"Employee Enrollment Application Form - New Mexico Public Schools Insurance" - New Mexico

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Former Employer
Basic Life Eff. Date
Other Cvrg Eff. Date
MEDICAL
DENTAL
VISION
DISABILITY
ADDITIONAL LIFE
For Employer Use:
(if covered under NMPSIA)
(mm/dd/yyyy)
(mm/dd/yyyy)
$
$
$
$
$
PAYROLL DEDUCTIONS
District/Entity Name
District/Entity #
New Mexico Public Schools Insurance Authority
EMPLOYEE ENROLLMENT APPLICATION
RESET FORM
Eligibility Administrative Office (505) 988-4974 (800) 233-3164 FAX (505) 988-8943
1
Social Security Number
Name
Date of Birth
(Last, First, Middle)
(mm/dd/yyyy)
Mailing Address
City
State
Zip Code
Home Phone Number
Marital Status
Gender
E-Mail Address
Work Phone Number
Cell Phone Number
By furnishing my e-mail address on this form, I am consenting to receive
communications related to my participation in NMPSIA’s benefit program by e-mail.
S
M
F
M
Check this box if you do not wish to receive plan communications by e-mail.
2
ENROLLMENT STATUS
Employee Only
2-Party (Employee + Spouse or Child)
Family (Employee + 2 or more)
3
ENROLLMENT
Elect your coverage offered by your employer
BASIC LIFE: The Standard (Paid in full by employer. Complete Schedule A Beneficiary Form)
MEDICAL:
Decline Medical. Reason for declining
Blue Cross Blue Shield NM (Default)
Presbyterian
New Mexico Health Connections
coverage:
OR
High Option (Default)
Low Option
HMO Option
Are you eligible for Medicaid?
Yes
No
DENTAL: United Concordia
High Option (Default)
Low Option
Decline Dental
VISION: Davis Vision (2 year enrollment required)
Decline Vision
LONG TERM DISABILITY: The Standard
Decline Long Term Disability
ADDITIONAL LIFE:
The Standard
Select:
1X
2X
3X Base Annual Salary
Decline Employee Additional Life
(Complete Schedule A Beneficiary Form)
Spouse Life
Child Life
Decline Dependent Life
DEPENDENT INFORMATION
List employee and all dependents with SSN. Indicate an A (add) or N/A (not applicable) for each person listed.
4
Please provide requested information for additional dependents on separate sheet if necessary.
Dependent’s
Proof of Marriage,
Social Security
Add’l
Date of Birth
Med
Dntl
Visn
Dependent’s Name
Gender
Relationship to
Birth, or Court
(Last, First, Middle)
Number
Life
(mm/dd/yyyy)
You
Order Attached
(REQUIRED)
F
M
Yes
No
F
M
Yes
No
F
M
Yes
No
F
M
Yes
No
5
EMPLOYEE AUTHORIZATION STATEMENT
I hereby authorize my school district/employer to deduct from my earnings until further written notice, amounts equal to the contribution required of me toward the plan(s) herein enrolled. I hereby apply to the Authority
for the coverage offered to myself and dependents shown above. I understand that services will be available subject to the exclusions, limitations and the conditions described in the Master Group Insurance Policies.
I authorize any hospital, physician, or other health care provider to furnish (when applicable) to the Insurance Carrier such medical information as it may require for myself and my dependents. I authorize the
Insurance Carrier to coordinate benefits and/or reimbursements with other health plans or insurance companies. Under penalties of perjury and insurance fraud, I declare that I have examined this application and
supporting documentation, and to the best of my knowledge and belief, they are true, correct, and complete. Read reverse side before signing.
EMPLOYEE SIGNATURE
DATE
RETURN THIS FORM TO YOUR EMPLOYEE BENEFITS OFFICE NO LATER THAN 31 DAYS FROM YOUR DATE OF HIRE
6
EMPLOYER CERTIFICATION
ALL INFORMATION IN THIS SECTION IS REQUIRED TO DETERMINE ELIGIBILITY. PLEASE COMPLETE THIS SECTION THOROUGHLY.
