Form BEN035 "Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients Tiers Ii & Iii (With System-Paid Medical)" - Alaska

What Is Form BEN035?

This is a legal form that was released by the Alaska Department of Administration - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Alaska Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form BEN035 by clicking the link below or browse more documents and templates provided by the Alaska Department of Administration.

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Download Form BEN035 "Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients Tiers Ii & Iii (With System-Paid Medical)" - Alaska

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Health Benefits Enrollment/Waiver
FOR OFFICE USE ONLY
For Retirees or Benefit Recipients
Tiers II & III (with system-paid medical)
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
SECTION I. PERSONAL INFORMATION
NAME
SOCIAL SECURITY NUMBER
Please indicate your retirement system:
PERS
TRS
SECTION II. DENTAL-VISION-AUDIO BENEFITS
To enroll into the DVA plan, you must select which DVA Plan (Standard or Legacy) and the coverage level (coverage for myself vs
coverage for myself and dependents). If you have multiple retirement systems, your DVA coverage level can vary, but the DVA plan type
(Standard or Legacy) applies to all retirement systems in which you are paying DVA premiums.
I elect the following Dental-Vision-Audio plan option:
No DVA coverage
Standard DVA Plan
Legacy DVA Plan
DVA coverage for myself (retiree) only
DVA coverage for myself and my spouse
DVA coverage formyself, my spouse, and children
DVA coverage for myself and children
SECTION III. LONG-TERM CARE BENEFITS
I elect the following Long-Term Care (LTC) option:
No Long-Term Care (LTC) coverage
Individual (Member) coverage:
Silver
Gold
Platinum
Spouse coverage (may elect only if member is electing individual coverage):
Silver
Gold
Platinum
Spouse’s date of birth: ______________________________________
Spouse’s SSN: ____________________________________________
I am covered under my spouse’s LTC plan.
SECTION IV. CERTIFICATION AND SIGNATURE
I acknowledge that I have been offered the two health plans available: Dental-Vision-Audio and Long-Term Care. I understand that this is
my only opportunity to enroll in these plans and that by not electing coverage at this time under either plan, I waive my right to future
participation in the DVA and LTC plan.
I authorize the deduction of premiums from my benefit check for any insurances elected above.
SIGNATURE
DATE
ben035 (Rev. 4/20)
G:\Communications_Only\200 Products\206\Benefits\ben035.indd
Health Benefits Enrollment/Waiver
FOR OFFICE USE ONLY
For Retirees or Benefit Recipients
Tiers II & III (with system-paid medical)
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
SECTION I. PERSONAL INFORMATION
NAME
SOCIAL SECURITY NUMBER
Please indicate your retirement system:
PERS
TRS
SECTION II. DENTAL-VISION-AUDIO BENEFITS
To enroll into the DVA plan, you must select which DVA Plan (Standard or Legacy) and the coverage level (coverage for myself vs
coverage for myself and dependents). If you have multiple retirement systems, your DVA coverage level can vary, but the DVA plan type
(Standard or Legacy) applies to all retirement systems in which you are paying DVA premiums.
I elect the following Dental-Vision-Audio plan option:
No DVA coverage
Standard DVA Plan
Legacy DVA Plan
DVA coverage for myself (retiree) only
DVA coverage for myself and my spouse
DVA coverage formyself, my spouse, and children
DVA coverage for myself and children
SECTION III. LONG-TERM CARE BENEFITS
I elect the following Long-Term Care (LTC) option:
No Long-Term Care (LTC) coverage
Individual (Member) coverage:
Silver
Gold
Platinum
Spouse coverage (may elect only if member is electing individual coverage):
Silver
Gold
Platinum
Spouse’s date of birth: ______________________________________
Spouse’s SSN: ____________________________________________
I am covered under my spouse’s LTC plan.
SECTION IV. CERTIFICATION AND SIGNATURE
I acknowledge that I have been offered the two health plans available: Dental-Vision-Audio and Long-Term Care. I understand that this is
my only opportunity to enroll in these plans and that by not electing coverage at this time under either plan, I waive my right to future
participation in the DVA and LTC plan.
I authorize the deduction of premiums from my benefit check for any insurances elected above.
SIGNATURE
DATE
ben035 (Rev. 4/20)
G:\Communications_Only\200 Products\206\Benefits\ben035.indd
Health Benefits Enrollment/Waiver Form
For Retirees or Benefit Recipients
This form is for retirees and other benefit recipients who were
DVA Coverage for:
Standard
Legacy
first hired under the Public Employees’ Retirement System
Individual only
$
67.32
$
74.46
(PERS) Defined Benefit plan after June 30, 1986 and before July
Individual and spouse
$ 133.62
$ 147.90
1, 2006, or under the Teachers’ Retirement System (TRS)
Individual and child(ren)
$ 121.38
$ 134.64
Defined Benefit plan after June 30, 1990 and before July 1,
Individual, spouse, and child(ren)
$ 190.74
$ 211.14
2006, and are eligible for system-paid medical coverage at
retirement.
Long-Term Care Benefits—Premium Rates by Age
To compare the Standard and Legacy DVA plans, refer to the
Age
Silver Option
Gold Option
Platinum Option
Dental Benefit Comparison Guide located on the AlaskaCare
at
$400,000 max
$300,000 max
$300,000 max
website, Alaska.gov/drb/alaskaCare/retiree/AKCare-DVA-
Retire-
No inflation
Simple inflation
Compound
ment
protection
protection
inflation protection
BenefitComparison.pdf.
40*
$26
$76
$148
If you are already covered under your spouse’s LTC plan, you
41
$27
$77
$150
cannot be covered under a second plan. Please provide your
42
$28
$78
$153
43
$30
$79
$155
spouse’s Social Security number so we may move your LTC
44
$31
$81
$158
coverage to your retirement benefit.
45
$33
$82
$161
46
$35
$84
$164
Your form must be postmarked or received in our office before
47
$37
$85
$167
your retirement date. This is your only opportunity to enroll in
48
$39
$89
$170
these plans. If you do not enroll at this time, you waive your right
49
$41
$92
$172
to participate in the future.
50
$44
$96
$175
51
$46
$100
$177
You may decrease or terminate your coverage at any time by
52
$49
$103
$180
notifying this office in writing. You may only increase DVA
53
$52
$109
$184
coverage within 120 days of the date you are married or have
54
$56
$114
$188
55
$60
$120
$192
your first child.
56
$63
$126
$195
LTC coverage may be added for your spouse within 120 days of
57
$67
$131
$199
marriage.
58
$75
$143
$212
59
$84
$156
$225
If you elect coverage, the premiums will be deducted from your
60
$92
$168
$237
benefit check each month. If your check is insufficient to deduct
61
$100
$181
$250
62
$108
$193
$263
the premiums, we will contact you to make payment
63
$123
$212
$281
arrangements. The chart in the next column shows the monthly
64
$137
$231
$300
premiums for each option.
65
$151
$250
$319
66
$166
$269
$338
67
$180
$288
$357
68
$201
$313
$381
69
$222
$339
$404
70
$244
$364
$428
71
$265
$389
$451
72
$286
$414
$475
73
$314
$444
$502
74
$343
$474
$529
75
$371
$503
$556
76
$399
$533
$584
77
$427
$563
$611
78
$471
$609
$654
79
$515
$654
$698
80
$559
$700
$741
81
$603
$746
$784
82
$646
$791
$828
83
$731
$887
$923
84
$815
$982
$1,018
85**
$900
$1,078
$1,113
* and under
** and over
ben035 (Rev. 4/20)
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