Fillable Form 9888943: ew Mexic chools In urance A (New Mexico Institute of Mining & Technology)

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Form 9888943: ew Mexic chools In urance A (New Mexico Institute of Mining & Technology)

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Revised September 2020
Please read the NMPSIA Program Guide (provided to you by your benefits office)
as you complete this form.
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 benefits office or at https://nmpsia.com.
ELIGIBILITY
The effective date for all your other lines of coverage is determined NM Tech. This
effective date can never be made retroactive (prior to the date you officially apply).
ENROLLMENT
You may only apply for the lines of NMPSIA coverage offered by NM Tech.
Please keep the following in mind:
● You may enroll as single only for any line of NMPSIA coverage.
Indicate the status (retiree only, two-party, or family) for each line of coverage.
If both you and your spouse have coverage with NM Tech or under 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.
Coverage for your dependents will begin on your effective date of coverage.
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.
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 NM
Tech). 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 NM Tech 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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Form 9888943: ew Mexic chools In urance A (New Mexico Institute of Mining & Technology)

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Completed 1 February 2021

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