Form A10385 "State Health Benefits Program Enrollment Form for Employees" - Virginia

What Is Form A10385?

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

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the Virginia Department of Human Resource Management;
  • 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 fillable version of Form A10385 by clicking the link below or browse more documents and templates provided by the Virginia Department of Human Resource Management.

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Download Form A10385 "State Health Benefits Program Enrollment Form for Employees" - Virginia

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State Health Benefits Program Enrollment Form For Employees
Review each section and carefully PRINT your enrollment information. For state health benefits eligibility
information, visit the DHRM website at
or contact your Benefits Administrator.
www.dhrm.virginia.gov
Section 1: Personal Information
________________________________________
Name ______________________________________________________________________
Identification Number
Last Name
First Name
M.I.
Assigned ID or Social Security Number
Date of Birth _________________________________________________________________ Gender:
Male
Female
n
n
Month
Day
Year
Important! Be sure to verify the correct format of your address at http://zip4.usps.com/zip4/welcome.jsp.
_______________________________________________________________________
________________________________
Street Address
P.O. Box
_____________________________________________________________
_________________________________
City
State _____________
Zip + 4
State E-mail: ____________________________________________________________ Personal E-mail: ______________________________________________________
State Phone: ( _________ ) __________________ Personal Phone: ( _________ ) __________________
Mobile
Section 2: Reason For This Enrollment or Election Change Request
Check the box that applies. The numbers in parentheses are for agency use.
Open Enrollment (56)
n
Initial Enrollment for Newly Eligible Employee: ____________________________ (01)
n
M O N T H / D A Y / Y E A R
Qualifying Mid-Year Event/Documentation to Support the Event
n
Check the type of event below, and attach the appropriate supporting documentation as indicated. Date of Event: ____________________________
M O N T H / D A Y / Y E A R
Events consistent with adding family members to coverage:
Other events:
Marriage (certified marriage certificate) (07)
Employment Change:
Full-time to Part-time (77)
Birth or Adoption (birth certificate/hospital announcement or adoption agreement) (15)
Part-time to Full-time (78)
Judgment, Decree, or Order to Add Child (court order) (71)
Unpaid Leave Began (49)
Lost eligibility Under Governmental Plan (government documentation) (76)
Unpaid Leave Ended (50)
Lost eligibility Under Medicare or Medicaid (government documentation) (09)
Dependent Care Cost or Coverage Change (documentation from
Spouse or Child Lost Eligibility Under Their Employers Plan (employer documentation) (13)
dependent care provider) (61)
HIPAA Special Enrollment Due to Loss of Other Coverage
Events consistent with removing family members from coverage:
(HIPAA certificate) (70)
Move Affecting Eligibility for Health Care Plan (agency validates
Divorce (divorce decree) (10)
move) (05)
Death of Spouse (documentation validating death) (08)
Other Employers Open Enrollment or Plan Change (employer
Death of Child (documentation validating death) (17)
documentation) (62)
Child Covered Under Plan Lost Eligibility (documentation to support) (38)
Enrollment in a Marketplace Exchange Health Plan (Documenta-
Judgment, Decree or Order to Remove Child (court order) (67)
tion of the Marketplace coverage enrollment and the effective
Gained Eligibility Under Medicare or Medicaid (government documentation) (66)
date of coverage)
Spouse or Child Gained Eligibility Under Their Employers Plan (employer documentation) (28)
Add to existing Family Membership (documentation to support eligibility) (19)
n
Section 3: Flexible Spending Accounts Election – You Must Enroll Every Plan Year
To enroll in or change an FSA, enter the amount you wish deducted each pay period. For assistance in determining your pay period election,
complete the FSA worksheet available on the DHRM website at
www.dhrm.virginia.gov
or from your Benefits Administrator.
I do not wish to participate in an FSA.
n
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
HEALTH FLEXIBLE SPENDING ACCOUNT
For eligible dependent care expenses incurred by you, your spouse and eligible
For eligible medical expenses incurred by you, your spouse and eligible dependents.
dependents. (Minimum is $10 per pay period; Maximum allowable contribution is
(Minimum is $10 per pay period; Maximum allowable contribution is up to $2,700.)
up to $5,000 depending on your tax filing status.)
