"Health Benefits Enrollment Form" - Delaware

Health Benefits Enrollment Form is a legal document that was released by the Delaware Department of Human Resources - a government authority operating within Delaware.

Form Details:

  • Released on June 22, 2017;
  • The latest edition currently provided by the Delaware Department of Human Resources;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Human Resources.

ADVERTISEMENT
ADVERTISEMENT

Download "Health Benefits Enrollment Form" - Delaware

1008 times
Rate (4.6 / 5) 71 votes
HEALTH BENEFITS
ENROLLMENT FORM
Employee Name:
Date of Hire (Not Prorated)
1st Day-Month 1
1st Day-Month 2
1st Day-Month 3
ELIGIBLE TO PARTICIPATE (Select One):
Health Insurance Plan
3 Emp & Child
TYPE 13
1 Emp Only
2 Emp & Spouse
4 Family
Highmark Delaware First State Basic PPO Plan
1
Aetna CDH Gold Plan
Aetna HMO Plan
Highmark Delaware Comprehensive PPO Plan
Waive Health Insurance
ELIGIBLE TO PARTICIPATE: First of the Month following 3 full months of employment: (Plan Type 10 - State Share)
Health Insurance Plan
3 Emp & Child
TYPE 10
1 Emp Only
2 Emp & Spouse
4 Family
Highmark Delaware First State Basic PPO Plan
2
Aetna CDH Gold Plan
Aetna HMO Plan
Highmark Delaware Comprehensive PPO Plan
Waive Health Insurance
ELIGIBLE TO PARTICIPATE: First of the Month: (Select One):
Following Hire Date
Following 90 Days of Employment
Dental Insurance Plans
DENTAL
1 Emp Only
2 Emp & Spouse
3 Emp & Child
4 Family
3
Dominion National HMO Select Dental Plan
Delta Dental PPO Plus Premier Plan
Waive Dental Insurance
Following 90 Days of Employment
ELIGIBLE TO PARTICIPATE: First of the Month: (Select One):
Following Hire Date
Vision Insurance
VISION
1 Emp Only
2 Emp & Spouse
3 Emp & Child
4 Family
4
EyeMed Vision Care Plan
Waive Vision Insurance
ELIGIBLE TO PARTICIPATE: UPON HIRE/ANY TIME
Blood Bank
BLOOD BANK
5
P R I N T
Participate
Waive Blood Bank
2017 HealthBenEnrollForm1 FINAL062217 PAGE1
Revised 06/22/17
HEALTH BENEFITS
ENROLLMENT FORM
Employee Name:
Date of Hire (Not Prorated)
1st Day-Month 1
1st Day-Month 2
1st Day-Month 3
ELIGIBLE TO PARTICIPATE (Select One):
Health Insurance Plan
3 Emp & Child
TYPE 13
1 Emp Only
2 Emp & Spouse
4 Family
Highmark Delaware First State Basic PPO Plan
1
Aetna CDH Gold Plan
Aetna HMO Plan
Highmark Delaware Comprehensive PPO Plan
Waive Health Insurance
ELIGIBLE TO PARTICIPATE: First of the Month following 3 full months of employment: (Plan Type 10 - State Share)
Health Insurance Plan
3 Emp & Child
TYPE 10
1 Emp Only
2 Emp & Spouse
4 Family
Highmark Delaware First State Basic PPO Plan
2
Aetna CDH Gold Plan
Aetna HMO Plan
Highmark Delaware Comprehensive PPO Plan
Waive Health Insurance
ELIGIBLE TO PARTICIPATE: First of the Month: (Select One):
Following Hire Date
Following 90 Days of Employment
Dental Insurance Plans
DENTAL
1 Emp Only
2 Emp & Spouse
3 Emp & Child
4 Family
3
Dominion National HMO Select Dental Plan
Delta Dental PPO Plus Premier Plan
Waive Dental Insurance
Following 90 Days of Employment
ELIGIBLE TO PARTICIPATE: First of the Month: (Select One):
Following Hire Date
Vision Insurance
VISION
1 Emp Only
2 Emp & Spouse
3 Emp & Child
4 Family
4
EyeMed Vision Care Plan
Waive Vision Insurance
ELIGIBLE TO PARTICIPATE: UPON HIRE/ANY TIME
Blood Bank
BLOOD BANK
5
P R I N T
Participate
Waive Blood Bank
2017 HealthBenEnrollForm1 FINAL062217 PAGE1
Revised 06/22/17
IMPORTANT NOTICE REGARDING SPOUSAL COORDINATION OF BENEFITS (SCOB):
If you have selected either an “Employee & Spouse” or “Family” level for
SCOB via Employee Self-Service
your Health care benefit on page one of this form, you MUST complete the electronic Spousal Coordination of Benefits Form upon initial enrollment, anytime enrollment
or insurance status changes and each year during Open Enrollment.
SCOB POLICY: The Spousal Coodination of Benefits Policy can be found at:/http://ben.omb.delaware.gov/documents/cob
Is your spouse a State Employee/
If you chose Yes, which Agency?
Pensioner?
No
Complete Only for Civil Union
To be Completed by HR/Ben Rep/
Yes
Spouse/ Dependent Coverage
Office Only
NAME
DOB
SSN
Gender
PCP ID#
Dentist ID#
Coverage Code:
Relationship Code
M
F
Employee:
Spouse/Dependent(s) Personal Information
