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Midyear Change Form Office use only Approved dat (Oregon)

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Page 1 of 8
MSC 6011 (07/2019)
Midyear Change Form
Office use only
Approved by:
Approved dat
e:
Effective date:
Use this form to update your benefits within 31 days of experiencing a Qualified Status Change (QSC) event.
These plan elections or changes will go into effect the first of the month after the event date unless you are requesting coverage
that requires carrier approval. Carrier approval coverage will go into effect the first of the month following carrier approval.
You may only make enrollment changes which are consistent with your QSC event. Some events may not allow the change you
are requesting. Review the QSC Matrix for more information: http://www.oregon.gov/oha/OEBB/Pages/QSC-Matrix.aspx
Employee information
Last name First name Middle
Employee ID, E number or Social Security number Gender
M
F
Other
Date of birth (mm/dd/yyyy)
Home phone number Work phone number Cell phone number
May OEBB send text messages to this number? Standard text message and data rates apply.
Yes
No
Address
Check if new address Apartment or space#
City
State ZIP County
Personal email Work email
Medicare eligible?
Yes
No
Are you serving or did you ever serve in the military?
Yes
No
If “Yes,” do you authorize OEBB to send your name and address to the Oregon Department of
Veterans’ Affairs (ODVA) for the purpose of receiving benefit information?
Yes
No
Race (Select at least one):
Tobacco usage
(Responses in this section are required)
Em
ployee
In the last 1
2 months
(Select
o
ne)
:
I have used tobacco products
I have not used tobacco products
I have never used tobacco products
Spouse/Domestic partner
In the last 12 months (Select one):
I do not currently have a spouse/domestic partner
My spouse/domestic partner has used tobacco products
My spouse/domestic partner has not used tobacco products
My spouse/domestic partner has never used tobacco products
Ethnicity (Select one):
Asian
White
Black/African American
Other
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Refused
Unknown
Hispanic
Non-Hispanic/Non-Latino
Refused
Unknown
Page 2 of 8
MSC 6011 (07/2019)
Qualifying status change event
Event date:
A. Change in employment affecting plan availability or gain/loss of other coverage by
Employee
Spouse/domestic partner
B. Gain spouse/domestic partner through
Marriage
Domestic partner meets eligibility
C. Loss of spouse/domestic partner by
Divorce/Annulment
Termination of Domestic Partnership
Death
D. Gain dependent through
Marriage/domestic partnership
Birth/adoption/legal custody
Court order
Meeting eligibility
E. Loss of dependent by
Divorce/Annulment
Termination of Domestic Partnership
Death
F. Other events
Moving out of current plan’s service area
Other
Dependent information
You must report to your employer’s benefits administrator within 31 days after a person enrolled as your spouse/domestic partner
or dependent child becomes ineligible for benefits. If you do not report this change on time, OEBB may consider that an intentional
misrepresentation of a material fact, for which OEBB may terminate the family members’ coverage effective the first of the month
after eligibility was lost.
If listing a Domestic Partner as a dependent, indicate the type of Domestic Partnership*:
By OEBB Affidavit of Domestic Partnership**
By Registered Certificate (copy not required)
* Domestic partner eligibility rules may vary by employer — verify with your benefits administrator before enrolling.
**Affidavit Information: If you are adding a domestic partner by OEBB Affidavit, you must submit the affidavit to your employer
within five business days of this enrollment or the individual’s coverage will not be effective. OEBB’s Affidavit of Domestic
Partnership can be found online at: http://www.oregon.gov/oha/OEBB/pages/Forms.aspx
Dependent A
Enroll
Change
Remove
Medical
Vision
Dental
Relationship to employee
Spouse
Domestic partner
Child
Gender
M
F
Other
Date of birth (mm/dd/yyyy) Social Security, HICN, or Tax ID number: Medicare eligible?
