To defer health plan enrollment, the retiree must submit the Retiree Coverage Election/Change form to the PEBB program no later than 60 days after employer-paid coverage or COBRA coverage ends. This page left intentionally blank. The PEBB Program must receive your Retiree Election/Change form for Open Enrollment and Retiree Medicare Advantage Enrollment form (form C) by November 30, 2020. Change in Status Form. $�p��~"�UA"��`�$�H��`v&���f�M�|KAd�u���q��`�1 ��X6D���_���ad`� �a`%GI�����0 �+� %PDF-1.6 %���� 2020 Washington plans. As a result, the PEBB Program has created a limited open enrollment opportunity from July 1 through 31, 2020. Number In light of the COVID-19 pandemic, we know that your health care needs may have changed. Online changes: PEBB My Account portal. In that case, PEBB may terminate the family member’s coverage retroactively, pursuant to PEBB rules. RMU – 2020 FSA Enrollment Change Form v4– 06.09.2020 PLEASE PRINT CLEARLY Employer Name NH FIRST Employee ID STATE OF NEW HAMPSHIRE Employee Name (Last, First MI) DOB (mm/dd/yy) SSN (last 4 digits only) Street Address City State Zip Type of Election Event Date New Hire Enrollment Change (complete section below) Description of Change: _____ Action: New Enrollment Stop (limited … Non-Medicare Retirees will see increases of $5-27 per month depending on their plan. For use only from July 1 through 31, 2020 . $�p��~"�UA��!ؿ� Y��`v&���f���8c��[ Use the Retiree Election Form (form A). Your employing agency must receive your form no later than 31 days after the date you become eligible for PEBB benefits. Return completed form to your personnel, payroll or benefits office. Do whatever you want with a PEBB Employee Enrollment/Change form 2020 - Health Care ...: fill, sign, print and send online instantly. 2. Standard Insurance Company. Changes to medical and dental plans, removal of a dependent, and spouse or state registered domestic partner may be made through PEBB My Account until 11:59 pm on Monday, November 30, 2020. Add dependent(s) Change dental plan Remove dependent(s) Enroll after … endstream endobj startxref }"��C�J��Se�նQoM�W3R�0�\>2M�)��b��`c�$.�P!�[�2׊>Ⱦ�=3��k������s�~�w��g�g @@{�t3�>.#��x��@Rm����@"߳����|���� ��G���rS����6�V��D�WZB�@���:�,b\�V�s�c���p{�n�QL�cwP�$О?����Vz�g7!�k+��i{�S�����`����)�gǡ�E��t�ɖ����3�����PΛ���V��}��c�rm:i�;�,�JclY�����;�c��� j���=B�i;Ӥ�m�sB�,e�$�+�'���˃N�7r�.�0�-/�r����c�_h��g{A������ϴْ�چ��{zX$_�=�A}�"�^�{�k�����3�j����L�,��9F䓭Y"YBu�i�����u����pYLe��x�z.��������qN��M�Ҵ��I3��� �#��qu�x�WN���y�L������6�f2r?9�ޗd"���_~3�1��Ü���bz���k��7�$~p�鯵+م��ye��3�QJ��qZ�F)B��5�x���b�|�E�|����{����X�u=�]��M�I+�u�Mur~�V��&;��a����f�)�V9���=X���z�l���h����O�)�*n-���0i�k��>��gG����5���KL�U������=N�U��gîI.�J�X�g�O�2Q���/=J�!b��QU�kR9���ׇ�,W�;_�G�Z�,2�x����1����ik>��NlZ�����V�wxl��8�>�8ߞ�1�pr���o����ٲ؍oF-a�v�ZM��S�L�$gqm��+o':EF݈-��2m���޴s�q��^K���{ƺ�e.��:q�%�. We are currently working to make all our forms fillable. Changes to medical and dental plans, removal of a dependent, and spouse or state registered domestic partner may be made through PEBB My Account until 11:59 pm on Monday, November 30, 2020. To Be Completed By Employee h�bbd```b`�~ "߃HVe0[L����xE�#��E��l�81���$G�l�zsi�"w��]`q7�\ fK��`RD�O��1�Xv&�d��M �BkAd�"{ Share. Standard Insurance Company. We recommend using your personal email address to access your account. We are currently working to make all our forms fillable. Filling in forms: Use the Form page instructions, if needed, to help find the form … 1984 0 obj <>/Filter/FlateDecode/ID[<63DE971082264E43A9CEDF6439029FF5>]/Index[1923 155]/Info 1922 0 R/Length 212/Prev 1071847/Root 1924 0 R/Size 2078/Type/XRef/W[1 3 1]>>stream 2021 FSA Enrollment Guide . Balance Changes I want to cover my balance for this semester Adjust my refund to $ Fund Changes. 