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• Type or print clearly in black ink. Inaccurate, incomplete, or illegible information may delay coverage. • List eligible family members you wish to cover or remove from coverage. This form replaces all Employee Enrollment/ Change forms previously submitted. 2016 Employee Enrollment/Change Additional changes you can make during the PEBB Program’s annual open enrollment All changes become effective January 1 of the following year. Check the box(es) next to the change requested. Add dependent(s) Change dental plan Remove dependent(s) Enroll after waiving medical coverage Change medical plan Waive medical coverage due to enrollment in other employer-based group medical insurance, TRICARE, or Medicare. HCA 50-400 (10/15) Are you making changes to an existing account? Yes If yes, what changes? (Check all that apply in the sections below.) No (If no, go to Section Changes you can make anytime Give date of event/change Name change Address change Remove dependent(s) from coverage due to loss of eligibility (divorce, dissolution of state-registered domestic partnership, death, or other loss of eligibility for PEBB benefits). Your personnel, payroll, or benefits office must receive this form no later than 60 days after the event. If applicable, provide former dependent’s new address: Additional changes you can make if an event creates a special open enrollment The PEBB Program only allows changes outside of annual open enrollment when an event creates a special open enrollment. The change must be allowable under Internal Revenue Code and correspond to and be consistent with a special open enrollment event for the subscriber, the subscriber’s dependent, or both. You are required to provide proof of the event. Your personnel, payroll, or benefits office must receive this form and proof of the event no later than 60 days after the event. However, if adding a newborn or newly adopted child increases your premium, you must submit this form no later than 12 months after the birth or adoption. Check the box next to each change you are requesting and indicate the corresponding event(s) on the following page. In most cases, the enrollment or change will be effective the first day of the month after the event date or the date this form is received, whichever is later. Add dependent(s) (allowable under events 1, 2, 3, 4, 5, 6, 7, 9, 10, 11) Enroll after waiving medical coverage (allowable under events 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 15, 16) Change medical plan (allowable under events 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14) Change dental plan (allowable under events 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14) Remove dependent(s) (allowable under events 1, 5, 6, 9, 10, 15, 16) Waive medical coverage due to enrollment in other employer-based group medical insurance, TRICARE, or Medicare. (allowable under events 1, 5, 6, 9, 10, 15,16) Give date of event (this section continued on next page) Agency name Agency/subagency Insurance effective date Hire date Subscriber’s last name First name Middle initial Social Security number 1 (continued) Clear Form ---PAGE BREAK--- Additional changes you can make if an event creates a special open enrollment (continued from previous page) Check the box(es) next to the corresponding event(s). The event number below must be listed next to the change(s) you are requesting on the previous page. 1. Marriage, registering a domestic partner, as defined by Washington Administrative Code 182-12-260(2), birth, adoption, or assuming a legal obligation for total or partial support in anticipation of adoption. Also complete a Declaration of Tax Status form if adding a registered domestic partner and/or his or her eligible children. 2. Child becoming eligible as an extended dependent through legal custody or legal guardianship. Also complete an Extended Dependent Certification form. 3. Child becoming eligible as a dependent with a disability. Also complete a Certification of Dependent With a Disability form. 4. Employee or dependent losing other coverage under a group health plan or through health insurance, as defined by the Health Insurance Portability and Accountability Act (HIPAA). 5. Employee or dependent having a change in employment status that affects the employee’s or dependent’s eligibility for their employer contribution toward employer-based group health insurance. 6. Employee or dependent having a change in enrollment under another employer-based group health insurance during its annual open enrollment that does not align with the PEBB Program’s annual open enrollment. 7. Employee’s dependent moving from outside the United States to live within the United States or moving from inside the United States to live outside the United States. 8. Employee or dependent having a change in residence that affects health plan availability. 9. A court order or National Medical Support Notice requiring the employee or any other individual to provide insurance coverage for an eligible child of the employee. 10. Employee or a dependent becoming entitled to or losing eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP). 11. Employee or dependent becoming eligible for a state premium assistance subsidy for PEBB health coverage from Medicaid or a state Children’s Health Insurance Program (CHIP). 