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). Contact PEBB; Login; Forgot your password? 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. 2. No paper. 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 Benefit changes will be effective 8/1/2020. 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. 2020 Connect Enrollment/Change of Status/Waiver Form P.O. To learn more about working with My Account, visit our Help with My Account webpage. You must submit your paper enrollment form and evidence of the event that created the special open enrollment to your benefits office within 60 days after the date of the qualifying event. Change in Status Form. 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. Public Employees Benefits Board (PEBB) Program Underwritten by Standard Insurance Company . 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. Your employing agency must receive your form no later than 31 days after the date you become eligible for PEBB benefits. Therefore, you must complete the entire form, including the dependent section for any children you want to continue to cover. 2020 Connect Enrollment/Change of Status/Waiver Form P.O. 0 If that day is the first of the month, the change begins 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 + … 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. WA State Health Care Authority PEBB Page 1 of 4 EF-RES101M-NW (09/19) Metropolitan Life Insurance Company, New York, NY 10166 . Enrollment and Change Form . The required form and evidence of continuous enrollment must be received by the PEBB program no later than sixty days after such coverage ends. Enrollment and Change Form . A Medical Home Selection Form can be found on page 3. Note: Coverage through the Benefit Exchange is not considered group coverage. Waive enrollment in medical coverage if you have (or are enrolling in) another employer-based group medical coverage, a TRICARE plan, or Medicare. 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. Note:UW employees must use Workday. Return completed form to your personnel, payroll or benefits office. Retiree Enrollment Form. Group Customer # 164995 : Report # Sub Code Branch : YOUR ENROLLMENT … This information is required to process your enrollment. To Be Completed By Employee Informational. 1. account. Remember to read and sign Section 8 on page 9. Long Term Disability (LTD) Enrollment/Change Form . 1923 0 obj <> endobj Attach additional dependent sheet if necessary. During this month, … 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). Share. Remember to sign and date page 8. 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. As we make forms fillable, they will be identified in the description column. Public Employees’ Benefit Board – 2020 Enrollment Guide. $�p��~"�UA��!ؿ� Y��`v&���f���8c��[ Employee Information _____ _____ Last Name, First Name SSN (or Employee ID if higher education) Address City State ZIP code Address Change … Enrollment Form for participants enrolling in a 2021 FSA or DCAP. The changes from 2019 vary by plan. 2020 fillable change form for Individual and family insurance PDF) Enrollment … ADD DROP FIRST NAME … 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. Public Employees’ Benefit Board – 2020 Enrollment Guide. To enroll or Your payroll or benefits office must receive the appropriate Enrollment/Change form by November 30 to make a plan change. Standard Insurance Company. Submit your 2020 PEBB Employee Enrollment/Change form to your personnel, payroll, or benefits office. How to contact PEBB during open enrollment. 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. 2021 PEBB Employee Enrollment/Change The information written on this form replaces all enrollment/change forms previously submitted. List all eligible family members you want to provide coverage for. Balance Changes I want to cover my balance for this semester Adjust my refund to $ Fund Changes. 377661 SI 7533 (4/20) WA Health Care Authority Public Employees Benefits Board (PEBB) Program Long Term Disability (LTD) Insurance . 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 The PEBB Program requires a $25-per-account premium surcharge in … COVID-19 updates | Fall 2020 Back to School Guide | Get ready to learn online | Get your books. 2021 FSA Enrollment Guide . Need help or have questions? $�p��~"�UA"��`�$�H��`v&���f�M�|KAd�u���q��`�1 ��X6D���_���ad`� �a`%GI�����0 �+� 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. 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. 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. 2077 0 obj <>stream TRS users, call … July 15, 2019 4,370 Views. 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 As a result, the PEBB Program has created a limited open enrollment opportunity from July 1 through 31, 2020. Human Resources PEBB Open Enrollment. Read this guide to learn about the 2021 FSA program. Complete a blank sample electronically to save yourself time and 2. 