2. To learn more about working with My Account, visit our Help with My Account webpage. By signing below, I acknowledge that I understand the benefits, I … In light of the COVID-19 pandemic, the PEBB Program is offering a limited open enrollment from July 1 through 31, 2020. 2020 Washington plans. Section 1: Employee information PEBB benefit number (P#####), OR#, University ID or Lottery ID Gender c M c F c Other Last name First name M.I. In July 2020, you have an opportunity to change some of your PEBB benefits We know the COVID-19 pandemic may have changed your health care needs. On any device & OS. PEBB Health Insurance Forms PEBB Enrollment, Update, and Beneficiary Forms Health Insurance Reimbursement Forms PEBB Statewide Plan Forms (Providence) (Includes Medical Claim Form, Prescription drug claim form, prescription drug prior authorization form, etc) Providence Choice Forms Moda Medical & Dental Forms Flexible Spending Account Claim Forms (Healthcare and Dependent COVID-19 MEDICAL FSA & DCAP CHANGE FORM WA STATE PEBB NAVIA BENEFIT SOLUTIONS. 1. In light of this, the PEBB Program is offering subscribers a limited open enrollment during which you can to make changes to some PEBB benefits. Make changes to your existing PEBB enrollment if you're within 60 days of a qualifying event (like the birth of a child, marriage, or divorce). Your payroll or benefits office must receive the appropriate Enrollment/Change form by November 30 to make a plan change. enrollment. If that day is the first of the month, the change begins %PDF-1.6 %���� Note: UW employees must use Workday. 2020 PEBB Retiree Coverage Election Form (form A). Updated: September 2020 Who should use Federal Employees Health Benefits (FEHB) Program enrollees in Kaiser Permanente’s California plans: Northern California, Fresno California, and Southern California. Tobacco use premium surcharge. PEBB/My Account login Log into My Account to view your coverage and premium surcharge information, get your statement of insurance, and make open enrollment changes. 2021 PEBB Employee Enrollment/Change The information written on this form replaces all enrollment/change forms previously submitted. 34 Submit your 2020 PEBB Employee Enrollment/Change form to your personnel, payroll, or benefits office. 2021 Premium Rate Sheet; PEBB MEDICAL ONLY-if you are not making any changes, you do not need to complete a new form… 3. You can: Change your medical or dental plan(s). Midyear Change Form (Qualified Status Change (QSC)) Office use only Approved by: Approved date: Effective date: See the Summary Plan Description and the QSC Matrix at www.pebbinfo.com. If you have more dependents than form space allows, attach an additional page. For K-12 PEBB members who are eligible for the SEBB Program, you will need to enroll during the first annual open enrollment, October 1 through November 15, 2019. This form continued on next page. You can change your attestation online using PEBB My Account at hca.wa.gov/my-account or submit a 2020 PEBB Premium Surcharge Attestation Change Form. Retiree Enrollment Form. Midyear Change Form (Qualified Status Change (QSC)) Office use only Approved by: Approved date: Effective date: See the Summary Plan Description and the QSC Matrix at www.pebbinfo.com. Submit your 2020 PEBB Employee Enrollment/Changeform to your personnel, payroll, or benefits office. COVID-19 updates | Fall 2020 Back to School Guide | Get ready to learn online | Get your books. Please complete all information on this form. 2021 DCAP Enrollment Guide . Adding a dependent that is not already listed on the account requires a paper form. Your employing agency must receive your form no later than 31 days after the date you become eligible for PEBB benefits. You may enroll during the 2020 plan year if you or an eligible family member has a qualified change in status event that creates a special open enrollment. Prescription Drug Reimbursement Request Form (PDF) Prescription Drug Prior Authorization Form (PDF) Health engagement model (HEM) 2020 HEM exemption request form (PDF coming soon) For additional questions about your enrollment,visit th e PEBB Program’s open enrollment webpa ge or, call PEBB Customer Service at 1-800-200-1004, 8 a.m. to 4:30 p.m., Monday through Friday. Return completed form to your personnel, payroll or benefits office. COVID-19 MEDICAL FSA & DCAP CHANGE FORM WA STATE PEBB NAVIA BENEFIT SOLUTIONS. This information is required to process your enrollment. PEBB Open Enrollment How to Make Changes and Re-Attest to the Spousal Premium Surcharges . Remember to read and sign Section 8 on page 9. Subscriber’s last name Subscriber’s Social Security number u u u u u u u u u u u u u u u u u u u u u u u u- u u- u u u u. 3. to fill in form: 2020 PEBB Employee . 2020 online Special Enrollment change form for individual and family insurance (PDF) 2020 fillable change form for individual and family insurance (PDF) (Use if your client needs to list more than four dependents.) Public Employees Benefits Board (PEBB) Program Underwritten by Standard Insurance Company . Identity confirmation - Step 1 of 3 . COVID-19 updates | Fall 2020 Back to School Guide | Get ready to learn online | Get your books. Inaccurate, incomplete, or illegible information may delay coverage. You will need to enroll your dependents, if you want to continue covering them for the 2020 If you are newly eligible and applying to enroll in or defer PEBB retiree insurance coverage, or enrolling after deferring, please complete the . 2077 0 obj <>stream No software installation. 2020 Connect Enrollment/Change of Status/Waiver Form P.O. If evidence of good health andunderwriting approval are required for ASU Life AD&D, Securian will maila form instructionsto you. Change in Status Form. WA State PEBB Medical Flexible Spending Arrangement (FSA) & Dependent Care Assistance Program (DCAP) Enrollment Form Plan Year: 1/1/2020–12/31/2020 with Medical FSA Grace Period through 3/15/2021 Instructions 1. Retiree Enrollment Form. PEBB COVID-19 Enrollment/ Change Form. I also understand that if I fail to report on this enrollment form a change that made an enrolled family member ineligible, PEBB may consider my omission an intentional misrepresentation of a fact material to my enrollment. You can choose to make your changes online or … 34 California Subscriber Enrollment/Change Form Instructions for FEHB Program Enrollees Kaiser Foundation Health Plan, Inc. Enrollment and Change Form . Go to My Account on the PEBB website. Retirees may defer enrollment in a PEBB retiree health plan if they are enrolled in other medical as described in WAC 182-12-205 (2)(a) through (d). In this brave new world PEBB understands the need for convenient information and efficiencies. Medical Claim Form (also for international claims) (PDF) Alternative Care Claim Form (for providers) (PDF) Mental Health/Chemical Dependency Claim Form (PDF) Pharmacy. In July 2020, you have an opportunity to change some of your PEBB benefits We know the COVID-19 pandemic may have changed your health care needs. Enroll in Medical. This page left intentionally blank. Long Term Disability (LTD) Enrollment/Change Form . Attach additional dependent sheet if necessary. In this brave new world PEBB understands the need for convenient information and efficiencies. Complete Section II — Elections. Note: Enrollment/changes cannot be made through PEBB/MyAccount for this enrollment event. Human Resources PEBB Open Enrollment. The PEBB Program must receive your Retiree Election/Change form for Open Enrollment and Retiree Medicare Advantage Enrollment form (form C) by November 30, 2020. Inaccurate, incomplete, or illegible information may delay coverage. I understand that I will receive reimbursements only for qualifying medical care or day care expenses. Need help or have questions? July 15, 2019 4,370 Views. The PEBB Program requires