12. Employee or dependent becoming entitled to or losing eligibility for Medicare, or enrolling in or cancelling enrollment in a Medicare Part D plan. 13. Employee’s or dependent’s current health plan becoming unavailable because the employee or dependent is no longer eligible for a health savings account (HSA). 14. Employee or dependent experiencing a disruption of care that could function as a reduction in benefits for the employee or his or her dependent for a specific condition or ongoing course of treatment (requires approval by the PEBB Program). 15. Employee or dependent becomes eligible and enrolls in TRICARE, or loses eligibility for TRICARE. 16. Employee becomes eligible and enrolls in Medicare, or loses eligibility for Medicare. Forms available at www.hca.wa.gov/pebb . Are you or any eligible dependents already enrolled in PEBB coverage under another account? q Yes q No If yes, please contact your personnel, payroll, or benefits office for assistance. Subscriber’s last name First name Middle initial Social Security number 2016 Employee Enrollment/Change 2 (continued) ---PAGE BREAK--- (continued) 2016 Employee Enrollment/Change 3 Section 1: Subscriber Information Social Security number Last name First name Middle initial Sex M F Street address Apt./unit number City State ZIP Code Mailing address (if different from above) Apt./unit number City State ZIP Code County of residence Date of birth (mm/dd/yyyy) Work phone number ( ) Home phone number ( ) Medical coverage Cover Waive: effective _If waiving, see Section 6. Note: If you waive coverage, you must be enrolled in other employer- _based group medical insurance TRICARE or Medicare. You cannot enroll your eligible dependents in medical. Dental coverage Cover (Dental may not be waived.) Tobacco Use Premium Surcharge The PEBB Program requires a $25 surcharge in addition to your premium if you or a family member (age 13 or older) enrolled on your PEBB medical coverage uses a tobacco product. Tobacco use is defined as any use of tobacco products within the past two months except for religious or ceremonial use. If you check YES or leave the check boxes blank, you will pay the $25 surcharge. See the 2016 Premium Surcharge Help Sheet for instructions on how to respond. Does the tobacco use premium surcharge apply to you? Check one: YES, I have used tobacco products in the past two months. NO, or I have used the tobacco cessation resources noted in the 2016 Premium Surcharge Help Sheet. Section 2: Spouse or Registered Domestic Partner Information • List an eligible spouse or registered domestic partner, as defined by Washington Administrative Code 182-12-260(2), you wish to cover or remove from coverage. • You may skip this section if you are not enrolling a spouse or registered domestic partner. • Family members cannot be enrolled in two PEBB medical or dental accounts at the same time. • If adding a spouse or registered domestic partner, you must provide proof of eligibility within PEBB’s enrollment timelines or the spouse or registered domestic partner will not be enrolled. • Forms and a list of documents we will accept to verify eligibility are available at www.hca.wa.gov/pebb . Relationship to subscriber (If adding a registered domestic partner, please attach a completed Declaration of Tax Status form.) Spouse: date of marriage Registered domestic partner: date registered Social Security number Last name First name Middle initial Sex M F Street address (only if different from subscriber) Apt./unit number City State ZIP Code Date of birth (mm/dd/yyyy) Medical coverage Cover Remove from medical coverage Reason_ Dental coverage Cover Remove from dental coverage Reason_ Tobacco Use Premium Surcharge Does the tobacco use premium surcharge apply to your spouse or registered domestic partner? Check one: YES, my spouse or registered domestic partner has used tobacco products in the past two months. NO, or my spouse or registered domestic partner has used the tobacco cessation resources noted in the 2016 Premium Surcharge Help Sheet. ---PAGE BREAK--- A Relationship to subscriber Check only if age 26 or older. Disabled? Yes No Extended dependent validated by court order? Yes No Social Security number Last name First name Middle initial Sex M F Date of birth (mm/dd/yyyy) Street address (only if different from subscriber) Apt./unit number City State ZIP Code Medical coverage Cover Remove from medical coverage Reason _ Dental coverage Cover Remove from dental coverage Reason _ Tobacco Use Premium Surcharge Does the tobacco use premium surcharge apply to this family member? (Response required for family members ages 13 and older.) Check one: YES, this family member has used tobacco products in the past two months. NO, or this family member has used the tobacco cessation resources noted in the 2016 Premium Surcharge Help Sheet. Subscriber’s last name First name Middle initial Social Security number 2016 Employee Enrollment/Change 4 (continued) Section 3: Family Member Information (such as a child) Use additional forms for more members. • You may skip this section if you are not enrolling additional family members. • List eligible family members you wish to cover or remove from coverage. • Family members cannot be