I attest that to the best of my knowledge that this applicant is an employee of my district/entity (or meets the one-bus owner definition) and works the minimum number of hours per week required for NMPSIA benefits.
Date of Hire
Base Annual Salary
# of hours
Date Eligible
Job Title
Date Received in Your
(First day to report
(Do not include increments or stipends:
worked weekly
Variable hour, part-
for Benefits
Office
to work)
i.e., coaching, prep time. etc.)
time, or seasonal
(Apply Date Stamp)
employee
$
BENEFITS SPECIALIST SIGNATURE
DATE
Revised October 2016
Former Employer
Basic Life Eff. Date
Other Cvrg Eff. Date
MEDICAL
DENTAL
VISION
DISABILITY
ADDITIONAL LIFE
For Employer Use:
(if covered under NMPSIA)
(mm/dd/yyyy)
(mm/dd/yyyy)
$
$
$
$
$
PAYROLL DEDUCTIONS
District/Entity Name
District/Entity #
New Mexico Public Schools Insurance Authority
EMPLOYEE ENROLLMENT APPLICATION
RESET FORM
Eligibility Administrative Office (505) 988-4974 (800) 233-3164 FAX (505) 988-8943
1
Social Security Number
Name
Date of Birth
(Last, First, Middle)
(mm/dd/yyyy)
Mailing Address
City
State
Zip Code
Home Phone Number
Marital Status
Gender
E-Mail Address
Work Phone Number
Cell Phone Number
By furnishing my e-mail address on this form, I am consenting to receive
communications related to my participation in NMPSIA’s benefit program by e-mail.
S
M
F
M
Check this box if you do not wish to receive plan communications by e-mail.
2
ENROLLMENT STATUS
Employee Only
2-Party (Employee + Spouse or Child)
Family (Employee + 2 or more)
3
ENROLLMENT
Elect your coverage offered by your employer
BASIC LIFE: The Standard (Paid in full by employer. Complete Schedule A Beneficiary Form)
MEDICAL:
Decline Medical. Reason for declining
Blue Cross Blue Shield NM (Default)
Presbyterian
New Mexico Health Connections
coverage:
OR
High Option (Default)
Low Option
HMO Option
Are you eligible for Medicaid?
Yes
No
DENTAL: United Concordia
High Option (Default)
Low Option
Decline Dental
VISION: Davis Vision (2 year enrollment required)
Decline Vision
LONG TERM DISABILITY: The Standard
Decline Long Term Disability
ADDITIONAL LIFE:
The Standard
Select:
1X
2X
3X Base Annual Salary
Decline Employee Additional Life
(Complete Schedule A Beneficiary Form)
Spouse Life
Child Life
Decline Dependent Life
DEPENDENT INFORMATION
List employee and all dependents with SSN. Indicate an A (add) or N/A (not applicable) for each person listed.
4
Please provide requested information for additional dependents on separate sheet if necessary.
Dependent’s
Proof of Marriage,
Social Security
Add’l
Date of Birth
Med
Dntl
Visn
Dependent’s Name
Gender
Relationship to
Birth, or Court
(Last, First, Middle)
Number
Life
(mm/dd/yyyy)
You
Order Attached
(REQUIRED)
F
M
Yes
No
F
M
Yes
No
F
M
Yes
No
F
M
Yes
No
5
EMPLOYEE AUTHORIZATION STATEMENT
I hereby authorize my school district/employer to deduct from my earnings until further written notice, amounts equal to the contribution required of me toward the plan(s) herein enrolled. I hereby apply to the Authority
for the coverage offered to myself and dependents shown above. I understand that services will be available subject to the exclusions, limitations and the conditions described in the Master Group Insurance Policies.
I authorize any hospital, physician, or other health care provider to furnish (when applicable) to the Insurance Carrier such medical information as it may require for myself and my dependents. I authorize the
Insurance Carrier to coordinate benefits and/or reimbursements with other health plans or insurance companies. Under penalties of perjury and insurance fraud, I declare that I have examined this application and
supporting documentation, and to the best of my knowledge and belief, they are true, correct, and complete. Read reverse side before signing.