2020 PEBB Health Insurance Rates. Your employing agency must receive your form no later than 31 days after the date you become eligible for PEBB benefits. 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. Prescription Drug Reimbursement Request Form (PDF) Prescription Drug Prior Authorization Form (PDF) Health engagement model (HEM) 2020 HEM exemption request form (PDF coming soon) PEBB Open Enrollment How to Make Changes and Re-Attest to the Spousal Premium Surcharges . h�bbd```b`�~ "߃HVe0[L����xE�#��E��l�81���$G�l�zsi�"w��]`q7�\ fK��`RD�O��1�Xv&�d��M �BkAd�"{ In July 2020, you have an opportunity to change some of your PEBB benefits We know the COVID-19 pandemic may have changed your health care needs. Ready to pick a plan? In light of the COVID-19 pandemic, the PEBB Program is offering a limited open enrollment from July 1 through 31, 2020. If you are newly eligible and applying to enroll in or defer PEBB retiree insurance coverage, or enrolling after deferring, please complete the . Online changes: PEBB My Account portal. As we make forms fillable, they will be identified in the description column. I understand that I will receive reimbursements only for qualifying medical care or day care expenses. For changes to current 2020 coverage, visit WaHealthPlanFinder.org. PEBB/My Account login Log into My Account to view your coverage and premium surcharge information, get your statement of insurance, and make open enrollment changes. 3. Note: UW employees must use Workday. %PDF-1.6 %���� h�bbd```b`����A$�� &}��y�X�I"ǥ��y�8S;��� b?��� R�.�� V�/ ����0)V9l�>�4��KA${3X�309Dr������� v�"{ 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. The Public Employees Benefits Board (PEBB) met on July 10 and approved the rates for both Non-Medicare and Medicare Eligible retirees for 2020. ENROLLMENT • CHANGE FORM . 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. Complete this form to make changes to an existing retiree . 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. 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. Standard Insurance Company. Tobacco use premium surcharge. Complete Section I — Employee Information. Your employing agency must receive your form no later than 31 days after the date you become eligible for PEBB benefits. 2020 fillable change form for Individual and family insurance PDF) Enrollment … As a result, the PEBB Program has created a limited open enrollment opportunity from July 1 through 31, 2020. to fill in form: 2020 PEBB Employee . If evidence of good health andunderwriting approval are required for ASU Life AD&D, Securian will maila form instructionsto you. Box 4327, Portland, OR 97208-4327, 800-878-4445, ProvidenceHealthPlan.com. This form continued on next page. During this month, … Use the Retiree Election Form (form A). PLAN DEDUCTIBLE As a Connect member, you will need to choose a Medical Home. 34 During November 2015, you can make changes to your PEBB account that will take effect January 1, 2015. In that case, PEBB may terminate the family member’s coverage retroactively, pursuant to PEBB rules. 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 . PEBB Open Enrollment How to Make Changes and Re-Attest to the Spousal Premium Surcharges . PEBB COVID-19 Enrollment/ Change Form. 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.) We recommend using your personal email address to access your account. Complete Section II — Elections. Number Do whatever you want with a PEBB Employee Enrollment/Change form 2020 - Health Care ...: fill, sign, print and send online instantly. COVID-19 MEDICAL FSA & DCAP CHANGE FORM WA STATE PEBB NAVIA BENEFIT SOLUTIONS. You can choose to make your changes online or … 2021 FSA Enrollment Guide . hޜUiTSg~/ B6 �E',�,uXRT@Gâ ��(�R([�c�X�26�!� ��� (���h���" KAΜF��°U��ws��9�3�ߏ�>��kr/ � �\� �ԇ TXd�R��J�ٺR�i�@��ƅO�ک��P�{�˳�=�Up� ��w�@�;�����"{G[��|�E�ۊ/4�b����lk��yv�A;�w�sי23�Sù'�-����s��wOH3R�$V��1�[���h���*8�Z;�,�'�R�S���ցu&�,^#�DZ�d�WQg��>�eӚy���E8șC �d��a����P�k�1�ĥ0� ##-��%�;*������_֕�8����9{�3�ê��. This form replaces all Employee Enrollment/ Change forms previously submitted. You can choose to make your changes online or … 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. 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. To Be Completed By Employee To begin, find the action you are taking . Add dependent(s) Change dental plan Remove dependent(s) Enroll after … Enroll in Medical. Informational. 2020 PEBB Employee Enrollment/hange ubscriber’s last name ubscriber’s ocial ecurity 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 Tobacco use premium surcharge The PEBB Program requires a $25-per-account . PEBB Benefit Update Forms. Medical Claim Form (also for international claims) (PDF) Alternative Care Claim Form (for providers) (PDF) Mental Health/Chemical Dependency Claim Form (PDF) Pharmacy. COVID-19 MEDICAL FSA & DCAP CHANGE FORM WA STATE PEBB NAVIA BENEFIT SOLUTIONS. Adding a dependent that is not already listed on the account requires a paper form. %%EOF PEBB Employee Enrollment/Change form 2020. 