NCAP 2018 Benefit Information Packet 1 Northwest Community Action Partnership 2018 Summary Benefit Plan Description - .75 FTE or Above Northwest Community Action Partnership is offering Options for our Benefit program. Get started by carefully reading the information contained in this guide and share it with your family. If you are a new hire, these forms and applications are due within seven days of hire and the benefits will be effective the first day of the month following 60 days from the date of hire. Employees are encouraged to fill out the required enrollment forms on the first day of employment. Northwest Community Action Partnership has an annual open enrollment period for benefit selection every year and staff has an opportunity to review the Benefit Choices available and make changes for the upcoming plan year of January 1st to December 31st. Remember, you’ll need to complete the necessary forms and applications and submit them to Katy Hughbanks, Payroll Clerk. If you have questions, please feel free to contact Katy at 308- 432-3393 or [email protected]. Benefit Dollars Benefit Options Full-Time Employees are given Benefit Dollars to pay for the “Benefit Options” that Northwest Community Action Partnership provides. 75-100% FTE $450 per month Benefit Options provided by Northwest Community Action Partnership that an employee can use their Benefit Dollars for are: Group Health Insurance Group Dental Insurance Group Vision Insurance Group Retirement Fund Voluntary Group Term Life Insurance Voluntary Short Term Disability During Enrollment If you don’t make an election… Review your benefit coverage and make adjustments, if necessary. Complete the necessary Benefit Enrollment Forms If enrolling in an option for the first time, complete the necessary applications and return them with your enrollment forms. If you do not complete the necessary Benefit Enrollment Forms and applications by the due date you will not be enrolled in any benefits and will not receive benefit dollars. This will continue until the next open enrollment period, unless you have a qualifying event. A qualifying event is: Getting married/ Divorced Losing coverage/ other special enrollment Having a baby or adopting a child Death of a spouse or child
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NCAP 2018 Benefit Information Packet
1
Northwest Community Action Partnership
2018 Summary Benefit Plan Description - .75 FTE or Above
Northwest Community Action Partnership is offering Options for our Benefit program. Get
started by carefully reading the information contained in this guide and share it with your family.
If you are a new hire, these forms and applications are due within seven days of hire and the
benefits will be effective the first day of the month following 60 days from the date of hire.
Employees are encouraged to fill out the required enrollment forms on the first day of
employment.
Northwest Community Action Partnership has an annual open enrollment period for benefit
selection every year and staff has an opportunity to review the Benefit Choices available and
make changes for the upcoming plan year of January 1st to December 31st.
Remember, you’ll need to complete the necessary forms and applications and submit them to
Katy Hughbanks, Payroll Clerk. If you have questions, please feel free to contact Katy at 308-
Blue Cross and Blue Shield of Nebraska is an Independent Licensee of the Blue Cross and Blue Shield Association. 31-072 (09-01-16) Page 1 of 4
PO Box 3248 • Omaha, Nebraska 68180-0001
BlueFreedom/SelectBlue Employee Enrollment Form
New Group New Hire Change
Section A. Applicant Information
Social Security Number Name (Last) (First) (MI) (Title) Date of Birth (MM/DD/YYY) Male Female
Are you a member of a federally-recognized American Indian or Alaska Native tribe? Yes No
Home Phone Number Work Phone Number Cell Phone Number Marital Status: Single
Married Divorced Address (Street, PO Box) (City) (State) (Zip+4 Code) (County) Height:
Weight: Group Name (Employer or Organization) Date Employed with Group Hours Worked per Week
Are you, your spouse or your dependent(s) current or former Blue Cross and Blue Shield insureds or applicants? If Yes, please give name(s) & ID number(s). Yes No
Are you or your spouse terminating other Blue Cross and Blue Shield coverage? If Yes, please give reason and date and complete Section F. Loss of Coverage Yes No
The group health/dental program has been offered to me and after seriously considering its benefits, I have decided: not to enroll myself in the health plan. not to enroll myself in the dental plan. not to enroll myself and my dependents in the health plan. not to enroll myself and my dependents in the dental plan. not to enroll my dependents in the health plan. not to enroll my dependents in the dental plan.
Coverage in the health/dental plan is declined because: I am enrolled and/or My dependents are enrolled, under my spouse's health coverage. My spouse is employed by (name of firm) I am enrolled and/or My dependents are enrolled, under my spouse's dental coverage. I am enrolled and/or My dependents are enrolled, under a COBRA continuation coverage or state continuation coverage. I have and/or My dependents have, individual coverage through Medicare Medicaid SCHIP another insurance company Other reason(s)
Signature of Applicant: Date:
Section C. Health And Dental Election(s) For Newly Eligible Employees
I Hereby Apply For:
One Person Family Employee and Spouse Employee and Child(ren)
If Dual Option Group Please indicate deductible $
If High Deductible Health Plan, Select One:
Health Savings Account (HSA)
One Person Family Employee and Spouse Employee and Child(ren)
(If Applicable To Your Plan)
MEDICARE SUPPLEMENT (Not available to active employees or their spouses age 65 and older unless the group has fewer than 20 full and/or part-time employees.)