EMPLOYEE SIGNATURE
DATE
RETURN THIS FORM TO YOUR EMPLOYEE BENEFITS OFFICE NO LATER THAN 31 DAYS FROM YOUR DATE OF HIRE
6
EMPLOYER CERTIFICATION
ALL INFORMATION IN THIS SECTION IS REQUIRED TO DETERMINE ELIGIBILITY. PLEASE COMPLETE THIS SECTION THOROUGHLY.
I attest that to the best of my knowledge that this applicant is an employee of my district/entity (or meets the one-bus owner definition) and works the minimum number of hours per week required for NMPSIA benefits.
Date of Hire
Base Annual Salary
# of hours
Date Eligible
Job Title
Date Received in Your
(First day to report
(Do not include increments or stipends:
worked weekly
Variable hour, part-
for Benefits
Office
to work)
i.e., coaching, prep time. etc.)
time, or seasonal
(Apply Date Stamp)
employee
$
BENEFITS SPECIALIST SIGNATURE
DATE
Revised October 2016
Please read the NMPSIA Program Guide (provided to you by your
letter of insurance verification, insurance ID card with dependent’s name
employee benefits office) as you complete this change card.
listed, etc.). If you are excluding a dependent and do not provide this
evidence, the dependents you are enrolling will suffer a delay in coverage
This Guide outlines the NMPSIA Eligibility Rules and administrative
until such evidence is provided. There is a 61-day deadline from your
guidelines for enrollment. If you do not have this Guide, you can obtain a
effective date of coverage to provide such evidence.
copy
from
your
school
district/entity
benefits
office
or
If both you and your spouse work for the same employer or for another
at https://nmpsia.com.
NMPSIA affiliated employer, you and your spouse cannot double insure
ELIGIBILITY
each other and your dependents under the NMPSIA Group Plan for any
line of NMPSIA coverage. (i.e., You work for Las Cruces Schools and
If you are reporting a change in status, you must turn in this form within
carry family medical, dental, vision, additional life insurance coverage for
31 days from your qualifying event.
yourself, your spouse, and your children. Your spouse who is employed
Contractors are not eligible to participate in NMPSIA coverage,
with Deming Schools cannot apply for family coverage to insure him, you
except for one-bus owners. Fleet bus owners and their employees are
and your children for these lines of NMPSIA coverage since you already
not eligible to participate in NMPSIA coverage.
carry this NMPSIA coverage at Las Cruces Schools.
You and your
spouse may decide it is best to carry the additional life independent from
To be eligible for NMPSIA Group Coverage, you must work the minimum
each other, and then the children can be insured either under your plan
number of hours per week established by your employer. In most cases,
or your spouse’s plan.)
employees are eligible for basic life insurance coverage when they work
a minimum of 15 hours per week. In most cases employees are eligible
To enroll your spouse and/or your married or unmarried children (who are
for all other lines of coverage when they work a minimum of 20 hours per
up to 26 years old) for any line of NMPSIA coverage offered by your
week. Variable hour, seasonal, or part-time employees should confirm
employer, you will be required to present your employee benefits office
eligibility for benefits with their Employee Benefits Office.
with copies of the supportive documentation to prove eligibility for your
Basic life insurance coverage is effective the first day of the month
dependents.
following your date of hire -- first day actively at work on contract. If you
To enroll your spouse, present your official state publicly filed
meet this requirement, your employer will enroll you in basic life even if
marriage certificate (from the County Clerk’s Office). You may provide
you decline (or are not eligible to participate) in any other line of NMPSIA
a chapel marriage certificate, but NMPSIA reserves the right to request
coverage. Subject to the actively at work provision, the effective date for
the official state copy at any time. If you divorce, you must report this
all your other lines of coverage is determined by your employer. This
within 31 days and cancel coverage for your ex-spouse effective the last
effective date can never be any sooner than your basic life effective date
day of the month the divorce is final. You will be required to provide
and can never be made retroactive (prior to the date you officially apply).
copies of certain pages of your final divorce decree. Covering an ex-
SALARY INFORMATION
spouse is considered misrepresentation.
