Form ADM4717 "Benefit Enrollment/Change Form" - Ohio

What Is Form ADM4717?

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Download Form ADM4717 "Benefit Enrollment/Change Form" - Ohio

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STATE OF OHIO
BENEFIT ENROLLMENT/CHANGE FORM
Use this form to select coverage, to change coverage, or to make changes to dependent information.
Instructions:
You may print this form and complete it by hand or enter the information online, print, sign and return to your agency benefits coordinator.
Ensure that Section I, II, and III are completed in their entirety.
If you are a bargaining unit employee and requesting dental/vision coverage through Union Benefits Trust (UBT) you must go to the UBT website
at
www.benefitstrust.org
and complete their enrollment form.
Ensure that all dependents and their information are listed.
You are required to submit documentation that verifies dependent eligibility when you initially enroll or have a change in status/qualifying event.
Documentation requirements can be found on the DAS website http://das.ohio.gov/EligibilityRequirements. The deadline for submitting your
documentation is 31 days after your date of hire or the date of your change in status/qualifying event. Your dependents are ineligible for benefit
coverage until all required documentation has been submitted.
SECTION I – EMPLOYEE INFORMATION (please print legibly)
State of Ohio User ID
Last Name
First Name
M.I.
Home Address (Cannot be a P.O. Box)
City
State
Zip Code
Work Phone
Phone
Home
Mobile
SECTION II – ENROLLMENT INFORMATION
Event
New hire
Open Enrollment
Change in Status/Qualifying Event (check event in the following section)
1
Exempt/Bargaining Unit change
(dental/vision coverage only)
2
Date of Change in Status/Qualifying Event
:
1
Dental and vision options may differ for bargaining unit versus exempt employees.
If the Date of Change in Status/Qualifying Event is more than 31 days prior to today’s date, an appeal form must accompany this submission. Please see your agency human resources office to obtain
2
the appeal form.
ADM 4717
Updated May 2016
STATE OF OHIO
BENEFIT ENROLLMENT/CHANGE FORM
Use this form to select coverage, to change coverage, or to make changes to dependent information.
Instructions:
You may print this form and complete it by hand or enter the information online, print, sign and return to your agency benefits coordinator.
Ensure that Section I, II, and III are completed in their entirety.
If you are a bargaining unit employee and requesting dental/vision coverage through Union Benefits Trust (UBT) you must go to the UBT website
at
www.benefitstrust.org
and complete their enrollment form.
Ensure that all dependents and their information are listed.
You are required to submit documentation that verifies dependent eligibility when you initially enroll or have a change in status/qualifying event.
Documentation requirements can be found on the DAS website http://das.ohio.gov/EligibilityRequirements. The deadline for submitting your
documentation is 31 days after your date of hire or the date of your change in status/qualifying event. Your dependents are ineligible for benefit
coverage until all required documentation has been submitted.
SECTION I – EMPLOYEE INFORMATION (please print legibly)
State of Ohio User ID
Last Name
First Name
M.I.
Home Address (Cannot be a P.O. Box)
City
State
Zip Code
Work Phone
Phone
Home
Mobile
SECTION II – ENROLLMENT INFORMATION
Event
New hire
Open Enrollment
Change in Status/Qualifying Event (check event in the following section)
1
Exempt/Bargaining Unit change
(dental/vision coverage only)
2
Date of Change in Status/Qualifying Event
:
1
Dental and vision options may differ for bargaining unit versus exempt employees.
If the Date of Change in Status/Qualifying Event is more than 31 days prior to today’s date, an appeal form must accompany this submission. Please see your agency human resources office to obtain
2
the appeal form.
ADM 4717
Updated May 2016
STATE OF OHIO
BENEFIT ENROLLMENT/CHANGE FORM
Change in Status/Qualifying Events
Divorce/Marriage
Qualified Medical Child Support Order (QMCSO)
Gain or loss of other employer coverage
Dependent no longer meets eligibility requirements
Student Status Change (Dental/Vision only)
Other Circumstances:
Birth/Adoption
Plan
(Check all boxes that apply) Check
A or C for each if applicable
Name
Dependent Type
Date of Birth
Gender
A=Add C=Cancel
Employee
and
Medical
☐ C
M
☐A
F
☐ C
Dental
Same as above
Self
☐A
Vision
☐ C
☐A
Add
Cancel
Spouse
Medical
☐ C
☐A
Last:
☐ Married Spouse
☐ M
Dental
☐ C
☐ Common Law Spouse
☐ F
☐A
First:
Vision
☐ C
☐A
SSN:
ADM 4717
Updated May 2016
STATE OF OHIO
BENEFIT ENROLLMENT/CHANGE FORM
Plan
(Check all boxes that apply)
Marital
Circle A or C for each if applicable
Name
Dependent Type
Date of Birth
Gender
Status
A=Add C=Cancel
Child
☐ Child under age 26
☐ M
☐ Single
Medical
☐ C
☐ Married
☐ Stepchild under age 26
☐ F
☐A
Last:
☐ Foster child under age 26
Dental
☐ C
☐ Legal Guardianship/Ward is
☐A
First:
under age 26
Vision
☐ C
☐ Disabled
☐A
☐ Student (age 19-23) for
dental/vision coverage only
SSN:
Child
☐ Child under age 26
☐ M
☐ Single
Medical
☐ C
☐ Married
☐ Stepchild under age 26
☐ F
☐A
Last:
☐ Foster child under age 26
Dental
☐ C
☐ Legal Guardianship/Ward is
☐A
First:
under age 26
☐ C
Vision
☐ Disabled
☐A
☐ Student (age 19-23) for
dental/vision coverage only
SSN:
Child
☐ Child under age 26
☐ M
☐ Single
Medical
☐ C
☐ Married
☐ Stepchild under age 26
☐ F
☐A
Last:
☐ Foster child under age 26
Dental
☐ C
☐ Legal Guardianship/Ward is
☐A
First:
under age 26
☐ C
Vision
☐ Disabled
☐A
☐ Student (age 19-23) for
dental/vision coverage only
SSN:
Child
☐ Child under age 26
☐ M
☐ Single
Medical
☐ C
☐ Married
☐ Stepchild under age 26
☐ F
☐A
Last:
☐ Foster child under age 26
Dental
☐ C
☐ Legal Guardianship/Ward is
☐A
First:
under age 26
Vision
☐ C