a $25-per-account premium surcharge in … PEBB Affidavit of Domestic Partnership PEBB Flexible Spending Account ASI Flex Debit Card Enrollment Providence Medical Home Designation UNUM Long-Term Care Enrollment Medical History Statement (Printable) Medical History Statement (Submit Online) Weight Watchers Enrollment. WA State Health Care Authority PEBB Page 1 of 4 EF-RES101M-NW (09/19) Metropolitan Life Insurance Company, New York, NY 10166 . During this month, … Number To learn more about working with My Account, visit our Help with My Account webpage. To enroll or 1923 0 obj <> endobj ADD DROP FIRST NAME … Enrollment Form for participants enrolling in a 2021 FSA or DCAP. endstream endobj startxref Box 4327, Portland, OR 97208-4327, 800-878-4445, ProvidenceHealthPlan.com. As a result, the PEBB Program has created a limited open enrollment opportunity from July 1 through 31, 2020. A Medical Home Selection Form can be found on page 3. Attach additional dependent sheet if necessary. Human Resources. As we make forms fillable, they will be identified in the description column. E. Coverage Change Form. %%EOF This enrollment form will remain in effect and cannot be revoked or changed during the 2020 plan year unless the revocation and new elections are consistent with federal regulations and Public Employees Benefits Board (PEBB) Program rules. Public Employees’ Benefit Board – 2020 Enrollment Guide. Note:UW employees must use Workday. You can choose to make your changes online or … If your account is locked due to typing the password incorrectly, you may wish to wait at least 10 minutes and you can try again. Note: UW employees must use Workday. in partnership with 2020 Member Enrollment / Change Form 38 Austin Street Wo rc est ,Ma 016 9 888-806-1041 Health Insurance Plan (check one): HMO 25 –Flex HMO 1000 –Flex HMO 2000 –Flex HMO 1750 Core –Flex HMO HSA 3400 –Flex Coverage Type (check one): Self Self + … PLAN DEDUCTIBLE As a Connect member, you will need to choose a Medical Home. WA STATE PEBB DIRECT DEPOSIT AUTHORIZATION FORM NAVIA BENEFITS CARD Customer Service: (425) 452-3500 or (800) 669-3539 Visit our website at pebb.naviabenefits.com Please read next page for important information about direct deposit and the debit card. Changes that result in a premium surcharge will begin the first day of the month after the status change (the date you or a dependent started using tobacco products). No paper. This form replaces all Employee Enrollment/ Change forms previously submitted. A Medical Home Selection Form can be found on page 3. Enrollment/Change. For changes to current 2020 coverage, visit WaHealthPlanFinder.org. How to contact PEBB during open enrollment. Informational. 2020 online Special Enrollment change form for individual and family insurance (PDF) 2020 fillable change form for individual and family insurance (PDF) (Use if your client needs to list more than four dependents.) Securely download your document with other editable templates, any time, with PDFfiller. 0 Benefit changes will be effective 8/1/2020. g3��k "{~�/��L��j`����(�����g�R� �R)� How to contact PEBB during open enrollment. Contact PEBB; Login; Forgot your password? TEAMSTERS GENERAL SERVICES. To Be Completed By Employee Therefore, you must complete the entire form, including the dependent section for any children you want to continue to cover. Complete and submitthe form even if you are waivingall coverage options. 