Y
N
Last name First name Middle
Address (if different from employee address)
City
State ZIP
Race (Select at least one. If selecting more than one, circle one as primary):
Ethnicity (Select one):
Asian
Black/African American
White
Other
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Refused
Unknown
Hispanic Non-Hispanic/Non-Latino Refused
Unknown
Page 3 of 8
MSC 6011 (07/2019)
Dependent B
Enroll
Change
Remove
Medical
Vision
Dental
Relationship to employee
Spouse
Domestic partner
Child
Gender
M
F
Other
Date of birth (mm/dd/yyyy) Social Security, HICN, or Tax ID number: Medicare eligible?
Y
N
Last name First name Middle
Address (if different from employee address)
City
State ZIP
Race (Select at least one. If selecting more than one, circle one as primary):
Dependent C
Enroll
Change
Remove
Medical
Vision
Dental
Relationship to employee Spouse
Domestic
partner
Child
Gender
M
F
Other
Date of birth (mm/dd/yyyy) Social Security, HICN, or Tax ID number:
Medicare eligible?
Y
N
Last name First name Middle
Address (if different from employee address)
City
State ZIP
Race (Select at least one. If selecting more than one, circle one as primary):
E
t
h
nicity (Select one):
Ethnicity (Select one):
c
Asian
c
White
c
Black/African American
c
Other
c
American Indian/Alaska Native
c
Native Hawaiian/Other Pacific Islander
c
Refused
c
Unknown
c
Asian
c
White
c
Black/African American
c
Other
c
American Indian/Alaska Native
c
Native Hawaiian/Other Pacific Islander
c
Refused
c
Unknown
c
Asian
c
Black/African American
c
White
c
Other
c
American Indian/Alaska Native
c
Native Hawaiian/Other Pacific Islander
c
Asian
c
Black/African American
c
White
c
Other
c
American Indian/Alaska Native
c
Native Hawaiian/Other Pacific Islander
Double coverage surcharge info
c
Yes
c
No
Are any of your covered family members offered medical insurance as an employee through
OEBB or PEBB?
Are they enrolled in the OEBB or PEBB medical insurance offered? (if both answers are yes a $5/
mo surcharge will be applied)
c
Yes
c
No
Hispanic
Non-Hispanic/Non-Latino
Refused
Unknown
Hispanic
Non-Hispanic/Non-Latino
Refused
Unknown
Page 4 of 8
MSC 6011 (07/2019)
Healthcare plan selections
Medical
Medical plan selection:
Write in plan selection
If enroll
ed in a Moda medical plan, each covered individual must choose a PCP 360 with Moda for that individual to receive the
enhanced “coordinated” benefit if using a provider in the Connexus network. If an individual has not chosen a PCP 360 with
Moda, they will receive the “non-coordinated” benefit if using a provider in the Connexus network. Any services by a provider
outside the Connexus network will be paid at the “out-of-network” level regardless of whether or not the individual has chosen a
PCP 360 with Moda. A list of PCP 360 providers can be found at:
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
If you are choosing to not enroll in an OEBB medical plan, select one of the following options:
OPT-OUT
Select this option if you and all your eligible dependents have other employer-sponsored group coverage and
you will receive a financial incentive from your employer to not enroll in OEBB medical coverage.
By selecting this option, I confirm all eligible dependents have other group coverage.
You and your eligible dependents MUST have other employer-sponsored group medical coverage to opt-out. Participation or
enrollment in the Individual Marketplace Coverage, Oregon Health Plan, Medicaid, Veterans’ Administration Benefit Programs,
or Student Health Insurance does NOT qualify for OEBB opt-out. You must provide proof of other group coverage to your
employer within five business days or your opt-out will not be effective:
Carrier Policy number Group number
Primary policy holder Employer Effective date (mm/dd/yyyy)
Waive
Select this option if you will not receive a financial incentive from your employer regardless of whether or
not you have other medical coverage.