Tax Qualified Dep?
M
F
Y
N
Spouse:
1
M
F
Y
N
2
Y
N
M
F
3
M
F
Y
N
4
M
F
Y
N
5
M
F
Y
N
6
M
F
Y
N
CERTIFICATION (Employee Must Sign and Date) By my signature below, I hereby certify the benefit elections made on this form are my choice and I have
completed the required forms necessary to enroll in the benefit elections chosen. I understand that, by completing and signing the required forms, I am making a
binding election with regard to my benefits for the current plan year unless I have a permissible family status change as defined by the Internal Revenue Service,
or I terminate employment with the State of Delaware.
EMPLOYEE SIGNATURE:
DATE:
FOR HR OFFICE USE ONLY:
HR/Ben Rep must print Employee's Name and Social Security Number below EXACTLY as it appears on the employee's SOCIAL SECURITY CARD.
Print Employee's Name
Print Employee's Social Security Number
Last Updated 06/21/17
Now that you have viewed the online new
hire orientation, you have been provided
NEO HEALTH BENEFITS
with a general overview of the benefit plans
offered to you as a new State of Delaware
ENROLLMENT FORM
employee. To get more detailed information
on each of the plans, we strongly encourage
y o u to visit the Statewide Benefits Office
(SBO) website at de.gov/statewidebenefits.
INSTRUCTION SHEET
And remember, you can always feel free to
contact your agency’s Human Resource/
Benefits Representative (HR/Ben Rep). You
will find easy to follow instructions below to help you fill out and complete the Health Benefits Enrollment Form.
If you still need assistance, please contact your agency’s HR/Ben Rep.
COMPLETING PAGE ONE OF THE
HEALTH BENEFITS ENROLLMENT FORM
ENROLLING IN A HEALTH & PRESCRIPTION PLAN
There are two areas labeled “Health Insurance Plans” on page 1, of the Health Benefits Enrollment
form.
The first section is for employees who choose to participate in Plan Type 13 (employees who wish to
participate in a Health Care Plan during their first 90 days of hire prior to being eligible for State Share) –
meaning, they will be responsible for paying the entire amount of the health care premium.
You will need to make a selection in each section for Plan Type 13 indicating:
1. Your Benefit Effective Date (you must choose one). (1) Effective your Date of Hire (premiums are not
pro-rated); (2) Effective the 1 st Day of Month 1, following your date of hire; (3) Effective the 1 st Day
of Month 2, following your date of hire; or, (4) Effective the 1 st Day of Month 3, following your date of
hire.
2. Your choice of one of the health plan options: Highmark Delaware First State Basic PPO Plan, Aetna
CDH Gold Plan, Aetna HMO Plan or Highmark Delaware Comprehensive PPO Plan along with the
corresponding plan tier (Employee, Employee/Spouse, Employee/Child, or Family),
3. Or, if you chose not to participate in a Health Care plan at this time, you must select “Waive”.
Last Updated 06/16/17
N E O H E A L T H B E N E F I T S E N R O L L M E N T F O R M
I N S T R U C T I O N S H E E T
PAGE 2
The second section is for employees who choose to participate in Plan Type 10 (for employees who
wish to participate in a Health Care Plan effective the first of the month after 90 days of employment, and
are eligible for State Share) – meaning, the state will then begin paying for a portion of their health
care premium.
You will need to make a selection in each section indicating:
Your choice of one of the health plan options: Highmark Delaware First State Basic PPO Plan,
1.
Aetna CDH Gold Plan, Aetna HMO Plan or Highmark Delaware Comprehensive PPO Plan;
Along with the corresponding plan tier (Employee, Employee/Spouse, Employee/Child, or Family plan).
2.
Or, if you chose not to participate in a Health Care plan at this time, you must select “Waive”.
3.
If you chose the Aetna HMO Plan, you must also indicate on page 2 of the Health Benefits Enrollment
Form, the physician identification number which can be found by clicking on the Provider Directory
hyperlinks.
If you are choosing a Primary Care Physician (PCP) as part of your enrollment in this plan, make
sure you call them and confirm they are accepting new patients prior to enrolling. If you already have a
