Fillable elf-Pay Early Retiree (SPER) S Midyear Change Form (Oregon)

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elf-Pay Early Retiree (SPER) S Midyear Change Form (Oregon)

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Page 1 of 8 MSC 6017 (07/2019)
S
elf-Pay Early Retiree (SPER)
Midyear Change Form
Office use
only
A
pproved by:
Approved date:
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
SPER information
Last name First name M.I.
Social Security Number, or E 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
* Warning: All SPERs and dependents of SPERs lose eligibility for OEBB plans on the day they become eligible for Medicare
due to age 65 or disability (regardless of whether you enroll in Medicare coverage). Notify OEBB immediately if you or your
dependent is eligible for Medicare. If dropping coverage for you or a dependent, it cannot be added back at a future date without
a qualifying event. See QSC Matrix for details.
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
Ethnicity (Select one): Hispanic
N
on-Hispanic/Non-Latino
R
efused
U
n
known
Race (Select at least one. If selecting more than one, circle one as primary):
Asian
White
Black/African American
~ Other
American Indian/Alaska Native Native Hawaiian/Other Pacific Islander
Refused Unknown
Page 2 of 8 MSC 6017 (07/2019)
Tobacco usage
(Responses in this section are required)
In this section, OEBB is collecting tobacco usage information for you and your spouse/domestic partner (if applicable).
This information will be used to determine your premium amount(s) for Optional Member and Optional Spouse/Domestic Partner
Life plans through The Standard. You must complete this section even if you do not enroll in these plans.
Employee
In the last 12 months (Select one):
Spouse/Domestic partner
In the last 12 months (Select one):
I have used tobacco products
I have not used tobacco products
~ I have never used tobacco products
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
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
D
ivorce/Annulment
T
ermination
o
f
D
omestic
P
artnership
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 (Attach additional sheets if necessary)
You must report to OEBB 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 member’s coverage effective the first of the month after eligibility was lost.
Page 3 of 8
MSC
6017
(07/2019)
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 employing entity — 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 OEBB 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 M.I.
Address (if different from employee address)
City
State ZIP
Ethnicity (Select one): Hispanic
Non-Hispanic/Non-Latino Refused Unknown
Race (Select at least one. If selecting more than one, circle one as primary):
American Indian/Alaska Native Native Hawaiian/Other Pacific Islander
Asian Black/African American
~ White Other
Refused
Unknown
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 M.I.
Address (if different from employee address)
City
State ZIP
Ethnicity (Select one): Hispanic
Non-Hispanic/Non-Latino Refused
Unknown
Race (Select at least one. If selecting more than one, circle one as primary):
American Indian/Alaska Native Native Hawaiian/Other Pacific IslanderAsian Black/African American
~ White Other Refused Unknown
* Warning: All SPERs and dependents of SPERs lose eligibility for OEBB plans on the day they become eligible for Medicare due to
age 65 or disability (regardless of whether you enroll in Medicare coverage). Notify OEBB immediately if you or your dependent
is eligible for Medicare. If dropping coverage for you or a dependent, it cannot be added back at a future date without a qualifying
event. See QSC Matrix for details.
Dependent C
Enroll Change Remove Medical Vision Dental
Relationship to employee Spouse Domestic partner
Child
G
ender
M
F
Other
Date of birth (mm/dd/yyyy) Social Security, HICN, or Tax ID number: Medicare eligible?*
Y
N
Page 4 of 8 MSC 6017 (07/2019)
Last name First name M.I.
Address (if different from employee address)
City
State ZIP
E
t
h
n
i
c
ity (Select one): Hispanic
Non-Hispanic/N
on-Latino
R
efused
U
n
known
Race (Select at least one. If selecting more than one, circle one as primary):
American Indian/Alaska Native Native Hawaiian/Other Pacific Islander
As
i
an Blac
k
/African
A
merican
~
W
h
i
t
e O
t
her
Refused
Unknown
Dependent D
Enroll C
h
ange Remove
Me
d
i
cal
Vision D
ental
Relationship to employee Spo
us
e D
o
mestic 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 M.I.
Address (if different from employee address)
City
State ZIP
E
t
h
n
i
c
ity (Select one): Hispanic
N
on-Hispanic/Non-Latino
R
efused
U