Note: Many employers do not offer a financial incentive, in those cases you should select “Waive.”
Vision
Vision plan selection:
Write in plan selection. (Must be enrolled in Kaiser Medical to enroll in Kaiser Vision)
Dental
Dental plan selection:
Write in plan selection
Dental late enrollment penalty
I understand if I decline dental coverage when initially eligible or allow coverage to lapse, then choose to enroll at a future
Open Enrollment period, any enrolled dependents and I will be subject to a 12-month waiting period, meaning only diagnostic
and preventive care (cleanings, x-rays, and exams) will be covered for the first 12 months of dental coverage.
Employee signature Date
Page 5 of 8
MSC 6011 (07/2019)
Optional plans (Employee paid voluntary payroll deduction plans)
Plan offering and availability is determined by your employer. Contact your employer for coverage information and to find out which
optional plans are available to you.
A. Optional life insurance
For any newly eligible employee, the Optional Employee Life has a guarantee issue* enrollment amount of up to $200,000 and
Optional Spouse/Domestic Partner Life has a guarantee issue* enrollment amount of up to $30,000 without needing to submit a
medical history** to The Standard Insurance Company underwriting for approval.
You can find a link to the Medical History Statement on the OEBB website at:
http://www.oregon.gov/oha/OEBB/Pages/Forms.aspx
* Guarantee issue, medical history is not required. If initial request is made with a QSC, guarantee issue amount is applicable.
** You are required to submit a medical history statement on any coverage amount that is not guarantee issue.
Employee optional life insurance
Enroll
Change enrollment
Decline coverage
Current enrollment* $ ($10,000 increments up to $200,000)
Additional requested amount** $ ($10,000 increments up to $300,000)
Total requested amount $ ($500,000 maximum)
Spouse/domestic partner optional life insurance
Enroll
Change enrollment
Decline coverage
Current enrollment* $
Additional requested amount** $ ($10,000 increments)
Total requested amount $ ($500,000 maximum)
Total requested amount must be equal to or less than employee optional life insurance coverage.
Children optional life insurance
Enroll
Change enrollment
Decline coverage
Total requested amount $ ($2,000 increments up to $10,000 maximum)
B. Optional accidental death & dismemberment (AD&D) insurance
Employee optional AD&D
Enroll
Change enrollment
Decline coverage
Total requested amount $
($10,000 increments up to
$500,000 maximum)
Medical history is not required
Spouse/domestic partner optional AD&D
Enroll
Change enrollment
Decline coverage
Total requested amount $
($10,000 increments up to
$500,000 maximum)
Medical history is not required. Total requested amount must be equal or less than employee optional AD&D coverage.
Child(ren) Optional AD&D
Enroll
Change enrollment
Decline coverage
Total requested amount $
($2,000 increments up to $10,000 maximum)
Medical history is not required. You must enroll in employee optional AD&D to enroll your child(ren) in this coverage.
Page 6 of 8
MSC 6011 (07/2019)
C. Voluntary disability insurance
Monthly premium is calculated on a percentage of your basic monthly salary. A late enrollment penalty will apply if you choose to
enroll in coverage at a later date or allow coverage to lapse.
Voluntary short term disability
Enroll for coverage
Decline coverage
Short term disability plans pay weekly benefits with coverage dates ending after 60 or 90 days depending upon plan enrollment.
Voluntary long term disability
Enroll for coverage
Decline coverage
Long term disability plans pay monthly benefits with benefits starting after 60 or 90 day waiting periods depending
upon plan enrollment.
D. Voluntary long term care insurance
Employee Long Term Care (LTC) enrollment as a newly eligible employee in an established employment group that has offered
LTC since 2014 has a guarantee issue* amount of up to $6,000 in monthly benefit, professional home care option for 3 or 6 year
duration without having to submit medical history for enrollment approval. Enrollment requests for unlimited duration, amount
over $6,000, total home care, and 5% simple inflation options, enrollment after first eligible or a future date, and Spouse/
Domestic Partner Long Term Care will require the UNUM medical history statement to be filled out and submitted to UNUM.