Primary Care Physician (PCP), make sure they participate in the Aetna HMO network prior to enrolling.
The State of Delaware offers prescription coverage as part of the State’s Group Health Insurance Program.
When you enroll in a health care plan you will automatically be enrolled in the prescription drug plan
managed by Express Scripts.
ENROLLING IN A DENTAL PLAN
If you have chosen to participate in a Dental plan, you will first need to indicate:
Your Benefit Effective Date, either: (1) the 1st of the month following your date of hire, or (2) the first
1.
of the month following 90 days of employment.
Your choice of one of the dental plan options: Delta Dental PPO Plus Premier Plan or Dominion National
2.
HMO Select Dental Plan.
Then, you will need to choose which plan tier you are enrolling in, i.e., Employee, Employee &
3.
Spouse, Employee and Children or Family coverage.
Or, if you chose not to participate in a Dental Plan at this time, you must indicate this by selecting the
4.
"Waive" option.
If you chose the Dominion National HMO Select Dental Plan, you must also indicate on page two of the
5.
Health Benefits Enrollment Form the Primary Care Dentist/Provider ID which can be found on the
Benefits Tab on the Home Page under Dominion National Provider Directory.
If you are choosing
a Primary Care Dentist as part of your enrollment in this plan, make sure you call them and confirm they
are accepting new patients prior to enrolling. If you already have a Primary Care Dentist, make sure they
participate in the Dominion National HMO Select Dental network prior to enrolling
Last Updated 06/16/17
N E O H E A L T H B E N E F I T S E N R O L L M E N T F O R M
I N S T R U C T I O N S H E E T
PAGE 3
ENROLLING IN THE VISION PLAN
If you have chosen to participate in the vision plan, you will first need to indicate:
Your Benefit Effective Date; either the 1st of the month following your date of hire, or the first of the
1.
month following 90 days of employment.
Then you will need to choose which plan tier you are enrolling in, i.e., Employee, Employee &
2.
Spouse, Employee and Children or Family coverage.
Or, if you chose not to participate in the Vision Plan you must indicate this by selecting the
3.
"Waive" option.
ENROLLING IN BLOOD BANK
Next, if you interested in participating in the Blood Bank of Delmarva’s Members for Life program check
“Participate” on the Health Benefits Enrollment Form. By checking “Participate” you are authorizing the
Blood Bank of Delmarva to contact you about donating blood. If you are not interested in participating,
check “Waive“.
COMPLETING PAGE TWO OF THE
HEALTH BENEFITS ENROLLMENT FORM
Let’s now take a look at page two of the Health Benefits Enrollment Form. If you chose to participate in
a Health or Dental plan, you will now need to complete this section of the enrollment form by providing
all the required personal information for yourself and each eligible dependent you will be covering, i.e.,
their name, date of birth, social security number, their Primary Care Physician’s Identification Number –
(only if enrolling in a health care HMO), gender, and Primary Care Dentist/Provider ID (only if enrolling
in a dental HMO). Physician and Dentist identification numbers can be found by accessing the vendor’s
Provider Directories on the Benefits Tab of the Home page. In addition, for employees (in a Civil Union
only) enrolling a spouse or dependent, you must also choose the appropriate Tax Coverage Code from
the drop down box, as well as indicate each dependent’s Tax Qualifying Dependent Status.
If enrolling a dependent(s) you MUST submit a copy of a birth certificate or another acceptable form of
legal documentation for each dependent. In addition, you must also submit an original, signed, social
security card for yourself and each of your dependents as well.
A Dependent Coordination of Benefits form must also be completed and sent to the appropriate
carrier for each enrolled dependent child regardless of age upon:
Enrollment in other health coverage;
Anytime other health coverage changes, or
Upon request by the Statewide Benefits Office, Highmark Delaware or Aetna.
Last Updated 06/16/17