HomeMy WebLinkAboutBenefit Enrollment Form_Active Employee 20261 5/17/2023
Benefit
Enrollment Form
Effective Date:
Group Name: Otay Water District
County: San Diego
Open Enrollment Add Dependent; Qualifying Event ; Qualifying Event Date _______ _ _______________________
New Enrollment Other
Delete Dependent
SELECTED COVERAGE (Select one)
Medical
Note: HMO Plans are not available for out-of-state participants.
Dental Group
Group # 00001- ACTIVE EMPLOYEE
Blue Shield Access + HMO 15 EE only EE + 1 EE + Family
Blue Shield EPO EE only EE + 1 EE + Family
Blue Shield Gold PPO EE only EE + 1 EE + Family
Kaiser HMO 15 EE only EE + 1 EE + Family
Dental Coverage for Employee Only is required.
Dental EE only EE + 1 EE + Family
Vision Coverage
Vision EE only EE + 1 EE + Family Decline
Decline Medical Coverage (Please complete the Declination of Coverage Section and attach necessary documentation, if
applicable)
EMPLOYEE INFORMATION
Last Name First Name M.I. Male
Female
Social Security Number (Required) Birth Date (mm/dd/yyyy) Home Phone: Work Phone:
Residence Street Address (No P.O. Box) City State Zip Code
Mailing Street Address
City
State
Zip Code
Occupation/Title:
Date of Hire (mm/dd/yyyy)
Employee Status:
FT PT
Marital Status: Single Married Registered Domestic Partner (RDP)* Legally Separated Divorced Widowed
Provider Name
Blue Shield HMO Provider Name Required. **Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician
(PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
E-Mail Address:
*Registered Domestic Partner (RDP). You must attach proof of Domestic Partnership Registration as defined under Section 297 and 299.2 of the California Family
Code.
**For Kaiser Participants only, if you are new to Kaiser and do not have a current provider, you will need to register on kp.org after you enroll to select your provider.
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DEPENDENT INFORMATION (Please list all eligible family members to be enrolled. Attach additional sheets if necessary.)
Spouse
RDP*
Add:
Delete:
Medical
Medical
Dental
Dental
Vision
Vision
Last Name First Name M.I.
Male
Female
Social Security Number (Required) Birth Date (mm/dd/yyyy)
Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code
Provider Name Blue Shield HMO Provider Name Required.**Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Vision
Vision
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code
Provider Name
Blue Shield HMO Provider Name Required.**Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Vision
Vision
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code
Provider Name
Blue Shield HMO Provider Name Required.**Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Vision
Vision
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code
Provider Name
Blue Shield HMO Provider Name Required. **Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Vision
Vision
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code
Provider Name
Blue Shield HMO Provider Name Required.**Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
*Registered Domestic Partner (RDP). You must attach proof of Domestic Partnership Registration as defined under Section 297 and 299.2 of the California Family
Code.
**For Kaiser Participants only, if you are new to Kaiser and do not have a current provider, you will need to register on kp.org after you enroll to select your provider.
3 5/17/2023
DECLINATION OF COVERAGE (Complete this section if medical coverage is to be declined by you or your eligible dependents.)
STOP AND READ CAREFULLY.
SIGN ONLY IF DECLINING COVERAGE FOR YOURSELF AND/OR DEPENDENTS. IF SIGNED IN ERROR, PLEASE
CROSS OUT AND INITIAL.
I understand that I am eligible for medical coverage through my employer. I waive the right to enroll in the medical plan as offered by my
employer for the following persons (please check all that apply below):
I decline Medical coverage for: You may elect to waive coverage if you or your dependents are covered by
another group health insurance plan. Please attach proof of medical
Self Spouse/RDP Child(ren) insurance coverage (i.e. insurance ID cards) if waiving for the first time.
List Dependent Name(s) Waiving Coverage:
Reason for waiver:
I have my own other group coverage
We are covered through my spouse’s employer
My spouse and dependents have other group coverage
I understand that by declining coverage, I will not be eligible for coverage until my employer’s next Open Enrollment period unless I
qualify for coverage due to a HIPAA qualifying event (including getting married, having a child, or involuntarily losing my other
coverage).
Further, if I am receiving a waiver incentive, I certify that I am enrolled in another group health coverage that is deemed to be
minimal essential coverage as required by law. I understand that if I choose to waive coverage, the waiver incentive I receive will be
taxable. Additionally, I understand that I can use this compensation for any purpose, but these monies are not intended to reimburse
me for an individual plan in the marketplace or a state exchange plan.
Employee Signature Date
If you are enrolling yourself in the medical plan, you must also sign under the “Authorization” section below.
4
Authorization Required by Blue Shield and Kaiser:
I declare that the information given on this form is true and complete to the best of my knowledge and belief. I understand that the information
I have provided is the basis on which coverage may be issued under these plans. Any misstatements or omissions may result in future claims
being denied and/or my coverage(s) being rescinded. I know that if I do not enroll within 30 days of becoming first eligible (or within 31 days
of an IRS qualified change in status) I will have to wait until the next annual enrollment and may be required to submit evidence of
insurability for certain coverage.
My signature below certifies that I have applied for the benefits indicated on this form. I understand that my benefit elections may result in
deductions from my pay and authorize my employer to make the required deduction.
Kaiser Foundation Health Plan, Inc., Arbitration Agreement* CALIFORNIA
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure
regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs,
relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers,
administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP,
including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly,
negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of
legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law
provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I
understand that the full arbitration provision is contained in the Evidence of Coverage.
By enrolling in a Kaiser health plan, I understand that this action will serve as my electronic signature of agreement to the conditions
provided in the Kaiser Foundation Health Plan Arbitration Agreement (above) and that by law this electronic signature will have the same
effect as a signature on a paper form. Note: if you do not wish to accept the arbitration agreement above you must return to the plan selection
section and make a new Health Plan selection.
*Disputes arising from the following fully-insured Kaiser Permanente Insurance Company coverages are not subject to binding arbitration: 1)
the Preferred Provider Organization (PPO) and the Out-of-Network portion of the Point-of-Service (POS) plans; 2) Preferred Provider
Organization (PPO) plans; 3) Out-of-Area Indemnity (OOA) plans; and 4) KPIC Dental plans.
If any changes to this enrollment is deemed a mid-year qualifying event, you are responsible to inform your employer within 31 days of the
qualifying event date.
By signing below, I acknowledge all of the terms and provisions as described above.
I hereby authorize Otay Water District to take my Medical and/or Dental premium deductions on a
(PLEASE SELECT ONE):
PRE-TAX BASIS OR POST-TAX BASIS
(If covering Domestic Partner, Post-Tax is required, per IRS guidelines.)
I acknowledge that each dependent listed in the Enrollment Form meets the definition of dependent per the District’s health plan rules and I
understand that any falsification, omission, or misrepresentation of information will be considered fraud and could lead to disciplinary action,
cancellation of the plan, and other necessary actions deemed appropriate by the District. I further acknowledge that I will be required to and,
by my signature below, hereby agree to reimburse the District for any insurance coverage expenses that the District incurred for ineligible
dependent coverage, including, but not limited to, via deduction from my wages or civil action. I further agree to notify the District within 31
calendar days if any of my eligible dependents become ineligible (e.g. legal separation, divorce, death, or over-age dependent). I further agree
to provide proof of eligibility upon request.
I further authorize the exchange of information necessary to provide the benefits afforded by the Plan.
Please sign and date this application:
Signature Date
REV. 5/17/2023
Med: ____ Den: ____ Vis: ____ HR Input: Notify Payroll