2020 PEBB Employee Enrollment/Change for Medical Only Groups. PEBB COVID-19 Limited Open Enrollment/Change Form (PDF 3.5 MB) Compare Medical Plans Check the box(es) next to the change requested. SI 7533D-377661-OE (10/18) (2/11) Public Employees Benefits Board (PEBB) Long Term Disability (LTD) Standard Insurance Company Enrollment/Change Form To Be Completed By Applicant Apply for Coverage Name Change Your Name (Last, First, Middle) Your Social Security Number Birth Date Employee I.D. 2020 PEBB Retiree . Section 1: Employee information PEBB benefit number (P#####), OR#, University ID or Lottery ID Gender c M c F c Other Last name First name M.I. Complete Section I — Employee Information. ENROLLMENT • CHANGE FORM . Otherwise, you can change your password here. Enrolling when I am first eligible or after deferring (postponing) my coverage. In light of the COVID-19 pandemic, we know that your health care needs may have changed. PEBB Continuation Coverage (COBRA and Unpaid Leave) Changing plans during Open Enrollment. Please confirm the email address you use to login, as well as the last 4 digits of the Subscriber SSN. Complete this form to make changes to an existing retiree . To begin, find the action you are taking . SI 7533D-377661-OE (10/18) (2/11) Public Employees Benefits Board (PEBB) Long Term Disability (LTD) Standard Insurance Company Enrollment/Change Form To Be Completed By Applicant Apply for Coverage Name Change Your Name (Last, First, Middle) Your Social Security Number Birth Date Employee I.D. Read this guide to learn about the 2021 DCAP program. (PEBB) Program, your PEBB coverage will likely change to the SEBB Program for 2020. List all eligible family members you want to provide coverage for. This information is required to process your enrollment. All enrollment forms and dependent verification documents must be received by HR no later than 7/31/2020. 2020-2021 FINANCIAL AID CHANGE FORM Student ID Number Student Name Enrollment Changes I am not attending this semester I am only attending credit hours I am attending credit hours in order to graduate at the end of this semester . 2119 0 obj <>stream In that case, PEBB may terminate the family member’s coverage retroactively, pursuant to PEBB rules. For use only from July 1 through 31, 2020 . PEBB Employee Enrollment/Change form 2020. If you are unsure of your PEBB benefits eligibility date, please consult your local benefits office. Group Customer # 164995 : Report # Sub Code Branch : YOUR ENROLLMENT … Human Resources PEBB Open Enrollment. If you experienced a qualified midyear change event and want to make midyear changes to your current year (2020) benefits or dependents, download the midyear change form and submit it to your agency payroll or university benefits office within 30 days of the event. PEBB Open Enrollment How to Make Changes and Re-Attest to the Spousal Premium Surcharges . PEBB Affidavit of Domestic Partnership PEBB Flexible Spending Account ASI Flex Debit Card Enrollment Providence Medical Home Designation UNUM Long-Term Care Enrollment Medical History Statement (Printable) Medical History Statement (Submit Online) Weight Watchers Enrollment. Need help or have questions? WA State Health Care Authority PEBB . Page 2 of 6 MSC 5507 (07/2020) Section 3: Dependent information 1. As a new hire you are eligible for benefit amounts on a guarantee issue basis of up to and including $4,000 and a duration of 3 or 6 years. Call PEBB at 503-373-1102 during the following times: > Monday–Friday, 7 a.m.–6 p.m. Email PEBB at: inquiries.pebb@dhsoha.state.or.us. hޜV}X�i?ϔ�Q3��1��V�( 0 2020 fillable change form for Individual and family insurance PDF) Enrollment … The changes from 2019 vary by plan. %%EOF Enrollment and Change Form . TRS users, call … During this month, … 377661 SI 7533 (4/20) WA Health Care Authority Public Employees Benefits Board (PEBB) Program Long Term Disability (LTD) Insurance . Your employing agency must receive your form no later than 31 days after the date you become eligible for PEBB benefits. Informational. 2020 Benefits Enrollment/Change form Instructions Step 1: Complete the form fully and legibly 1. PEBB Benefit Update Forms. Please complete all information on this form. h�bbd```b`����A$�� &}��y�X�I"ǥ��y�8S;��� b?��� R�.