(Please complete Form 37-044, if applicable) No Account Set-Up Required
NETWORK OPTION (not all options may be available to you under your Plan) NEtwork BLUE Premier Select BlueChoice Other - Network Name:
Within the past six months, have you or any dependents used tobacco products four or more times a week? Yes No
DENTAL HEALTH
Section B. Declination of Coverage Complete only if you elect not to participate in the group insurance offered.
Please print and complete all sections of this enrollment form with black ballpoint pen. Be sure to complete all questions in full. Incomplete enrollment forms cause unnecessary delays. If you need more space for any answers, you can use a separate piece of paper. Please include your name and social security number. Complete Section B, if applicable.
For Internal Use Group No. Group Dept.
Name (Last) (First) (MI) (Title) Social Security Number
Page 2 of 4 31-072 (09-01-16)
Section D. Personal Data
List below spouse and other dependent(s) to be covered including eligible dependent children under age 26. List in order of age - oldest first.
Full Name (Last, First, MI) Social Security Number
Date of Birth (MMDDYYYY)
M
F
Relation to Employee
Section E. Coverage Change Election(s) For Current Members I Hereby Apply For The Following Changes In Coverage: Health Only Dental Only Both
Change To: One Person Coverage Employee and Spouse Coverage Employee and Child(ren) Coverage Family Coverage
Change Reason: Marriage Divorce Spouse Deceased Other: Date:
Add New Dependent(s): Date Dependent(s) joined your household: (Complete Section D.)
Date Dependent(s) joined your household: (Complete Section D.)
Date Dependent(s) joined your household: (Complete Section D.)
Change Network Options (if applicable) NEtwork BLUE Premier Select BlueChoice Other - Network Name:
Other Health Changes:
Within the past six months, have you or any dependents used tobacco products four or more times a week? Yes No
Section F. Loss of Coverage - Special Enrollment Are You or Dependent terminating (or losing) other health coverage?
If Yes, please complete the following:
1) Give us the reason for loss of other health coverage:
Yes No
Employment terminated Death, divorce, or legal separation I/we voluntarily chose to drop other insurance
Spouse employment terminated
2) Coverage termination date:
I/we have reached the end of COBRA coverage Other:
3) Please provide the notice of termination, or loss of eligibility documentation from the other insurance company.
Section G. Medicare Secondary Payor Information Are you, your spouse, or dependent(s) enrolled in Medicare? Yes No If the answer is “Yes,” please fill in requested information below: If Medicare: Name of Beneficiary Medicare HIC #: Part A effective date: Part B effective date: Reason for entitlement (check all applicable boxes): Age Disability End stage renal disease
Page 3 of 4 31-072 (09-01-16)
Name (Last) (First) (MI) (Title) Social Security Number
Section H. Health History Answer each question YES or NO. For conditions answered "Yes," give details below. This information is necessary for rating purposes. Your enrollment for health coverage will not be declined based on answers to these questions, or any health status-related factors. You should not disclose genetic information (including family history). If you are a new hire or changing your coverage, you are not required to complete this section. To request a copy of our Privacy Policy, contact us in Omaha 402-390-1820 or toll free 800-642-8980.