You can find a link to UNUM forms on the OEBB website:
http://www.oregon.gov/oha/OEBB/Pages/Forms.aspx
*You are required to submit a medical history statement on any coverage amount that is not guarantee issue or if you are
requesting a change in enrollment coverage. Some employee groups may not be eligible.
Employee long term care*
Request coverage
Change coverage
Decline coverage
Plan option
Coverage amount
Durati
on
Professional Home Care
Total Home Care
Professional Home Care –
5% inflation
Total Home Care – 5% inflation
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
3 Years
6 Years
Unlimited
Spouse/domestic partner long term care*
Request coverage
Change coverage
Decline coverage
Plan option
Coverage amount Duration
Professional Home Care
Total Home Care
Professional Home Care –
5% inflation
Total Home Care – 5% inflation
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
3 Years
6 Years
Unlimited
Page 7 of 8
MSC 6011 (07/2019)
Beneficiary designation
I elect:
The Standard Order of Survivorship (If you have a Domestic Partner, an Affidavit* must be on file for distribution.
T
o d
esignate the following as beneficiary (Attach additional sheets if necessary.)
Total of primary percentages must = 100% Total of contingent percentages must = 100%
Name Address
City State ZIP Relationship Primary or contingent
OR
Whole %
Name Address
City State ZIP Relationship Primary or contingent
OR
Whole %
Name Address
City State ZIP Relationship Primary or contingent
OR
Whole %
Name Address
City State ZIP Relationship Primary or contingent
OR
Whole %
*Affidavit Information: OEBB’s Affidavit of Domestic Partnership can be found online at:
http://www.oregon.gov/oha/OEBB/pages/Forms.aspx
Employee signature and authorization
I declare the dependents listed above and I are eligible for the coverages requested per OEBB Administrative Rule (OAR)-Division
10. I have read and understand OAR-Division 10 concerning Definitions and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_010.html
I have read and understand OAR-Division 80, Sections 111-080-0040, 111-080-0045 and 111-080-0050 concerning Eligibility and
Policy Term Violations and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_080.html
I understand I have 31 days to notify my employer of a Qualified Status Change (QSC) which affects eligibility. I have read and
understand OAR-Division 40 concerning Enrollment and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_040.html
I understand the benefit elections I make are in effect for as long as I continue to meet OEBB’s eligibility requirements, or until I
elect to change them subject to the provisions of OEBB’s plan. I understand I cannot alter my plan selections during the plan year
unless I have a QSC; then I am subject to the restrictions of the OEBB QSC’s. I have reviewed and understand the Qualified Status
Change (QSC) Matrix and can find the matrix at
http://www.oregon.gov/oha/OEBB/Pages/QSC-Matrix.aspx
Page 8 of 8
MSC 6011 (07/2019)
I have read the benefit materials and I understand the limitations and qualifications of the OEBB benefits program. If necessary,
I authorize premium payments deducted from my pay, unless I self-pay premiums. If I self-pay the premiums, I agree to submit
monthly payments by the date specified, or my coverage will terminate; I will not be able to reinstate coverage until the next open
enrollment period or may lose OEBB eligibility altogether.
A person who knowingly makes a false statement in connection with an application for any benefit may be subject to imprisonment
and fines. Additionally, knowingly making a false statement may subject a person to termination of enrollment, denial of future
enrollment, or civil damages.
This election supersedes all elections and submissions I previously made for OEBB coverage. I hereby declare that the above
statements are true to the best of my knowledge and belief, and I understand that they are subject to penalty for perjury.
Employee signature Date
Submit this completed form to your payroll/benefits office.
Do not submit this form to OEBB.
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Midyear Change Form Office use only Approved dat (Oregon)

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Completed 13 November 2020

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