☐A
☐ Disabled
☐ Student (age 19-23) for
dental/vision coverage only
SSN:
ADM 4717
Updated May 2016
STATE OF OHIO
BENEFIT ENROLLMENT/CHANGE FORM
Terms and Conditions:
1. I have read the provisions of dependent eligibility. Specifically, I have read and agree to the dependent eligibility rules that can be accessed at
www.das.ohio.gov/benefits. Further, by submitting my benefit choices, I certify that the dependent(s) under my coverage comply with these eligibility
rules. Importantly, I understand that enrolling an ineligible dependent(s) may be considered fraud, and could result in disciplinary actions up to and
including removal. In addition, my employer may decide to initiate court or collections action for any fraudulently paid monies.
I understand that I may be subject to an eligibility audit during any benefit year
in which I am enrolled for benefits coverage. I may also be
required to supply documentation such as certified birth certificate(s), marriage certificate(s), front/last page of income tax returns or other
documentation related to the eligibility of my dependents. Finally, I understand that if it is found that I have fraudulently obtained benefit coverage for
a dependent, I may be held financially liable by the provider for the cost of any claims paid for that dependent. If enrolling for coverage, which I
understand is voluntary. I authorize the deduction from my paycheck for the cost of coverage, which I have elected. I understand that payment on a
pre-tax basis means that my gross pay will be reduced by the cost of the coverage before any applicable taxes are deducted.
I acknowledge that the information on this Benefit Enrollment/Change Form is complete and accurate. I understand that the information provided on
this Form will be used to determine eligibility for coverage. Incomplete/inaccurate information could provide the basis to refuse or revoke coverage and
may result in disciplinary action up to and including removal.
2. If waiving health insurance coverage at this time, I understand I will have to wait until the next open enrollment period in order to enroll in any of the
Plans, unless I have a change in status/qualifying event.
3. I cannot start, stop, or change any pretax election until the next open enrollment unless I experience a change in status/qualifying event. If I experience
a change in status/qualifying event, I must complete the Benefit Enrollment/Change Form within 31 days of the change in status/qualifying event and
provide applicable supporting documentation.
4. Any change made in anticipation of a qualifying event will not be allowed. No dependents can be added or dropped from coverage until the qualifying
event has occurred.
5. I acknowledge the requirement that my and my dependent’s Social Security Numbers may be used as identifiers, as required under the Health Insurance
Portability and Accountability Act (HIPAA). Social Security Numbers are required for all dependents.
6. Unless otherwise prevented by law, I authorize, for myself and my dependents, health care providers, insurers, claims administrators and employers to
provide medical, employment and benefit information to the insurance provider or its authorized representatives. Furthermore, the insurance provider
or its authorized representatives may share such information and provide it to the employer, other insurers, claims administrators, re-insurers and other
provider organizations only for the purpose of administering the group coverage and claims for benefits, utilization review, risk management, provider
peer review and the resolution of grievances in relation to health benefit coverage and care.
ADM 4717
Updated May 2016
STATE OF OHIO
BENEFIT ENROLLMENT/CHANGE FORM
You are responsible for enrolling/disenrolling a dependent that becomes eligible/ineligible under the plan provisions.
You must notify your agency’s benefits representative and submit the required documentation within 31 calendar days of the change in
2
status/qualifying event.
Please review the “Required Documents Worksheet for Adding and Maintaining Dependents” and “Required Documents for Disenrolling
Dependents” and confirm your dependents are eligible or not eligible for coverage by completion of this form and the submission of the required
documents.
Please return the completed form with all required documents to your agency human resources office.
2
For exceptions to this, please review the information below.
By signing this form, I attest that I have reviewed the Dependent Eligibility Definitions and that the information I am submitting is true and accurate.
Signature:
Date:
Telephone:
Best time to call:
Mailing Address:
E-mail Address:
If you are unable to obtain certain documents (e.g. birth or marriage certificate) within the required deadline, you may initiate the
enrollment/disenrollment process without submitting all the required documentation. See the requirements below -- if you do not meet these
requirements your change request will be denied. Please note: The coverage change will not be processed until all forms and proof of eligibility are
received and approved.
☐ You must initiate the enrollment/disenrollment process and submit as much documentation as possible within 31 days of the qualifying/change in
status event; and
☐ You must provide a valid reason with your submission as to why documentation is missing, along with an estimated date when it will be available; and
☐ You must submit the required missing documentation within 31 days from the receipt of the document to your agency for processing.
If you believe this situation applies to you, please include the name of the delayed document, reason for the delay and an estimated date of when the
document will be available below.
Missing Document:
Estimated date of submission:
Reason:
ADM 4717
Updated May 2016
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