Amount per regular paycheck
Amount per regular paycheck
=
(Whole dollar amounts only)
___________________
=
(Whole dollar amounts only)
____________________
A10385 (3/2019)
3/2019 Eligibility and Enrollment Information For Employees
Page 1
State Health Benefits Program Enrollment Form For Employees
Review each section and carefully PRINT your enrollment information. For state health benefits eligibility
information, visit the DHRM website at
or contact your Benefits Administrator.
www.dhrm.virginia.gov
Section 1: Personal Information
________________________________________
Name ______________________________________________________________________
Identification Number
Last Name
First Name
M.I.
Assigned ID or Social Security Number
Date of Birth _________________________________________________________________ Gender:
Male
Female
n
n
Month
Day
Year
Important! Be sure to verify the correct format of your address at http://zip4.usps.com/zip4/welcome.jsp.
_______________________________________________________________________
________________________________
Street Address
P.O. Box
_____________________________________________________________
_________________________________
City
State _____________
Zip + 4
State E-mail: ____________________________________________________________ Personal E-mail: ______________________________________________________
State Phone: ( _________ ) __________________ Personal Phone: ( _________ ) __________________
Mobile
Section 2: Reason For This Enrollment or Election Change Request
Check the box that applies. The numbers in parentheses are for agency use.
Open Enrollment (56)
n
Initial Enrollment for Newly Eligible Employee: ____________________________ (01)
n
M O N T H / D A Y / Y E A R
Qualifying Mid-Year Event/Documentation to Support the Event
n
Check the type of event below, and attach the appropriate supporting documentation as indicated. Date of Event: ____________________________
M O N T H / D A Y / Y E A R
Events consistent with adding family members to coverage:
Other events:
Marriage (certified marriage certificate) (07)
Employment Change:
Full-time to Part-time (77)
Birth or Adoption (birth certificate/hospital announcement or adoption agreement) (15)
Part-time to Full-time (78)
Judgment, Decree, or Order to Add Child (court order) (71)
Unpaid Leave Began (49)
Lost eligibility Under Governmental Plan (government documentation) (76)
Unpaid Leave Ended (50)
Lost eligibility Under Medicare or Medicaid (government documentation) (09)
Dependent Care Cost or Coverage Change (documentation from
Spouse or Child Lost Eligibility Under Their Employers Plan (employer documentation) (13)
dependent care provider) (61)
HIPAA Special Enrollment Due to Loss of Other Coverage
Events consistent with removing family members from coverage:
(HIPAA certificate) (70)
Move Affecting Eligibility for Health Care Plan (agency validates
Divorce (divorce decree) (10)
move) (05)
Death of Spouse (documentation validating death) (08)
Other Employers Open Enrollment or Plan Change (employer
Death of Child (documentation validating death) (17)
documentation) (62)
Child Covered Under Plan Lost Eligibility (documentation to support) (38)
Enrollment in a Marketplace Exchange Health Plan (Documenta-
Judgment, Decree or Order to Remove Child (court order) (67)
tion of the Marketplace coverage enrollment and the effective
Gained Eligibility Under Medicare or Medicaid (government documentation) (66)
date of coverage)
Spouse or Child Gained Eligibility Under Their Employers Plan (employer documentation) (28)
Add to existing Family Membership (documentation to support eligibility) (19)
n
Section 3: Flexible Spending Accounts Election – You Must Enroll Every Plan Year
To enroll in or change an FSA, enter the amount you wish deducted each pay period. For assistance in determining your pay period election,
complete the FSA worksheet available on the DHRM website at
www.dhrm.virginia.gov
or from your Benefits Administrator.