n
known
Race (Select at least one. If selecting more than one, circle one as primary):
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Asian Black/African American
~ White Other
Refused Unknown
Dependent E
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 M.I.
Address (if different from employee address)
City
State ZIP
Ethnicity (Select one): Hispanic
Non-Hispanic/Non-Latino
Refused
Unknown
Race (Select at least one. If selecting more than one, circle one as primary):
c
Asian
c
Black/African American
c
American Indian/Alaska Native
c
Native Hawaiian/Other Pacific Islander
c
White
c
Other
c
Refused
c
Unknown
* Warning: All SPERs and dependents of SPERs lose eligibility for OEBB plans on the day they become eligible for Medicare due to
age 65 or disability (regardless of whether you enroll in Medicare coverage). Notify OEBB immediately if you or your dependent
is eligible for Medicare. If dropping coverage for you or a dependent, it cannot be added back at a future date without a qualifying
event. See QSC Matrix for details.
Healthcare plan selections
Medical
Page 5 of 8 MSC 6017 (07/2019)
Medical plan selection:
Decline Medical
Write in plan selection.
If enrolled 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
Vision
Vision plan selection:
Decline Vision
Write in plan selection. Must be enrolled in Kaiser Medical to enroll in Kaiser Vision.
Dental
Dental plan selection:
Decline Dental
Write in plan selection.
Page 6 of 8 MSC 6017 (07/2019)
Optional plans (Employee paid voluntary payroll deduction plans)
Plan offering and availability is determined by your previous employer. Contact OEBB for coverage information and to
find out which optional plans are available to you.
A. Optional life insurance
Employee (SPER) optional life insurance
Decrease my current enrollment amount to* $
Decrease enrollment Cancel coverage
($10,000 increments up to $100,000)
Spouse/domestic partner optional life insurance
Decrease enrollment
Cancel coverage
Decrease my current enrollment amount to* $
Total requested amount must be equal to or less than employee optional life insurance coverage.
Child(ren) optional life insurance
Decrease enrollment
Cancel coverage
Decrease my current enrollment amount to* $ ($2,000 increments up to $10,000 maximum)
Medical history is not required, you must enroll in member optional life to enroll your child(ren) in this coverage.
Declining coverage ends eligibility
I understand that if I decline Medical, Dental and/or Vision coverage, I lose eligibility for that type of coverage and will not be
allowed to re-enroll in that type of coverage in the future, regardless of any life events that may occur.
Employee signature Date
B. Optional accidental death & dismemberment (AD&D) insurance
Employee optional AD&D
Decrease enrollment
Cancel coverage
Decrease my current enrollment amount to* $
($10,000 increments up to
$500,000 maximum)
Medical history is not required
Spouse/domestic partner optional AD&D
Decrease
enrollment Cancel coverage
Decrease my current enrollment amount to* $
($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
Decrease enrollment Cancel coverage
Decrease my current enrollment amount to* $
($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.
* 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.
Page 7 of 8 MSC 6017 (07/2019)
C. Voluntary long term care insurance
Member Long Term Care enrollment as a newly eligible member has guarantee issue amounts 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
Employee (SPER) long term care*
Decrease 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
Spouse/domestic partner long term care*
Decrease 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
Beneficiary designation
I elect:
The Standard Order of Survivorship (If you have a Domestic Partner, an Affidavit* must be on file for distribution.)
To designate 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
Page 8 of 8 MSC 6017 (07/2019)
SPER 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 OEBB 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
I have read the benefit materials and I understand the limitations and qualifications of the OEBB benefits program. 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.
SPER Signature Date
Submit this form to OEBB
email: OEBB.Benefits@dhsoha.state.or.us
by fax: (503) 378-5832
or by mail: OEBB Member Services
500 Summer Street NE, E-88
Salem, OR 97301-1063
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elf-Pay Early Retiree (SPER) S Midyear Change Form (Oregon)

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Completed 20 November 2020

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