3. 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. 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. Number 2119 0 obj <>stream Page 2 of 6 MSC 5507 (07/2020) Section 3: Dependent information 1. Need help or have questions? This information is required to process your enrollment. During November 2015, you can make changes to your PEBB account that will take effect January 1, 2015. California Subscriber Enrollment/Change Form Instructions for FEHB Program Enrollees Kaiser Foundation Health Plan, Inc. 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. g3��k "{~�/��L��j`����(�����g�R� �R)� 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. 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. List all eligible family members you want to provide coverage for. Please complete all information on this form. 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. Read this guide to learn about the 2021 DCAP program. Go to My Account on the PEBB website. To learn more about working with My Account, visit our Help with My Account webpage. 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. You can: Change your medical or dental plan(s). 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 … 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. Return completed form to your personnel, payroll or benefits office. Non-Medicare Retirees will see increases of $5-27 per month depending on their plan. 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. Medical Claim Form (also for international claims) (PDF) Alternative Care Claim Form (for providers) (PDF) Mental Health/Chemical Dependency Claim Form (PDF) Pharmacy. Change in Status Form. u u u u u u u u u u u u. 1956 0 obj <> endobj Enrollment Form for participants enrolling in a 2021 FSA or DCAP. Box 4327, Portland, OR 97208-4327, 800-878-4445, ProvidenceHealthPlan.com. Complete and submitthe form even if you are waivingall coverage options. 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. 2020 PEBB Employee Enrollment/Change for Medical Only Groups. For use only from July 1 through 31, 2020 . By signing below, I acknowledge that I understand the benefits, I … endstream endobj startxref 2020 PEBB Retiree . Page 2 of 6 MSC 5507 (07/2020) Section 3: Dependent information 1. E. Coverage Change Form. All enrollment forms and dependent verification documents must be received by HR no later than 7/31/2020. WA State Health Care Authority PEBB . 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. Filling in forms: Use the Form page instructions, if needed, to help find the form … 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. 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.) In this brave new world PEBB understands the need for convenient information and efficiencies. enrollment. Adding a dependent that is not already listed on the account requires a paper form. Enrolling when I am first eligible or after deferring (postponing) my coverage. We recommend using your personal email address to access your account. Please complete all information on this form. This page left intentionally blank. In this brave new world PEBB understands the need for convenient information and efficiencies. PLAN DEDUCTIBLE As a Connect member, you will need to choose a Medical Home. We are currently working to make all our forms fillable. Read this guide to learn about the 2021 DCAP program. Otherwise, you can change your password here. Page 2 of 3 MSC 5563 (07/2020) Newly Hired Employees Will have 30 days from date of hire to sign up for guarantee issue coverage. In that case, PEBB may terminate the family member’s coverage retroactively, pursuant to PEBB rules. 2020 Benefits Enrollment/Change form Instructions Step 1: Complete the form fully and legibly 1. We are currently working to make all our forms fillable. Return completed form to your personnel, payroll or benefits office. ADD DROP FIRST NAME … 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. For changes to current 2020 coverage, visit WaHealthPlanFinder.org. Attach additional dependent sheet if necessary. This page left intentionally blank. PEBB Continuation Coverage (COBRA and Unpaid Leave) Changing plans during Open Enrollment. %%EOF 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. 377661 SI 7533 (4/20) WA Health Care Authority Public Employees Benefits Board (PEBB) Program Long Term Disability (LTD) Insurance . TEAMSTERS GENERAL SERVICES. Identity confirmation - Step 1 of 3 . 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. Human Resources. Than 31 days after the date you become eligible for PEBB benefits forms and dependent documents... Pandemic, the PEBB Program no later than 31 days after such coverage ends the dependent Section any! Health care Authority PEBB page 1 of 4 EF-RES101M-NW ( 09/19 ) Metropolitan Life Insurance Company by PEBB! 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