I do not wish to participate in an FSA.
n
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
HEALTH FLEXIBLE SPENDING ACCOUNT
For eligible dependent care expenses incurred by you, your spouse and eligible
For eligible medical expenses incurred by you, your spouse and eligible dependents.
dependents. (Minimum is $10 per pay period; Maximum allowable contribution is
(Minimum is $10 per pay period; Maximum allowable contribution is up to $2,700.)
up to $5,000 depending on your tax filing status.)
Amount per regular paycheck
Amount per regular paycheck
=
(Whole dollar amounts only)
___________________
=
(Whole dollar amounts only)
____________________
A10385 (3/2019)
3/2019 Eligibility and Enrollment Information For Employees
Page 1
Section 4: Health Care Coverage Election
I do not wish to participate in health care coverage (W)
n
No change to my current health plan selection and family members/membership level
n
(If you check either box above proceed to Section 5.)
A. Health Plan Selection – Check the box that applies
No change to my current health care plan
n
STATEWIDE HEALTH PLANS
Administered by Anthem Blue Cross Blue Shield*
Administered by Aetna*
COVA Care (with preventive dental) (ACCO)
COVA HealthAware (with preventive dental) (CHA)
n
n
COVA Care + Out of Network (ACC1)
COVA HealthAware + Expanded Dental (CHA2)
n
n
COVA Care + Expanded Dental (ACC2)
COVA HealthAware + Expanded Dental & Vision (CHA1)
n
n
COVA Care + Out of Network and Expanded Dental (ACC3)
n
Administered by Selman & Company
COVA Care + Expanded Dental + Vision & Hearing (ACC4)
n
COVA Care + Out of Network + Expanded Dental + Vision & Hearing (ACC5)
TRICARE Supplement (TRC)
n
n
COVA HDHP- High Deductible Plan (with preventive dental) (CHD)
DEERS # ___________________________ (required)
n
COVA HDHP- High Deductible Plan + Expanded Dental (CHD1)
n
*Anthem Pharmacy delivered by IngenioRx administers pharmacy benefits. Delta Dental administers dental benefits.
REGIONAL HEALTH PLANS
Administered by Kaiser Permanente of the Mid-Atlantic States, Inc.
Kaiser Permanente HMO- available in Northern Virginia, Central Virginia and Northern Neck designated zip codes (KP)
n
Administered by Optima
Optima Health HMO – available primarily in Hampton Roads zip codes (OH)
n
B. Family Members – Check the box that applies
No change to my existing covered family members
n
I do not wish to cover any family members
n
I wish to cover the eligible family members listed below. (Note: you will be required to submit documentation when adding family
n
members to your coverage.)
RELATIONSHIP
DATE OF BIRTH
SOCIAL SECURITY
CODE**
LAST NAME
FIRST NAME
MIDDLE INITIAL
MM/DD/YYYY
NUMBER
Spouse
Children
**Relationship Codes: SM=spouse male SF=spouse female S=son D=daughter SS=stepson SD=stepdaughter OF=other female child OM=other male child
Section 5: Employee Certification and Authorization
I certify that I have reviewed and understand the State Health Benefits Program eligibility and enrollment information and I agree to abide by all
participation requirements. I certify that all dependents listed meet the eligibility requirements of the program and that the information I have provided
on this form is complete and accurate to the best of my knowledge. I understand that intentionally giving incorrect information is considered perjury
and punishable to the fullest extent of the law. I understand that the health plan and its business associates have the right to use protected health
information in connection with the treatment, payment and health plan operations allowed for by HIPAA. I understand that participating in a Flexible
Spending Account (FSA) is completely voluntary, and that payments from my FSA are independently reviewed for compliance with IRS regulations. I
further understand that the IRS requires me to reimburse the Plan for any improper, erroneous or excess reimbursement amount that I do not resolve
within the timeframe provided by the Plan. In accordance with §40.1-29(C) of the Code of Virginia, by enrolling in an FSA I specifically authorize the
Commonwealth of Virginia to withhold from my paycheck on a post-tax basis such amounts as are necessary to replenish my FSA for any improper,
erroneous or excess reimbursement.
