Full Text
City of Woodburn Health Insurance Declination Employee Waiver Form City of Woodburn offers Medical/Vision and Dental employer-sponsored group insurance enrollment options for both the employee only and the employee and eligible dependents. Employees may decline coverage subject to the following: • Opt-out o For an employee covered under another group health insurance plan. o Employee is eligible to receive opt-out compensation of $100 per month. The opt- out amount the employee receives is considered taxable income payable as salary. o Employees who choose the medical/vision opt-out option can still enroll in dental coverage. • Waive o If you are covered under Medicare, Tricare, Oregon Health Plan (Medicaid), Veteran’s Administration (VA) Benefit Programs, Tribal Benefit Programs, Individual Marketplace Coverage, Student Health Insurance Coverage, or any other federal, state, or tribal subsidized health insurance program, and waive City of Woodburn employer-sponsored group insurance coverage then you are not eligible for opt-out compensation. This form, along with accompanying proof of other coverage, if applicable, must be received by Human Resources Department in accordance with newly eligible or open enrollment deadlines, or within 60 days of an eligibility or status change event. Name (Please print): Please check one: Opt-Out – Other Group Health Insurance Coverage: I am covered by other group health insurance, and I elect to opt-out of employer-sponsored group health insurance offered to me by City of Woodburn, and to receive the opt-out compensation. I understand that opt- out compensation is considered taxable income payable to the employee as salary and shall not, under any circumstances, be considered a reimbursement or subsidy for purchase of an individual health insurance plan. I have attached proof of other group health insurance coverage to this form. I understand that failure to provide proof of other group health insurance coverage within the submission deadline will result in denial of the opt-out, and I will not be able to enroll in City of Woodburn employer-sponsored group health insurance or elect to opt out with compensation until the next Open Enrollment period unless I experience a qualified event or status change as defined in the Plan Rules. ---PAGE BREAK--- Waive – No Other Health Insurance Coverage: I am not covered by any other insurance, and I wish to waive the employer-sponsored group health insurance offered to me by City of Woodburn. I understand that I am not eligible for opt out compensation and I will not be able to enroll in City of Woodburn employer-sponsored group health insurance coverage, or elect to opt out with compensation, until the next Open Enrollment period unless I experience a qualified event or status change as defined in the Plan Rules. Waive – Other Subsidized Health Insurance: I am eligible for federal, state, or tribal subsidized health insurance (as described above) and elect to waive the employer- sponsored group health insurance offered to me by City of Woodburn. I understand that I am not eligible for opt-out compensation. I further understand that it is my responsibility to check with my subsidized health insurance provider to determine the implications of waiving City of Woodburn employer-sponsored group health insurance coverage on my eligibility for the subsidized health insurance plan. I hereby certify that information on the City of Woodburn’s employer-sponsored group health plan has been provided to me. I understand that the City offered me a compliant employer- sponsored group health plan as defined by the Affordable Care Act (ACA). I elect to decline participation in the City’s employer-sponsored group health plan at this time for the above reason. I understand that by electing not to enroll in the City’s ACA compliant plan that I will not be eligible for a premium subsidy at either a state based or federally operated insurance exchange. I understand that failure to enroll in a City sponsored group health insurance plan may effect my eligibility for federal / state / tribal insurance and hereby agree to release, indemnify, defend and hold harmless the City and its officers, agents and employees from any loss, liability, claims, costs, or damages that may occur or be claimed with regard to my coverage through federal / state / tribal subsidized insurance. Employee Signature: Date: SIGN