enrolled in two PEBB medical or dental accounts at the same time. • If adding a family member, you must provide proof of eligibility for each family member within PEBB’s enrollment timelines or the family member will not be enrolled. If adding a child of your registered domestic partner, also attach a Declaration of Tax Status form. • Attach an Extended Dependent Certification form if enrolling an extended dependent. If enrolling a dependent with a disability age 26 or older, submit a completed Certification of Dependent With a Disability form as instructed on the form. Refer to the 2016 Employee Enrollment Guide for eligibility information. • Forms and a list of documents we will accept to verify eligibility are available at www.hca.wa.gov/pebb . Section 2: Spouse or Registered Domestic Partner Information (continued from previous page) Spouse or Registered Domestic Partner Coverage Premium Surcharge The PEBB Program requires a $50 surcharge in addition to your premium if you are enrolling your spouse or registered domestic partner in PEBB medical coverage and your spouse or registered domestic partner has elected not to enroll in other employer-based group medical insurance that is comparable to Uniform Medical Plan Classic. See the 2016 Premium Surcharge Help Sheet for instructions on how to respond. If you check YES below or leave this section blank, you will pay the surcharge. Does the spouse or registered domestic partner coverage surcharge apply to you? Check one: YES, I used the 2016 Premium Surcharge Help Sheet and completed the 2016 Spousal Plan Calculator online. NO, I used the 2016 Premium Surcharge Help Sheet and, if needed, completed the 2016 Spousal Plan Calculator online. Which questions, if any, on the 2016 Premium Surcharge Help Sheet did you check NO? Check all that apply. Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Employer to determine. I used the 2016 Premium Surcharge Help Sheet and am completing and submitting a printed 2016 Spousal Plan Calculator. My employer will determine whether my spouse’s or registered domestic partner’s employer-based group medical insurance is comparable to UMP Classic. The 2016 Premium Surcharge Help Sheet and the 2016 Spousal Calculator are available at www.hca.wa.gov.pebb . To change your attestation, use the 2016 Premium Surcharge Change Form. ---PAGE BREAK--- B Relationship to subscriber Check only if age 26 or older. Disabled? Yes No Extended dependent validated by court order? Yes No Social Security number Last name First name Middle initial Sex M F Date of birth (mm/dd/yyyy) Street address (only if different from subscriber) Apt./unit number City State ZIP Code Medical coverage Cover Remove from medical coverage Reason _ Dental coverage Cover Remove from dental coverage Reason _ Tobacco Use Premium Surcharge Does the tobacco use premium surcharge apply to this family member? (Response required for family members ages 13 and older. Check one: YES, this family member has used tobacco products in the past two months. NO, or this family member has used the tobacco cessation resources noted in the 2016 Premium Surcharge Help Sheet. C Relationship to subscriber Check only if age 26 or older. Disabled? Yes No Extended dependent validated by court order? Yes No Social Security number Last name First name Middle initial Sex M F Date of birth (mm/dd/yyyy) Street address (only if different from subscriber) Apt./unit number City State ZIP Code Medical coverage Cover Remove from medical coverage Reason _ Dental coverage Cover Remove from dental coverage Reason _ Tobacco Use Premium Surcharge Does the tobacco use premium surcharge apply to this family member? (Response required for family members ages 13 and older. Check one: YES, this family member has used tobacco products in the past two months. NO, or this family member has used the tobacco cessation resources noted in the 2016 Premium Surcharge Help Sheet. D Relationship to subscriber Check only if age 26 or older. Disabled? Yes No Extended dependent validated by court order? Yes No Social Security number Last name First name Middle initial Sex M F Date of birth (mm/dd/yyyy) Street address (only if different from subscriber) Apt./unit number City State ZIP Code Medical coverage Cover Remove from medical coverage Reason _ Dental coverage Cover Remove from dental coverage Reason _ Tobacco Use Premium Surcharge Does the tobacco use premium surcharge apply to this family member? (Response required for family members ages 13 and older. Check one: YES, this family member has used tobacco products in the past two months. NO, or this family member has used the tobacco cessation resources noted in the 2016 Premium Surcharge Help Sheet. Subscriber’s last name First name Middle initial Social Security number 2016 Employee Enrollment/Change 5 (continued) ---PAGE BREAK--- Subscriber’s last name First name Middle initial Social Security number 2016 Employee Enrollment/Change 6 Section 4: Medical Plan Selection Check only one. Contact the plans for benefits information; their contact information is at the end of this form. Kaiser Foundation Health Plan of the Northwest Kaiser Permanente Classic Kaiser Permanente Consumer-Directed Health Plan Uniform Medical Plan, administered by Regence BlueShield UMP Classic UMP Consumer-Directed Health