Print Your Name ____________________________________________________________________ Assigned ID or Social Security Number ____________________
Sign Here __________________________________________________________________________ Date __________________________________________________
Section 6: Agency Verification and Approval
Date Received _________________________________ Date Keyed ___________________________ BES Effective Date ___________________________
Month/Day/Year
Month/Day/Year
Month/Day/Year
Print Contact Name ____________________________________________ Phone ____________________ Agency/Group Number __________/__________
Important: The daily Agency Transaction Turnaround document is the official record of this change. It is your responsibility to review and confirm this
document to ensure that changes made are accurate.
3/2019 Eligibility and Enrollment Information For Employees
Page 2
2019-20 Language Assistance Statement
State Health Benefits Program
The Commonwealth of Virginia’s State and Local Health Benefits Programs (the "Health Plan")
complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. Our Nondiscrimination Notice lists the services
available and how to file a complaint if you feel that the Health Plan has failed to provide these
services or discriminated in another way.
ATTENTION: If you need help in the language you speak, language assistance services are available
to you free of charge. Send your request for language assistance to
appeals@dhrm.virginia.gov
or
fax to 804-786-0356.
Spanish:
ATENCIÓN: Si necesita ayuda en el idioma que habla, servicios de asistencia lingüística están a su
disposición de forma gratuita. Envíe su solicitud de asistencia lenguaje para
appeals@dhrm.virginia.gov~~V o por fax al 804-786-0356.
Korean:
주의 : 당신이 말하는 언어로 도움이 필요한 경우, 언어 지원 서비스를 무료로 당신에게
사용할 수 있습니다. 804-786-0356에 언어 appeals@dhrm.virginia.gov~~V하는 지원이나 팩스에
대한 요청을 보냅니다.
Vietnamese:
Chú ý: Nếu bạn cần giúp đỡ trong ngôn ngữ bạn nói, các dịch vụ hỗ trợ ngôn ngữ có sẵn cho bạn miễn
phí. Gửi yêu cầu để được hỗ trợ ngôn ngữ để appeals@dhrm.virginia.gov~~V hoặc fax 804-786-0356.
Chinese:
注意:如果你需要在你講的語言幫助,語言協助服務提供給您免費。發送您的語言協助
appeals@dhrm.virginia.gov~~V或傳真至804-786-0356請求。
Arabic:
.‫تنبيه: إذا كنت بحاجة إلى مساعدة باللغة التي تتحدثها، فإن خدمات المساعدة اللغوية متوفرة لك مجا ن ً ا‬
appeals@dhrm.virginia.gov
‫أرسل طلبك للحصول على المساعدة اللغوية عبر البريد اإللكتروني إلى‬
.
804-786-0356
‫الفاكس إلى‬
‫عبر‬
‫أو‬
Persian:
‫توجه: اگر شما نياز به کمک در زبان شما صحبت می کنند، خدمات کمک زبان در دسترس شما هستند رايگان می باشد. ارسال‬
‫درخواست خود را برای کمک به زبان‬appeals@dhrm.virginia.gov~~V
.
0356
-
786
-
804
‫يا فکس به‬
Amharic:
አ ዳ ምጥ : አ ን ተ የ ሚና ገ ሩ ት ቋ ን ቋ እ ር ዳ ታ የ ሚፈ ል ጉ ከ ሆነ , የ ቋ ን ቋ እ ር ዳ ታ አ ገ ል ግ ሎቶ ች ከ ክ ፍ ያ
ነ ፃ ለ እ ር ስ ዎ የ ሚገ ኙ ና ቸ ው. 804-786-0356 ቋ ን ቋ appeals@dhrm.virginia.gov~~V እ ር ዳ ታ ወ ይ ም
በ ፋ ክ ስ ጥ ያ ቄ ዎ ን ይ ላ ኩ.
