Fillable Group Insurance Commision Health Insurance Buy-Out Election Form FY20

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Group Insurance Commision Health Insurance Buy-Out Election Form FY20

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The Group Insurance Commision Health Insurance Buy-Out Election Form FY20 form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Page 1 of 2 Rev. 2-26-19
COMMONWEALTH OF MASSACHUSETTS
GROUP INSURANCE COMMISSION
Health Insurance Buy-Out Election Form
YOU MUST READ PAGE TWO BEFORE COMPLETING FORM – PRINT CLEARLY
Social Security Number
Insured Name (First) (MI) (Last)
Street Address
City State Zip Code
1. I hereby elect a monetary allowance in lieu of a Group Insurance Commission sponsored group health
insurance plan. I understand that the allowance will be paid monthly, beginning in February, in twelve equal
payments. I understand that taxes will be withheld from these payments. I understand that I must maintain
basic life insurance and be a state employee or retiree to receive these payments; municipal enrollees are
not eligible. I was covered by a Group Insurance Commission health insurance plan on July 1, 2019, and I
will continue that GIC health coverage through December 31, 2019.
Type of coverage you’re canceling December 31, 2019: Individual Family
GIC health plan in which you are enrolled:
2. I will have non-GIC employer-sponsored health insurance coverage as of January 1, 2020, with:
____
_____________ and the subscriber is _________________ _________________. This covera
ge
Name of Employer Name of Subscriber Relationship to GIC Insured
meets minimum essential coverage under the Affordable Care Act.
3. I understand that I may cancel this election only:
• during the GIC spring annual enrollment period
;
• af
ter involuntary loss of my other coverage through no fault of my own;
• if the other health insurance is revoked; or
• if there is a qualifying status change such as marriage, divorce, birth of a child, or end of
spouse’s employment.
4. I understand that forms received at the GIC after November 1, 2019, will not be accepted.
Signature of Insured Date
RETURN COMPLETED FORMS TO: GIC, P.O. BOX 8747, BOSTON, MA 02114
FOR GIC USE ONLY
1. Agency/Division #
2. Current Health Plan
3. Effective Date
4. Coverage changed to Effective
5. Buy-out period From To
6. Processed by By
Page 2 of 2 Rev. 2-26-19
COMMONWEALTH OF MASSACHUSETTS
GROUP INSURANCE COMMISSION
Health Insurance Buy-Out
Under the terms of the Buy-Out program, eligible state employees and retirees who are enrolling as of
January 1, 2020, in another employer-sponsored plan that meets minimum essential coverage under
the Affordable Care Act (ACA) may cancel their Group Insurance Commission (GIC) health coverage
and receive 12 taxable monthly payments equal to 25% of the full-cost premium based upon:
• your current health plan; and
• type of coverage (individual or family) as of December 31, 2019
Municipal members are not eligible for buy-out. To qualify for this plan, you must meet ALL of the
following requirements:
• you were covered by a Group Insurance Commission Health Plan on July 1, 2019, and you will
continue that GIC health plan coverage through December 31, 2019; you are enrolling in
another employer-sponsored plan as of January 1, 2020, that meets minimum essential
coverage under the ACA.
• you are a state employee or retiree; and
• you must continue to maintain basic life insurance.
You may not cancel your election to participate in this plan until an annual enrollment period, or
unless one of the following occurs:
• the involuntary loss of your other health insurance coverage through no fault of your own; or
• there is a qualifying status change such as marriage, divorce, birth or adoption of a child, or
end of spouse’s employment.
If you elect to participate in the buy-out and one of the above events occurs you will be able to re-
enroll and resume your health insurance through the Group Insurance Commission as long as you
provide documentation within 60 days of the qualifying event.
To participate in this plan you must complete the form on the other side of this page and return it to
the Group Insurance Commission. Employees in HR/CMS and UMass Agencies will receive their
remittance on a monthly basis in their paycheck with “Reimburse” listed on the pay advice. Retirees
and employees of Housing and Redevelopment Authorities will receive a check monthly. If your
application is approved, you will receive your first payment in February.
The effective date of this buyout is January 1, 2020. Do not give this form to your GIC
Coordinator. It is your responsibility to be sure the completed form is received by the Group
Insurance Commission NO LATER THAN November 1, 2019.
Group Insurance Commission, P.O. Box 8747, Boston, MA 02114
*If you are enrolled in the UniCare State Indemnity Plan/Basic with CIC benefits, the payment will not include the
cost of CIC, as CIC is a member-pay-all benefit.
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Group Insurance Commision Health Insurance Buy-Out Election Form FY20

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Completed 12 May 2020

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