you must work the minimum
number of hours per week established by your employer. In most cases,
employees are eligible for basic life insurance coverage when they work a
minimum of 15 hours per week. In most cases employees are eligible for
all other lines of coverage when they work a minimum of 20 hours per
week. Variable hour employees should confirm eligibility for benefits with
their Employee Benefits Office.
Basic life insurance coverage is effective the first day of the month
following your date of hire -- first day actively at work on contract. If you
meet this requirement, your employer will enroll you in basic life even if
you decline (or are not eligible to participate) in any other line of NMPSIA
coverage. Subject to the actively at work provision, the effective date for
all your other lines of coverage is determined by your employer. This
effective date can never be any sooner than your basic life effective date
and can never be made retroactive (prior to the date you officially apply).
SALARY INFORMATION
NMPSIA uses your base annual salary to determine your additional life
(ADL) coverage and long term disability (LTD) coverage. For ADL and
LTD insurance purposes, your employer will not prorate your salary if you
begin after the school year AND your employer will not include salary
increments for other duties, such as coaching, department head,
yearbook, etc.
ENROLLMENT
You may only apply for the lines of NMPSIA coverage offered by your
employer.
Please keep the following in mind:
● If you decline medical coverage within 31 days of becoming eligible,
you may apply to enroll in NMPSIA medical coverage within 31 days
from a qualifying event or special enrollment event, or enroll during
open enrollment for medical coverage in the fall with an effective date
of January 1st.
● You may enroll as employee only for any line of NMPSIA coverage.
● If you enroll in vision coverage, you and each of your enrolled
dependents must meet the 24-month enrollment requirement before
you can cancel this coverage.
● If you enroll for ADL coverage, you may apply for coverage up to 1x,
2x, or 3x your base annual salary. You may also apply for life
coverage for your spouse at the rate of 1x your salary or 50% of your
additional life coverage, whichever is less. You may also insure your
dependent children for $5,000 of life coverage.
● If you decline ADL or LTD coverage, you may apply through the
evidence of insurability process. The carrier will make a determination
on this application.
● If you decline dental and/or vision coverage, you may not enroll late to
either of these plans unless you apply within 31 days from involuntarily
losing other dental and/or vision coverage, or enroll during the open
enrollment for dental/vision in the fall with an effective date of January
1st.
Indicate the status (employee only, two-party, or family) for each line of
coverage. If you enroll one eligible dependent, you must enroll all eligible
dependents, unless one or more dependents have other coverage. When
enrolling dependents, you may exclude a dependent from a particular line
of NMPSIA coverage only if you provide evidence that the dependent you
are excluding has that particular line of coverage elsewhere. In this case,
evidence of the other coverage is required (i.e., letter of insurance
verification, insurance ID card with dependent’s name listed, etc.). If you
are excluding a dependent and do not provide this evidence, the
dependents you are enrolling will suffer a delay in coverage until such
evidence is provided. There is a 61-day deadline from your effective date
of coverage to provide such evidence.
If both you and your spouse work for the same employer or for another
NMPSIA affiliated employer, you and your spouse cannot double insure
each other and your dependents under the NMPSIA Group Plan for any
line of NMPSIA coverage. (i.e., You work for Las Cruces Public Schools
and carry family medical, dental, vision, additional life insurance coverage
for yourself, your spouse, and your children. Your spouse who is
employed with Deming Public Schools cannot apply for family coverage to
insure him, you and your children for these lines of NMPSIA coverage
since you already carry this NMPSIA coverage at Las Cruces Public
Schools. You and your spouse may decide it is best to carry the
additional life independent from each other, and then the children can be
insured either under your plan or your spouse’s plan.)
To enroll your spouse and/or your married or unmarried children (who are
up to 26 years old) for any line of NMPSIA coverage offered by your
employer, you will be required to present your employee benefits office
with copies of the supportive documentation to prove eligibility for your
dependents.
To enroll your spouse, present your official state publicly filed marriage
certificate (from the County Clerk’s Office). You may provide a chapel
marriage certificate, but NMPSIA reserves the right to request the official
state copy at any time. If you divorce, you must report this within 31 days
and cancel coverage for your ex-spouse effective the last day of the
month the divorce is final. You will be required to provide copies of
certain pages of your final divorce decree. Covering an ex-spouse is
considered misrepresentation.
To enroll your married or unmarried children (who are up to 26 years old)
for any line of NMPSIA coverage offered by your employer, present their
official state publicly filed birth certificates (from the Bureau of Vital
Statistics). You may provide hospital birth certificates, but NMPSIA
reserves the right to request the official state copy at any time.
Coverage for your dependents will begin on your effective date of
coverage when you provide your employee benefits office with the
appropriate supportive documentation at the time of application or prior to
your coverage going into effect. You have 61 days from your effective
date of coverage or 61 days from your qualifying event to provide the
appropriate supportive documentation for your dependents, but their
effective date of coverage will be on the first day of the month following
the date your employee benefits office receives this documentation.
Coverage for your dependents will not be made retroactive. If you do not
provide this information within 61 days, you may apply to cover your
dependents during the established open enrollment period in the fall for
coverage that will become effective on January 1.
Medical and Prescription Drug Coverage – If you enroll in the medical
plan, you are automatically enrolled in the Prescription Drug Program.
You will receive a separate ID card from the NMPSIA Prescription Drug
Manager to purchase your prescription drugs.
BENEFICIARY INFORMATION
Complete a Schedule A form to make your selection(s) for your
beneficiary for basic life and/or additional life coverage. You may change
your beneficiary designation at any time. If you do not designate a
beneficiary for your life insurance, the life insurance carrier will apply its
established processes to determine the individual(s) entitled to your life
benefit.
CONFIRMATION OF ENROLLMENT
Once your enrollment has been processed, the NMPSIA Eligibility Administrative
Office will email you or mail you a Confirmation of Enrollment Notice to your home
(and to your employer). Please review this confirmation notice carefully and report
any discrepancies to your Employee Benefits Office or to the NMPSIA Eligibility
Administrative Office at 1 (800) 233-3164.
If you do not provide your employer with all of the appropriate documentation
necessary to finalize your enrollment request, you will be contacted for the
appropriate documentation. Please be sure to adhere to all deadlines associated
with this request.
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EMPLOYEE CHANGE CARD New Mexico Public Schools Insurance (New Mexico Public School Insurance Authority)

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Completed 7 January 2021

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