A10398
1 of 2
2019-20 Language Assistance Statement
3/2019 Eligibility and Enrollment Information For Employees
Page 3
Urdu:
‫بالکل‬
‫ليے‬
‫کے‬
‫آپ‬
‫خدمات‬
‫کی‬
‫مدد‬
‫ميں‬
‫زبان‬
‫تو‬
‫ہے‬
‫درکار‬
‫مدد‬
‫ميں‬
‫زبان‬
‫والی‬
‫جانے‬
‫بولی‬
‫اپنی‬
‫کو‬
‫آپ‬
‫اگر‬
‫فرمائيں‬
‫توجہ‬
:
‫ہيں۔‬
‫دستياب‬
‫مفت‬
‫پر‬
804
-
786
-
0356
‫پر بهيجيں يا‬
appeals@dhrm.virginia.gov
‫واستيں‬
‫درخ‬
‫اپنی‬
‫ليے‬
‫کے‬
‫مدد‬
‫ميں‬
‫زبان‬
‫فيکس کريں۔‬
French:
ATTENTION: Si vous avez besoin d'aide dans la langue que vous parlez, les services d'assistance
linguistique sont à votre disposition gratuitement. Envoyez votre demande d'assistance linguistique
pour appeals@dhrm.virginia.gov~~V ou par télécopieur au 804-786-0356.
Russian:
ВНИМАНИЕ: Если вам нужна помощь на языке вы говорите, переводческие услуги доступны
бесплатно. Отправьте запрос о помощи языка к appeals@dhrm.virginia.gov~~HEAD=pobj~~V
или по факсу 804-786-0356.
Hindi:
ध्यान दें : यदद आपको उस भाषा के लिए मदद की ज़रूरत ह ै , लिस भाषा में आप बात करत े ह ैं , तो आपके लिए भाषा
सहायता से व ाएं लनशु ल् क में उपिब्ध हैं । भाषा की सहायता के लिए अपना अनु र ोध
पर
appeals@dhrm.virginia.gov
या फ ै क्स के लिए 804-786-0356 पर भे ि ें ।
German:
ACHTUNG: Wenn Sie in der Sprache sprechen Sie Hilfe benötigen, die Sprache Hilfeleistungen zur
Verfügung stehen Ihnen kostenlos zur Verfügung. Senden Sie Ihre Anfrage für sprachliche
Unterstützung zu appeals@dhrm.virginia.gov~~V oder Fax an 804-786-0356.
Bengali:
দৃ ষ্ট ি আকর্ষ ণ : আপষ্ট ি ভার্া আপষ্ট ি কথা বলতে সাহায্য প্রত াজি হ , োহতল ভার্া সহা ো সসবা ষ্ট ি খরচা আপিার
জিয উপলব্ধ. appeals@dhrm.virginia.gov~~V অথবা ফ্যাক্স ভার্া সহা ো 804-786-0356 করার জিয
আপিার অিু ত রাধ পাঠাি.
Bassa:
Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m ̀ [Ɓàsɔ ́ ɔ ̀ - wùɖù-po-nyɔ ̀ ] jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ ̀ ɓ ɛ ́ ì n m ̀
gbo kpáa. Ɖá 804-786-0353.
Igo (Igbo):
Ntị: Ọ bụrụ na ị chọrọ enyemaka na asụsụ ị na-asụ, asụsụ aka ọrụ dị ka ị n'efu. Send gị arịrịọ maka
asụsụ aka appeals@dhrm.virginia.gov~~V ma ọ bụ faksị ka 804-786-0356.
Yoruba:
Akiyesi: Ti o ba nilo iranlọwọ ninu ede ti o sọrọ, ede iranlowo iṣẹ ni o wa wa si o free ti idiyele. Fi
ìbéèrè rẹ fun ede iranlowo to appeals@dhrm.virginia.gov tabi Faksi to 804-786-0356.
Filipino(Tagalog):
Pansin: Kung kailangan mo ng tulong sa wikang nagsasalita ka, serbisyo ng tulong sa wika ay
magagamit sa iyo nang walang bayad. Ipadala ang iyong kahilingan para sa tulong sa wika upang
appeals@dhrm.virginia.gov~~V o fax sa 804-786-0356.
2019-20 Language Assistance Statement
2 of 2
3/2019 Eligibility and Enrollment Information For Employees
Page 4
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