NMPSIA uses your base annual salary to determine your additional life
To enroll your married or unmarried children (who are up to 26 years old)
(ADL) coverage and long term disability (LTD) coverage. For ADL and
for any line of NMPSIA coverage offered by your employer, present their
LTD insurance purposes, your employer will not prorate your salary if you
official state publicly filed birth certificates (from the Bureau of Vital
begin after the school year AND your employer will not include salary
Statistics).
You may provide hospital birth certificates, but NMPSIA
increments for other duties, such as coaching, department head,
reserves the right to request the official state copy at any time.
yearbook, etc.)
Coverage for your dependents will begin on your effective date of
coverage when you provide your employee benefits office with the
ENROLLMENT
appropriate supportive documentation at the time of application or prior to
You may only apply for the lines of NMPSIA coverage offered by your
your coverage going into effect. You have 61 days from your effective
employer.
date of coverage or 61 days from your qualifying event to provide the
appropriate supportive documentation for your dependents, but their
Please keep the following in mind:
effective date of coverage will be on the first day of the month following
● If you decline medical coverage within 31 days of becoming eligible,
the date your employee benefits office receives this documentation.
you may apply to enroll in NMPSIA medical coverage within 31 days
Coverage for your dependents will not be made retroactive. If you do not
from a qualifying event or special enrollment event, or enroll during
provide this information within 61 days, you may apply to cover your
open enrollment for dental/vision in the fall with an effective date of
dependents during the established open enrollment period in the fall for
January 1st.
coverage that will become effective on January 1.
● You may enroll as employee only for any line of NMPSIA coverage.
Medical and Prescription Drug Coverage – If you enroll in the medical
● If you enroll in vision coverage, you and each of your enrolled
plan, you are automatically enrolled in the Prescription Drug Program.
dependents must meet the 24-month enrollment requirement before
You will receive a separate ID card from the NMPSIA Prescription Drug
you can cancel this coverage.
Manager to purchase your prescription drugs.
● If you enroll for ADL coverage, you may apply for coverage up to 1x,
BENEFICIARY INFORMATION
2x, or 3x your base annual salary.
You may also apply for life
Complete a Schedule A form to make your selection(s) for your
coverage for your spouse at the rate of 1x your salary or 50% of your
beneficiary for basic life and/or additional life coverage. You may change
additional life coverage, whichever is less. You may also insure your
your beneficiary designation at any time.
If you do not designate a
dependent children for $5,000 of life coverage.
beneficiary for your life insurance, the life insurance carrier will apply its
● If you decline ADL or LTD coverage, you may apply through the
established processes to determine the individual(s) entitled to your life
evidence of insurability process.
The carrier will make a
benefit.
determination on this application.
CONFIRMATION OF ENROLLMENT
● If you decline dental and/or vision coverage, you may not enroll late to
either of these plans unless you apply within 31 days from
Once your enrollment has been processed, the NMPSIA Eligibility
involuntarily losing other dental and/or vision coverage, or enroll
Administrative Office will email you or mail you a Confirmation of
during the open enrollment for dental/vision in the fall with an effective
Enrollment Notice to your home (and to your employer). Please review
date of January 1st.
this confirmation notice carefully and report any discrepancies to your
Employee Benefits Office or to the NMPSIA Eligibility Administrative
Indicate the status (employee only, two-party, or family) for each line of
Office at 1 (800) 233-3164.
coverage. If you enroll one eligible dependent, you must enroll all eligible
dependents, unless one or more dependents have other coverage.
If you do not provide your employer with all of the appropriate
When enrolling dependents, you may exclude a dependent from a
documentation necessary to finalize your enrollment request, you will be
particular line of NMPSIA coverage only if you provide evidence that the
contacted for the appropriate
documentation. Please be sure to adhere
dependent you are excluding has that particular line of coverage
to all deadlines associated with this request.
elsewhere. In this case, evidence of the other coverage is required (i.e.,
Revised October 2016
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