Plan UMP Plus-Puget Sound High Value Network UMP Plus-UW Medicine Accountable Care Network Section 5: Dental Plan Selection Check only one. Contact the plans for benefits information; their contact information is located below and at the end of this form. Preferred Provider Organization Uniform Dental Plan, administered by Delta Dental of Washington (Group #3000) (You may receive services from any provider.) Managed-Care Plans You must choose a provider from the dental plan network. Before you select a managed-care plan, be sure to call the dental plan to verify your provider is in their network and fill in the requested information below. DeltaCare, administered by Delta Dental of Washington (Group #3100) Call DeltaCare at 1-[PHONE REDACTED] to verify your provider is in the DeltaCare PEBB network. Dentist name or clinic code (You must receive services from a DeltaCare network provider.) Willamette Dental of Washington, Inc. administered by Willamette Dental Group (no group number). Call Willamette at 1-[PHONE REDACTED] to verify your provider is in the Willamette Dental Group network. Clinic location (You must receive services from a Willamette Dental Group plan provider.) Group Health Cooperative Group Health Classic Group Health SoundChoice Group Health Value Group Health Options Inc. Group Health Consumer-Directed Health Plan Please sign and date this form on the next page. (continued) ---PAGE BREAK--- Please sign and date this form. Return completed form and documentation to your personnel, payroll, or benefits office. Section 6: Signature Required By signing this form, I declare that the information I have provided is true, complete, and correct. If it isn’t, or if I do not update this information within the timelines in PEBB rules, to the extent permitted by federal and state laws, I must repay any claims paid by my health plan(s) or premiums paid on my behalf. My family members and I may also lose PEBB benefits as of the last day of the month we were eligible. To the extent permitted by law, PEBB or my employer may retroactively terminate coverage for me and my dependents if I intentionally misrepresent eligibility, or do not fully pay premiums when due. In addition, I understand that knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company is a crime, and can result in imprisonment, fines, denial of PEBB benefits, and loss of my job. If adding a registered domestic partner to my account, I declare that my domestic partner and I have registered through the Washington Secretary of State’s Office or another state. Enrollment is not complete until verification of the family member’s eligibility is successful. I understand that if I’m applying to add a dependent to my PEBB coverage, I must provide copies of documents that verify the dependent’s eligibility within PEBB’s enrollment timelines, or the dependent will not be enrolled. Employees must enroll in PEBB dental, basic life, and basic long-term disability insurance. However, employees may waive PEBB medical if they are enrolled in other employer-based group medical insurance, TRICARE, or Medicare. If I waive medical, I understand I can enroll during the annual open enrollment period or within 60 days after a special open enrollment event as defined in PEBB rules. If I waive medical for myself, I cannot enroll my eligible family members in medical. I allow my employer to deduct money from my earnings to pay for insurance coverage and any applicable surcharges. If I am enrolling in a consumer-directed health plan with a health savings account (HSA), I must meet HSA eligibility conditions. I understand that my employer will contribute to an HSA on my behalf based on the information I have provided, and that there are limits to these contributions and my HSA contributions (if any) under federal tax law. I understand if I am enrolled in retiree life insurance, I may keep it by completing and submitting the Employee Life and AD&D Insurance Enrollment/Change Form and having the premiums deducted from my paycheck. This form replaces all Employee Enrollment/Change forms previously submitted. HCA’s Privacy Notice: We will keep your information private as allowed by law. To see our Privacy Notice, go to www.hca.wa.gov/pebb. Subscriber’s signature Date_ Subscriber’s last name First name Middle initial Social Security number 2016 Employee Enrollment/Change 2016 PEBB Medical Contractors Group Health Cooperative 320 Westlake Ave. Suite 100, Seattle, WA 98109-5233 1-[PHONE REDACTED] or TTY 1-[PHONE REDACTED] Group Health Options Inc. 320 Westlake Ave. N, Suite 100, Seattle, WA 98109-5233 1-[PHONE REDACTED] or TTY 1-[PHONE REDACTED] Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah St., Suite 100, Portland, OR 97232-2099 1-[PHONE REDACTED] or TTY 711 Uniform Medical Plan, administered by Regence BlueShield 1800 Ninth Avenue, Suite 235, Seattle, WA 98101 1-[PHONE REDACTED] or TTY 711 2016 PEBB Dental Contractors DeltaCare, administered by Delta Dental of Washington 9706 Fourth Avenue NE, Seattle, WA 98115-2157 1-[PHONE REDACTED] Uniform Dental Plan, administered by Delta Dental of Washington 9706 Fourth Avenue NE, Seattle, WA 98115-2157 1-[PHONE REDACTED] Willamette Dental of Washington, Inc. 6950 NE Campus Way, Hillsboro, OR 97124-5611 1-855-4DENTAL (1-[PHONE REDACTED]) 7