1. In the past 5 years, have you or any of your dependents been tested, diagnosed or treated (including prescription medication usage) or been
advised to seek treatment for:
1. Alcohol or drug abuse............................................................................................................................................. Yes No
2. Arthritis, Bone, Joint, Spine, Muscle or Connective Tissue Disorder..................................................................... Yes No
3. Autoimmune disease, including Crohn's disease, Lupus or Multiple Sclerosis...................................................... Yes No
4. Cancers, tumors or polyps...................................................................................................................................... Yes No
5. Circulatory, blood or heart disorders including high blood pressure....................................................................... Yes No
6. Cirrhosis, hepatitis or any other disease of the liver............................................................................................... Yes No
7. Cystic Fibrosis or Rheumatic Fever........................................................................................................................ Yes No
8. Digestive disorders including any conditions of the colon, esophagus, gallbladder, intestines, pancreas or stomach.... Yes No
9. Diabetes, hyperthyroidism, hypothyroidism or any endocrine disorder or disease................................................ Yes No
10. Manifested genetic or developmental disorders including use of growth hormones.............................................. Yes No
11. HIV / AIDS or any other immune system disorder.................................................................................................. Yes No
12. Infertility or any other reproduction system disorder............................................................................................... Yes No
13. Lung disease or disorder........................................................................................................................................ Yes No
14. Neurological disorders including Alzheimer's, Cerebral Palsy, Epilepsy, migraines, Parkinson's or seizures........ Yes No
15. Organ transplant..................................................................................................................................................... Yes No
16. Paralysis including paraplegia and quadriplegia.................................................................................................... Yes No
17. Vascular disorders including stroke, CVA or TIA.................................................................................................... Yes No
2. In the past 5 years, have you or any of your dependents been hospitalized, had surgery or plan to have surgery for any illness, injury or condition or is anyone currently pregnant?......................................................................................... Yes No
3. In the past year, have you or any of your dependents incurred medical or pharmacy expenses in excess of $5,000?...... Yes No
For any "Yes" answers identified above, please provide complete details below. Attach a separate piece of paper if necessary. Question Number
Person
Condition
Treatment Performed or Recommended
Degree of Recovery
Page 4 of 4 31-072 (09-01-16)
Name (Last) (First) (MI) (Title) Social Security Number
Section I. Acknowledgement and Authorizations I represent that my answers and statements in this enrollment form are true and complete to the best of my knowledge and belief. I understand that any intentional misrepresentation in this enrollment form may cause the coverage to be void. I further understand that Blue Cross and Blue Shield of Nebraska reserves the right to accept or decline this enrollment form and that no right whatever is created by it. I authorize Blue Cross and Blue Shield of Nebraska to obtain and/or release medical information to the extent necessary for processing claims. I authorize my employer to deduct from my earnings any required premiums.
By providing your telephone numbers you agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you give us, including a wireless number, using an automatic telephone dialing system and/or prerecorded message. Without limit, these calls may be about treatment options, other health-related benefits and services, enrollment, payment, or billing.
Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. If you are declining coverage for yourself or your dependents because of coverage under Medicaid or a State Child Health Insurance Program (SCHIP), you may be able to enroll yourself or your dependents in this plan if that coverage terminates due to a loss of eligibility. You must request enrollment in the plan no later than 60 days after the termination of coverage.
Additionally, if you decline coverage and you or your dependents become eligible for premium assistance for this group health plan under Medicaid or SCHIP, you or your dependents may be able to enroll in the plan at that time. You must request enrollment no later than 60 days after the date you are determined to be eligible for the premium assistance.
To request special enrollment or obtain more information contact our Member Services Department at 402-390-1820 or toll free 888-592-8961.
Signature of Applicant:
Date:
Form #125DC2 01/18
First Concord Benefits Group
Employer: NW Community Action Part.
Plan Year: 1/1/2018 to 12/31/2018 . No.Payrolls: 26
YES I want the convenience of using the take care debit card to pay for qualified expenses.
E-MAIL (required-if YES): .
NO At this time, I do NOT want to use the take care debit card.
Flexible Spending Account (FSA)
Allows you to use pre-tax dollars to pay for expenses which are not covered, or are not eligible for payment through any group health care plan(s), under which you or your spouse are covered.
_______ YES, I elect to participate: $______________Per Pay $_______________Annual Amount
Dependent Care Spending Account The Dependent Care Spending Account allows you to use pre-tax dollars to pay for eligible Dependent Care Expenses which allow you or your spouse (if applicable) to work, look for work, or attend school on a full-time basis.
_______ YES, I elect to participate: $______________Per Pay $_______________Annual Amount
Group Premium Payment Plan The Premium Payment Plan allows you to pay for your portion and your dependent(s) portion of employer-provided benefits on a pre-tax basis. I understand that my share of these insurance benefits will be paid with pre-tax dollars.
_______ YES, I elect to participate: $______________Per Pay $_______________Annual Amount
_______ NO, I WAIVE my right to participate and understand that I will lose all tax savings I may have received as a participant.
My employer and I agree that my taxable income will be reduced each pay period by the amount set forth in this agreement. I understand that I may only change my election in the event of certain changes in my status. Prior to the first day of each plan year, I will be offered the opportunity to change my benefit election for the upcoming plan year. Any qualified expenses that are submitted by me will be reimbursed to me on a tax-free basis. Any contributions that are not used during the plan year or after termination of employment or benefits will be forfeited and will not be paid to me in cash or used in a later plan year.
LastName____________________FirstName____________ Date of Birth _______SocSecNo.______________
Home Address ____________________________________City_________________State_____Zip_________
DEBIT CARD REQUEST/ CONTINUATION I understand that the take care debit card is available to pay only qualified expenses. I also understand that if a payment is
made that is not for qualified expenses, I will repay my employer. For any expenses not repaid by me, I authorize my
employer to deduct the amount from my paycheck (if permitted by law). www.myflexonline.com