Fillable Non-Active Family Status and Benet Change Form (University of Delaware)

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Non-Active Family Status and Benet Change Form (University of Delaware)

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Non-Active Family Status and Benefit Change Form
Please complete this benefits change form if you have experienced a change in family status (marriage, birth of a child,
adoption, divorce, death of a spouse or child, etc.) as the benefits you chose at the beginning of the plan year may be
affected. Return the signed form within 30 days of the event. Please contact us with any question about this form or your
benefits.
Demographic information – Please help us keep your records current. Fill in your name, employee ID number, address, and
phone number, then identify any other information that has changed.
Name: Employee ID:
Home Address: City/State/Zip:
Home Phone: Date of Event:
Family Status Change – Indicate the family status change by marking an selecting in the appropriate change with an “X”:
Marriage Divorce Death of spouse or dependent
Birth or Adoption of child Change in spouse’s employment Change in your percent time worked
Change in child’s eligibility Moving out of service area
Medicare eligible Other, Explanation Required
Dependent Information – If you are removing a dependent, please provide the dependent’s current address:
___________________________________________________ __________________________ ________ ___________
Street City State
Zip
Action Spouse/Dependent
Name(s) Gender SSN DOB Relationship Primary Care Physician
(Aetna HMO, only)
Add
Remove
Add
Remove
Please note - documentation is required when initially enrolling a dependent under a health plan. This includes a marriage
certificate when covering a spouse, and birth or adoption certification when covering a dependent child(ren) and a copy of
their social security card.
CHECK ONLY THE BENEFITS YOU ARE CHANGING:
Medicare Supplemental Plan Selections
Name: Please indicate your coverage election below with an “X”:
Special Medicfill with prescription drug coverage (must not be enrolled in a non-UD Medicare D plan)
Special Medicfill without prescription drug coverage (if enrolled in non-UD Medicare D prescription drug plan)
Waive – Medical Coverage
Non-Medicare Plan Selections
Name: Please indicate your election below with an X:
Aetna CDH Gold Highmark First State Basic
Aetna HMO Highmark Comprehensive PPO
Waive
Please indicate your coverage election below with an “X”:
Individual Individual & Child(ren)
Individual & Spouse Family
You must download this form to your computer to make fillable.
1
Revised August 2019
Dental Plan Selections Vision Plan Selections
Please indicate your coverage election below with an “X”: Please indicate your coverage election below an “X”:
Dominion Dental HMO
Enroll
Delta PPO Plus Premier Waive
Waive
Please indicate your level election below an “X”: Please indicate your level election below an “X”:
Individual & Spouse Individual & Child(ren) Individual & Spouse Individual & Child(ren)
Individual Family Individual Family
Changes during the year
Please know that you may be eligible to change your coverage between annual enrollments only if you have a change
in status
such as: you marry, divorce or legally separate; a child joins your family through birth or adoption; your
spouse becomes
employed, loses his or her job (full-time employment) or involuntarily loses medical coverage; your
spouse or dependent child
dies; your dependents become ineligible for coverage; you or your spouse have a change in job
status from full-time to part-time
or vice versa; your spouse takes an unpaid leave of absence; you or your spouse have a
significant change in health coverage due
to a change in your spouse’s employment, or you become eligible for Medicare.
If you have a change in status, you have only 30
days to change your coverage. Furthermore, the requested change must
be consistent with the event.
Spousal Coordination of Benefits Policy
If you are covering your spouse under a University health plan, we also want to share some very important information
with you
about the Spousal Coordination of Benefits Policy. This policy affects how health insurance benefits payments
are made for
spouses who are eligible for, but not enrolled in, coverage through their employer. According to this policy, if
your spouse works
full-time and would pay 50% or less of the total premium for individual coverage (premium based on
the lowest-cost individual
plan available through their employer), s/he must enroll in their employer’s health plan. If your
spouse meets the above criteria,
but does not enroll in his/her employer’s health plan, the University’s plan will pay only
20% of allowable charges.
Misinterpretation and/or failure to comply with this policy may have significant financial
implications for you. If applicable,
please take a few minutes to read this policy and sign the spousal coordination of
benefits policy form. Information on this form is
shared with Statewide Benefits and is used to verify your spouse’s access
to health insurance. The Spousal Coordination of
Benefits Policy Form can be found at: https://secomb.delaware.gov/cob/
Retiree Life Insurance
Retiree life insurance is administered by MetLife. Please contact MetLife Customer Service at 1-866-492-6983
with any
questions or changes regarding billing, coverage, or beneficiary designations.
Health Plan Authorization
I understand that rights to service are subject to acceptance of my enrollment and to the terms and conditions
specified in the
present contract between the health insurance carrier and the State of Delaware. I certify that all
information supplied by me is
true. I, on behalf of myself and my covered dependents, authorize any physician, hospital
or any other health care provider to
release information available to them concerning any diagnosis, treatment or other
health care services they render to me or my
covered dependents to the health insurance carrier or its designee for
purposes reasonably related to their contract or as required
by law. I have read and agree with the above terms and
authorize the University to collect premium contributions for remittance
to applicable benefit carriers.
_______________________________________________________________________ ____________________________
Signature (Participant) Date
_______________________________________________________________________ ____________________________
Signature (Spouse of Participant) Date
If you have questions regarding this form or your benefits, please contact us by e-mail (hrhelp@udel.edu) or
phone (302-831-2171). Please return your completed form to UD HR-Benefits Office, 413 Academy Street, Newark,
DE 19716.
You must download this form to your computer to make fillable.
2
Revised August 2019
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Non-Active Family Status and Benet Change Form (University of Delaware)

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Completed 2 February 2021

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