�� V�/ ����0)V9l�>�4��KA${3X�309Dr������� v�"{ During November 2015, you can make changes to your PEBB account that will take effect January 1, 2015. 1956 0 obj <> endobj Ready to pick a plan? 2020 fillable change form for Individual and family insurance PDF) Enrollment … You may enroll during the 2021 plan year if you or an eligible family member has a qualified change in status event that creates a special open enrollment. Prescription Drug Reimbursement Request Form (PDF) Prescription Drug Prior Authorization Form (PDF) Health engagement model (HEM) 2020 HEM exemption request form (PDF coming soon) Read this guide to learn about the 2021 DCAP program. 2021 DCAP Enrollment Guide . Enrollment Form for participants enrolling in a 2021 FSA or DCAP. If you experienced a qualified midyear change event and want to make midyear changes to your current year (2020) benefits or dependents, download the midyear change form and submit it to your agency payroll or university benefits office within 30 days of the event. Coverage is effective the first of the month following the date your form is received by PEBB. Employee Information _____ _____ Last Name, First Name SSN (or Employee ID if higher education) Address City State ZIP code Address Change … 2018 Employee Enrollment/Change Changes you can make during the PEBB Program’s annual open enrollment (November 1-30) All changes become effective January 1 of the following year. During November 2015, you can make changes to your PEBB account that will take effect January 1, 2015. PEBB Benefit Update Forms. Consolidation of PEBB and SEBB programs November 15, 2020 3 In the long-term, administrative efficiencies could likely be gained by fully consolidating the PEBB and SEBB Programs, including eligibility, enrollment, plan offerings, communications, the PEB and SEB Boards, risk pools and tier ratios, rate development and premiums, and collective bargaining. In light of this, the PEBB Program is offering subscribers a limited open enrollment during which you can to make changes to some PEBB benefits. For changes to current 2020 coverage, visit WaHealthPlanFinder.org. I also understand that if I fail to report on this enrollment form a change that made an enrolled family member ineligible, PEBB may consider my omission an intentional misrepresentation of a fact material to my enrollment. Public Employees’ Benefit Board – 2020 Enrollment Guide. 2. As we make forms fillable, they will be identified in the description column. Filling in forms: Use the Form page instructions, if needed, to help find the form … 2021 FSA Enrollment Guide . HCA 50-400 (10/19) Type or print clearly in dark ink, use only capital block lettering inside the boxes as shown in the example. Medical Claim Form (also for international claims) (PDF) Alternative Care Claim Form (for providers) (PDF) Mental Health/Chemical Dependency Claim Form (PDF) Pharmacy. Return completed form to your personnel, payroll or benefits office. Read this guide to learn about the 2021 FSA program. Remember to sign and date page 8. Return completed form to your personnel, payroll or benefits office. enrollment. The required form and evidence of continuous enrollment must be received by the PEBB program no later than sixty days after such coverage ends. PLAN DEDUCTIBLE As a Connect member, you will need to choose a Medical Home. 2020 PEBB Health Insurance Rates. 2020 0 obj <>/Filter/FlateDecode/ID[<63DE971082264E43A9CEDF6439029FF5>]/Index[1956 164]/Info 1955 0 R/Length 217/Prev 1101559/Root 1957 0 R/Size 2120/Type/XRef/W[1 3 1]>>stream The PEBB Program’s annual open enrollment is November 1 to November 30. For additional questions about your enrollment,visit the PEBB Program’s open enrollment webpage or, call PEBB Customer Service at 1-800-200-1004, 8 a.m. to 4:30 p.m., Monday through Friday. Call PEBB at 503-373-1102 during the following times: > Monday–Friday, 7 a.m.–6 p.m. Email PEBB at: inquiries.pebb@dhsoha.state.or.us.